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Patient Safety and Health Information Technology E-Newsletter

May 28, 2009, Issue No. 53

Quote of the Month

"Healthcare-associated infections can make illnesses worse, further debilitate patients who are already struggling and sometimes lead to death. Through the funding provided by the Recovery Act, we can help prevent these infections and improve the quality of care for all patients." (For more details, go to item no. 1.)

—HHS Secretary Kathleen Sebelius

Today's Headlines:

HHS Secretary Sebelius highlights AHRQ reports on health care quality and disparities
AHRQ and DoD release new team training tool for hospital rapid response systems
AHRQ researchers improve diabetes care through use of automated telephone support system
AHRQ report finds most staff not reporting medical errors in hospitals
AHRQ and DoD TeamSTEPPS™ program receives special recognition
AHRQ highlights initiatives to reduce health care-associated infections
AHRQ issues new report on using health IT technologies for managing chronic illnesses
New AHRQ health IT resource for implementers of clinical decision support tools
Materials from March 31 Web conference on e-prescribing and medication management now available
Register now for AHRQ's 2009 annual conference: Research to Reform: Achieving Health System Change on September 13-16
Latest issue of WebM&M is available online
AHRQ in the patient safety and health IT professional literature-some useful citations

1. HHS Secretary Sebelius Highlights AHRQ Reports on Health Care Quality and Disparities

In a May 9 speech to the United Nurses of America, HHS Secretary Kathleen Sebelius discussed two new AHRQ reports on the quality of and disparities in health care in America and challenged nurses to work to reduce health care associated infections. The 2008 National Healthcare Quality Report and 2008 National Healthcare Disparities Report indicate that patient safety measures have worsened and that a substantial number of Americans do not receive recommended care. Upon issuing the reports, Secretary Sebelius also announced the availability of $50 million in Recovery Act resources to fight health care-associated infections (HAIs) and improve patient safety. Patient safety has declined in part because of this rise in HAIs. Secretary Sebelius also called on hospitals across America to commit to reduce central line associated blood stream infections in intensive care units by 75 percent over the next 3 years. She challenged hospitals to make use of a proven patient-safety checklist that can significantly and dramatically reduce the rate of these life-threatening infections. Select to read the HHS press release; access the reports; and read the checklist.

2. AHRQ and DoD Release New Team Training Tool for Hospital Rapid Response Systems

AHRQ and the Department of Defense have released a new TeamSTEPPS™ module on Rapid Response Systems. Designed for use by hospital teams, the module can be used to help implement team training principles that can improve care delivery and patient safety. The new module includes vignettes and customizable educational slides that provide insight into the core concepts of teamwork relevant to Rapid Response Systems. After implementing the system, hospitals have experienced a decrease in the number of cardiac arrests, deaths from cardiac arrest, the number of days in the intensive care unit and the hospital overall following heart attacks, and inpatient death rates. This new module provides an overview of the Rapid Response System and the role of the Rapid Response Team, which is composed of clinicians who bring critical care expertise to patients requiring immediate treatment while under hospital care. This evidence-based module, available in CD format, provides insight into the core concepts of teamwork as they are applied to the Rapid Response System. The curriculum can be customized to meet an institution's unique needs. Select to order a free copy of the new CD or call the AHRQ Publications Clearinghouse at 800-358-9295.

3. AHRQ Researchers Improve Diabetes Care through Use of Automated Telephone Support System

A patient-centered approach to diabetes management using an automated telephone self-management support system can help underserved populations better manage their diabetes, according to AHRQ researchers. The study, called "Improving Diabetes Efforts Across Language and Literacy," also known as the IDEALL project, is a three-arm clinical trial that compared two diabetes self-management support interventions with usual care to determine their impact on a variety of diabetes outcomes, ranging from communication with health care providers, self-care behaviors, functional abilities, and patient safety. Researchers, led by Dean Schillinger, M.D., Director, University of California San Francisco Center for Vulnerable Populations, San Francisco General Hospital, found patients who used the automated system, which was tailored to the literacy and language needs for the target population, fared better. For example, they were more involved in managing their disease, communicated better with their primary care physicians and other health care providers, demonstrated an increase and improvement in physical activity and overall physical function, and spent fewer days in bed due to illness. The system also promoted patient safety through its surveillance function and was found to be as cost-effective as other widely accepted diabetes interventions. Findings from the study are published in "Effects of Self-Management Support on Structure, Process, and Outcomes among Vulnerable Patients with Diabetes," that appears in the April issue of Diabetes Care. Select to access an abstract of the article on the IDEALL project. With AHRQ's continued support, researchers have started to expand this work in a real-world setting by implementing and evaluating a large-scale, adapted version of the automated system at a local Medicaid managed care plan. Select for more information on the new project.

