Industry Insight

Major Study Finds Significant National Patient Safety Improvement

A study published in JAMA: The Journal of the American Medical Association (JAMA) and funded and carried out by the Agency for Healthcare Research and Quality (AHRQ) shows that rates of in-hospital adverse events for health care related patient harm fell significantly in the United States in the decade prior to the onset of the COVID-19 pandemic.

Researchers found significant decreases in in-hospital adverse event rates for heart attack, heart failure, pneumonia, and major surgical procedures. After reviewing records of nearly 245,000 patients in more than 3,100 hospitals between 2010 to 2019, this study shows that pre-COVID hospital care was getting safer.

Researchers of this study tracked a total of 21 adverse events over the study period. Examples of the events included adverse medication events such as those associated with the use of insulin or anticoagulants, infections such as central line–associated bloodstream infections and catheter-associated urinary tract infections, and postprocedure events such as those associated with hip joint or knee joint replacement surgeries or postoperative cardiac events.

“America’s doctors, nurses, and allied health workers dedicate their professional lives to serving patients and keeping them safe,” says AHRQ Director Robert Otto Valdez, PhD, MHSA. “These study results indicate that we know how to improve patient safety by working together and that we can sustain those results over time. The pandemic has undoubtedly put those successes at risk, but this study should provide motivation for health care officials to rebuild and rededicate ourselves to a patient and provider safety doctrine.”

This analysis is the most comprehensive evaluation to date of adverse events that occurred in hospitalized patients in the United States. Adverse events are often defined as physical or psychological harm caused by a person’s interaction with the health care system (rather than the underlying disease) that may result in prolonged hospitalization, pain, discomfort, disability, or even death. Tracking the rates of adverse events is a common way of measuring changes in patient safety.

In the study, researchers examined the rates of adverse events by looking at the raw (observed) rates of adverse events and looking at rates after adjustment for changes in the patient populations and hospitals included in the study over a 10-year period. In the observed data for 2010 and 2019, adverse event rates fell 36% for heart attack patients, 31% for heart failure patients, 39% for pneumonia patients, and 36% for major surgery patients but were unchanged for the group of patients representing all other conditions. After adjustment, the relative risk of experiencing an adverse event diminished for all five patient groups, as follows: 41% for heart attack patients, 27% for heart failure patients, 36% for pneumonia patients, 41% for major surgery patients, and 18% for patients with all other conditions.

Patient safety has been a major health care policy issue since 1999, when the Institute of Medicine (now known as the National Academy of Medicine) published “To Err Is Human,” a report that estimated that up to 98,000 Americans die each year as a direct result of medical errors.

Since then, many health care organizations have developed and implemented interventions and programs with the aim of improving patient safety. AHRQ’s patient safety efforts, including its Healthcare-Associated Infections Program and implementation of CUSP methodology, team-training curriculum TeamSTEPPS, CAHPS suite of surveys to assess patients’ experience with care, and Patient Safety Organization Program, have been at the forefront of national patient safety efforts.

Those also include programs from other federal and private-sector organizations, such as CMS, which managed the Partnership for Patients and implemented payment programs and publicly reported outcomes all geared towards improving patient safety; the CDC’s work addressing gaps in the public health system and investments in data systems and sharing, infection control, including Project Firstline, environment and sanitation, and vaccines, therapeutics, and diagnostics; and the Institute for Healthcare Improvement, which led the 5 Million Lives Campaign among many others.

“This study serves as evidence of what many in the field of patient safety have long believed, that when we work together towards a common goal, rely on the evidence, and attend to individual patient needs, we can achieve great results,” says Erin Grace, MHA, acting director of AHRQ’s Center for Quality Improvement and Patient Safety, and another of the study’s coauthors. “This all-in approach will also be critical to future analyses of the impact the COVID-19 pandemic has had on patient safety.”

The study was conducted by researchers at AHRQ, CMS, the Office of the National Coordinator for Health Information Technology, Harvard Medical School, Harvard T.H. Chan School of Public Health, Yale-New Haven Hospital, Yale University School of Medicine, Yale School of Public Health, and University of Connecticut School of Medicine, and was published by JAMA.

In addition to the main paper, an additional 74 pages of figures, tables, graphs, and other information is also available in an online appendix on the JAMA website. JAMA has also included an editorial consisting of an interview related to the paper with former ARHQ grantee Peter J. Pronovost, MD, PhD, FCCM, chief quality and transformation officer at University Hospitals Cleveland Medical Center.

