Hospitals falling short on NQF's 30 'safe practices'
Hospitals falling short on NQF's 30 'safe practices'
Resources sometimes make progress difficult
A first-of-its-kind study of a state's hospitals and their progress in implementing the National Quality Forum's "30 Safe Practices" has yielded some interesting results and, according to the authors, opened up some new benchmarking opportunities.
The study, published in the American Journal of Medical Quality1, was completed by 100 facilities in Iowa – or 86% of the state's hospitals. The survey included a list of all 30 practices and asked respondents to rate both the priority and the progress for each practice. Here are some of the key findings:
- Overall, the hospitals gave higher ratings for priority than for progress.
- Respondents gave a higher rating for priority than progress in all but two of the practices — adhering to effective methods of preventing central venous catheter-associated blood stream infections, and evaluating each patient upon admission, and regularly thereafter, for risk of malnutrition.
- The highest progress ratings were for items involving hand washing, unit-dose medication dispensing, influenza vaccinations, implementing protocols to prevent wrong-site procedures, and standardized methods for labeling and storing medications.
- The lowest progress ratings were for intensive care units staffed by intensivists and implementing a computerized order entry system (CPOE).
The authors say these findings can provide a benchmark for hospitals to see how their peers rate priorities and progress in each of these areas. "Hospitals should make their own ratings and see how they compare,"1 they recommend.
They also say the findings can help hospitals choose which of the practices are most suitable for targeted QI efforts. "For example," they write, "The current findings suggest that progress on intensivist staffing of ICUs will be hampered if the supply of appropriately trained physicians is low in an area, as is the case in most rural areas in the United States."1
No lack of will
That's exactly the case in Iowa, notes Thomas C. Evans, MD, president and CEO of the Iowa Healthcare Collaborative in Des Moines, and one of the authors of the article. "Our ICUs are not staffed 24/7 [by intensivists]," he shares. "The respondents are not saying that this [safe practice] isn't important, or that they don't want to be farther along with CPOE; we all want to do this, but there's no way we can go there. We are 50th in the country, for example, in Medicare reimbursement."
Interestingly, he continues, the study's findings mirror those of a private study conducted by the University of Iowa's College of Public Health. "We looked at the application of the three key Leapfrog Group initiatives [computer physician order entry, intensive care unit physician staffing and evidence-based hospital referral]," he recalls. "In terms of CPOE, people thought we all needed to go there, but it's such a big leap they can't even conceive of it. Also, it won't be successful before you have cleaned up your processes, so we need to walk a little slower on that."
Realism is important
As for designated referrals, Iowa is one of the lowest-ranking states in terms of physicians per capita, "So we do not have the luxury of creating a competitive environment," Evans asserts.
"24/7" coverage of ICUs "sounds wonderful," he admits, "But when you take all the intensivists in Iowa, you might be able to staff two of our hospital ICUs 24/7."
In other words, says Evans, safety goals like those established by the Leapfrog Group are laudable, but it's important to know what your limitations are before judging your facility too harshly. "Each of those 'leaps' they chose is supposed to be some great bound forward," Evans explains.
"They are challenging us not to be about evolution, but revolution. They are a big climb for almost everyone, but if you take a rural state with a geographically dispersed population and a resource challenge, those three leaps have limited applications to that environment."
Remember the basics
In terms of CPOE, for example, all Iowa facilities are working toward that goal, but "You have to deploy 'gazillions' of dollars of software, and that's something these hospitals don't have," says Evans. In fact, he adds, "I don't know of one place that has completely implemented CPOE."
One thing all hospitals can do, he continues, is to pursue the basics of a safe culture. "First, you must break down the walls between physicians, nurses, and the pharmacy," he advises. "Communicate your common goals, and then engage them all in the process."
To create a culture of safety, says Evans, means defining your culture, and creating a safe environment where people actually talk to each other. "And when something goes wrong, instead of assigning blame, they talk about how to keep it from happening again," he says.
"Once you have been able to define a safe culture, have communicated it to your staff and have everyone beginning to understand what it means to be part of such a culture, you have to find ways of measuring it — which reinforces the culture going forward," Evans observes.
For more information, contact:
Thomas C. Evans, MD, Pres/CEO Iowa Healthcare Collaborative, Des Moines. Phone: (515)283-9347.
References
- Ward MM, Evans TC, Spies AJ, Roberts LL, Wakefield DS. National Quality Forum 30 safe practices: priority and progress in Iowa hospitals. Am J Med Qual. 2006;21:101-108.
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