4. AHRQ Report Finds Most Staff Not Reporting Medical Errors in Hospitals

On average, over half (52 percent) of hospital staff surveyed did not report any medical errors in their hospital over a 12-month period, according to a report based on data from nearly 200,000 hospital staff from 622 hospitals nationwide. The Hospital Survey on Patient Safety Culture: 2009 Comparative Database Report is an update that summarizes the latest results from hospitals that have administered the AHRQ Hospital Survey on Patient Safety Culture. Teamwork within hospital units and supervisor and manager support for patient safety are areas of strength for most hospitals, but non-punitive response to error and handoffs continue to be main areas for improvement in patient safety culture. Trend analyses found that hospitals with improvements over time in non-punitive response to error had slight increases in event reporting. Select to access the report and hospital survey. Print copies of both are available by sending an E-mail to ahrqpubs@ahrq.hhs.gov. Hospitals using the survey are encouraged to submit data to the database between May 1 and June 30; select for details.

5. AHRQ and DoD TeamSTEPPS™ Program Receives Special Recognition

The National Patient Safety Foundation (NPSF) announced it has awarded this year's Chairman's Medal to Heidi King, Director of the Department of Defense (DoD) Healthcare Team Coordination Program and Acting Director of the DoD Patient Safety Program. The award, issued last week at NPSF's Patient Safety Congress in Washington, DC, recognizes individuals who have demonstrated an ability to inspire, lead change for safer health care, and create a culture of respect, learning, and positive team dynamics. Ms. King's efforts have resulted in the successful TeamSTEPPS™ program, an evidence-based system aimed at optimizing patient outcomes and promoting a culture of team-driven care. The program, developed in partnership with AHRQ, establishes interdisciplinary team training systems to serve as the foundation for patient safety strategy. Since its launch in 2006, over 1700 trainers/coaches in the DoD and 930 master trainers through the AHRQ TeamSTEPPS National Implementation Project are assessing, planning, training or sustaining TeamSTEPPS in their organizations. Under Ms. King's leadership, the TeamSTEPPS initiative has received widespread recognition from the Joint Commission, the National Quality Forum, the Institute for Healthcare Improvement, and Centers for Medicare & Medicaid Services (CMS). Select to access NPSF's press release for more details on the award.

6. AHRQ Highlights Initiatives to Reduce Health Care-Associated Infections (HAIs)

On April 1, AHRQ Director Carolyn M. Clancy, M.D., testified before the House Appropriations Subcommittee on Labor, HHS, Education, and Related Agencies on initiatives to improve and expand health care-associated infection (HAI) prevention efforts. Dr. Clancy provided a brief synopsis on HAI infection rates and the excess costs to the health care system; discussed AHRQ projects aimed at reducing HAIs, including methicillin-resistant Staphylococcus aureus and central line-associated blood stream infections; and explained AHRQ's planned investments for addressing new, high-priority HAIs. Select to view Dr. Clancy's complete testimony. In addition, a recent Healthcare 411 podcast is on AHRQ's project to implement methods for reducing central line-associated bloodstream infections in hospital intensive care units. Hospital associations and patient safety groups in 10 states will be involved in the project. The podcast features an interview with co-principal investigator Peter Pronovost, M.D., Ph.D., from the Johns Hopkins University Quality and Safety Research Group, Baltimore, MD. Select to listen to the podcast or select to read the transcript.

7. AHRQ Issues New Report on Using Health IT Technologies for Managing Chronic Illnesses

AHRQ's National Resource Center for Health Information Technology has released a new report, titled "Innovations in Using Health IT for Chronic Disease Management," that provides an overview of the challenges faced by AHRQ health IT grantees and contractors when implementing or evaluating health IT systems to support care processes for the chronically ill. The approaches used by the various projects include clinical-decision support systems, health information exchange and disease registries, telehealth, and hospital information systems. Select to access the report.

8. New AHRQ Health IT Resource for Implementers of Clinical Decision Support Tools

To further its mission of supporting the use of health IT to drive improvements in health care outcomes, AHRQ is providing online access to the first chapter of Improving Medication Use and Outcomes with Clinical Decision Support: A Step-by-Step Guide, designed for implementers of clinical decision support (CDS) tools. Chapter 1 of this new guide outlines foundational elements for applying CDS to medication management, including:

The 'CDS Five Rights' approach (getting the right information to the right stakeholder, at the right point in workflow, through the right channel, and the right format).
Steps in the medication management cycle and opportunities for applying CDS to improve medication use and outcomes;
Current and desired future states of CDS use for medication management.
An overview of the CDS medication management literature.

9. Materials from March 31 Web Conference on E-Prescribing and Medication Management Now Available

AHRQ has made available the materials from its March 31 Web conference titled "A National Web Conference on E-Prescribing and Medication Management" on its Web site. The event, the first in a series of three teleconferences, discussed the tradeoffs involved in providing prescribing decision support when the accuracy of recommendations is mixed; the operational challenges of generating good patient histories and medication lists; the experiences working with personal health record medication lists and medication reconciliation; utilizing pharmacy fill data and claims data not only to populate patient lists but also to inform providers about their patients' behavior; and ways of impacting meaningful use within the prescribing process. Speakers also presented a conceptual model of the medication management process, with an emphasis on prescribing and key areas for improvement. Select to access the presentation transcript, slides, and recording.