— Source: Agency for Healthcare Research and Quality

AHDI Announces New Board Members, 2022–2023 Executive Committee

The Association for Healthcare Documentation Integrity (AHDI) announces the addition of two new members and one returning member to the Board of Directors, who will serve under the leadership of incoming President Tina Hincka, RHDS, AHDI-F. The Board of Directors also announced officers for 2022–2023.

AHDI recognizes and expresses gratitude to outgoing president Stacy Lehto, CHDS, AHDI-F, who will begin her term as immediate past president, and board members Kat King, ASHI, AHDI-F, and Bonnie Monico, CHDS, AHDI-F, whose terms ended August 31, 2022.

“Stacy Lehto has been instrumental in helping AHDI spread its wings as AHDI president this past year,” says Sheila Guston, CHDS, CHDP-A, CHDP-S, AHDI-F, interim CEO of AHDI. “Her passion and willingness to try new things were exactly what we needed to bring AHDI and the role of the documentation specialist into the future. Building on momentum of the leaders before her, AHDI accomplished big things this year with her at the helm. I have no doubt that momentum will continue in the year ahead.”

As she transitions to immediate past president, AHDI thanks Lehto for her time and expertise as well as her love and passion for the organization and its members. AHDI wishes to thank King and Monico for their many contributions during their time on the Board of Directors also. AHDI is very grateful for their willingness to serve and to continue the important work ahead.

The following individuals were recently elected by the AHDI membership and will serve three-year board terms from September 1, 2022, to August 31, 2025:

• Georgia Green, RHIA, CHDS, CCS, CPC, AHDI-F;
• Susan Lucci, RHIA, CHPS, CHDS, AHDI-F; and
• Theresa Parks, CHDS, AHDI-F.

Hincka states, “I am both excited and honored to serve as your next AHDI president. Over the last year I have had the opportunity to watch and be a part of some truly amazing things. It is inspiring to watch the evolution and expansion of the term “documentation specialist.” I cannot wait to see what’s next and share what’s already in the making, none of which would be possible without our committed AHDI board, staff, and volunteers. It will be my pleasure to serve and work with all of you as we continue to bring new opportunities for all.”

The Board of Directors elected the following individuals to serve as officers for 2022–2023, taking office September 1, 2022:

• Green, secretary;
• Julia Dyviniak, CHDS, AHDI-F, treasurer; and
• Patricia King, CHDS, AHDI-F, president-elect.

— Source: Association for Healthcare Documentation Integrity

Impact Advisors Acquires Chicago-Based C2 HEALTHCARE

Impact Advisors, a health care consultancy providing strategy, operations, revenue cycle, and technology services, has acquired Chicago-based C2 HEALTHCARE, a health care business intelligence consulting firm specializing in delivering bottom-line savings to health care organizations through a cost-based planning and productivity system. The strategic partnership will allow Impact Advisors to continue to grow and enhance its workforce innovations service line.

“We are excited to join forces with C2 HEALTHCARE because it makes sense for the need in the market right now,” says John Klare, managing partner at Impact Advisors. “Organizations are continuing to struggle with staffing pressures creating retention challenges and increased premium pay and labor expense. This strategic partnership allows us to combine talent and resources to provide a new and creative labor solution for healthcare organizations. This collaboration also demonstrates Impact Advisors’ commitment to providing a broad range of health care solutions to meet our client’s needs.”

Founded in 1998, C2 HEALTHCARE helps hospital operations improve by utilizing the existing strengths within organizations, empowering teams to make informed decisions, and increasing employee engagement and retention. The firm focuses on developing proactive management, providing timely productivity reporting, and enhancing the stewardship of organizational resources. C2 HEALTHCARE prides itself on its unique approach to creating an environment of fiscal accountability and continuous improvement by implementing the OPTIX Reporting System, a cost-based planning and productivity system.

“There is a tremendous need in the health care industry for workplace staffing solutions, so the timing is right to enter this partnership with Impact Advisors,” says David LeClercq, president and CEO of C2 HEALTHCARE. “With Impact Advisors’ clinical, operations, analytics, and IT experience paired with C2 HEALTHCARE’S expertise in training, coaching and reporting, we are the perfect combination to help clients decrease labor costs while improving quality and safety, reducing burnout, and enhancing patient experience organizationwide.”

Impact Advisors’ workforce innovation services help health care organizations improve staff engagement and retention through automating components of their clinical operations to lessen the overall burden on providers, improve care delivery, and address workload and labor factors. Through data-driven solutions focused on engagement, optimization, and automation, Impact Advisors enables clients to align supply with demand, capture efficiencies, better source, retain and manage teams, and reduce labor expense.

C2 HEALTHCARE will operate under C2 HEALTHCARE, a Division of Impact Advisors. The deal closed on August 1, 2022.

— Source: Impact Advisors