10. Register Now for AHRQ's 2009 Annual Conference: Research to Reform: Achieving Health System Change on September 13-16

Register now for AHRQ's third annual conference, scheduled for September 13-16, at the Bethesda North Marriott Convention Center in Bethesda, MD. Leading authorities in health care research and policy will hold sessions on health care infrastructure, delivery of services, quality and safety, improving Americans' health status, provider performance and payment reform, and patient engagement.

11. Latest Issue of WebM&M Is Available Online

The May issue of AHRQ WebM&M is now available online. The Perspectives on Safety section highlights the business case for improving patient safety. The "In Conversation With" article features William B. Weeks, M.D., Dartmouth Medical School, Hanover, NH, who speaks about how business and economics apply to the quality and safety of care. In an accompanying article, Richard Baron, M.D., an internist in a small primary care practice in Philadelphia, PA, and chair of the American Board of Internal Medicine, offers a perspective from office practice. The Spotlight Case, titled "Delirium or Dementia," features a commentary by James L. Rudolph, M.D., Harvard Medical School, Boston, MA, who discusses issues surrounding the evaluation of altered mental status in hospitalized patients. The second case, titled "Vial Mistakes Involving Heparin," features a commentary by Tim Vanderveen, Pharm.D., Cardinal Health, Dublin, OH, discussing heparin errors in the operating room and strategies to avoid such mistakes. The third case, titled "Missing Trauma," features a commentary by Gregory J. Jurkovich, M.D., of University of Washington, Seattle, who discusses errors in trauma assessment and care. Physicians and nurses can receive free free medical education (CME), continuing education units (CEU), or trainee certification by taking the Spotlight Quiz. You can easily share AHRQ WebM&M cases by using the " email a colleague" feature.

12. AHRQ in the Patient Safety and Health IT Professional Literature—Some Useful Citations

We are providing the following hyperlinks to abstracts of journal articles describing AHRQ-funded research. If you are having problems accessing the abstracts because of firewalls or specific settings on your individual computer systems, you should ask your technical support staff for possible remedies.

Harris LT, Haneuse SJ, Martin DP, Ralston JD. Diabetes quality of care and outpatient utilization associated with electronic patient-provider messaging: A cross-sectional analysis. Diabetes Care 2009 Apr 14. Select to access the abstract

Li P, Bahensky JA, Jaana M. et al. Role of multihospital system membership in electronic medical record adoption. Health Care Manage Rev 2008 Apr-Jun; 33(2):169-77. Select to access the abstract.

Ralston JD, Rutter CM, Carrell D, Hecht J, Rubanowice D, Simon GE. Patient use of secure electronic messaging within a shared medical record: a cross-sectional study. J Gen Intern Med 2009 Mar;24(3):349-55. Select to access the abstract.

Sarkar U, Handley MA, Gupta R, Tang A, Murphy E, Seligman HK, Shojania KG, Schillinger D. Use of an interactive, telephone-based self-management support program to identify adverse events among ambulatory diabetes patients. J Gen Intern Med 2008 Apr;23(4):459-65. Select to access the abstract.

Schillinger D, Hammer H, Wang F, Palacios J, McLean I, Tang A, Youmans S, Handley M. Seeing in 3-D: examining the reach of diabetes self-management support strategies in a public health care system. Health Educ Behav. 2008 Oct;35(5):664-82. Select to access the abstract.

13. AHRQ in the Patient Safety and Health IT Professional Literature—Some Useful Citations

Handley MA, Shumway M, Schillinger D. Cost-Effectiveness of Automated Telephone Self-Management Support with Nurse Care Management Among Patients with Diabetes. Ann Fam Med 2008 Nov-Dec;6(6):512-8. Select to access the abstract.

Hinman AR, Davidson AJ. Linking Children's Health Information Systems: Clinical Care, Public Health, Emergency Medical Systems, and Schools. Pediatrics 2009 Jan;123 Suppl 2:S67-73. Select to access the abstract.

Zhan C, Elixhauser A, Richards CL Jr, Wang Y, Baine WB, Pineau M, Verzier N, Kliman R, Hunt D. Identification of Hospital-Acquired Catheter-Associated Urinary Tract Infections from Medicare Claims: Sensitivity and Positive Predictive Value. Med Care 2009 Mar;47(3):364-9. Select to access the abstract.

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Current as of May 2009

Internet Citation:

Patient Safety and Health Information Technology E-Newsletter. May 28, 2009, Issue No. 53]. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/ptsnews/ptsnews53.htm