official publication of the california association for ... · official publication of the...

CAHQ JOURNALCAHQ JOURNAL Official publication of the California Association for Healthcare Quality

Spring Conference brochure on page 35

Spring Conference brochure on page 35

Rapid Response Teams Run, Don’t Walk...Rapid Response Teams Run, Don’t Walk...

Business Case For Patient SafetyBusiness Case For Patient Safety

Volume 32, Number 1 1st Quarter, 2008

2 CAHQ Journal, Quarter 1, 2008

2007-2008 CAHQBoard Of Directors

President .................................................................................................................................. Julie BoothPresident-Elect .......................................................................................................................Tricia KassabImmediate Past President ...................................................................................................... Ruth CountsSecretary ................................................................................................................................... Val EmeryEducation Co-Chairs ...............................................................................................................Tricia West

........................................................................................................Jada SalamatianTreasurer .......................................................................................................................... Marcie CochranMembership Chair .................................................................................................................. Laura MarxNominating Chair ................................................................................................................. Judy PugachJournal Co-Chair ..................................................................................................................... Pat Lucken

.................................................................................................................... Kathy ChaiFinance Manager.................................................................................................................Janet MarondeAssociation Manager ..............................................................................................................Hellen GattiWebsite Master ..........................................................................................................................Paul Kittle

.....................................................................................................................Gilbert AbellaCPA .......................................................................................................................................... Jim Miller

CAHQ JournalCAHQ Journal is published quarterly. It is the official publication of the California Association for

Healthcare Quality and is a referred journal. Opinions expressed in signed articles or features are those of the author and do not necessarily reflect the views of CAHQ. CAHQ reserves the right to edit mate-rial and to accept or reject contributions whether solicited or not. Advertising in CAHQ Journal does not imply endorsement of products or services. Letters to the Editor, comments, suggestions and requests for information should be addressed to:

Kathy Chai, [email protected]

Pat Lucken, [email protected]

CAHQ Journal Editorial Staff

Catherine Carson-MartinMarilyn Drone

Tricia KassabPamela J. Simpson

mailto:[email protected]


http://www.colinmacgregor.com/

CAHQ Journal, Quarter 1, 2008 3

VisionWe will be recognized as a leader in healthcare quality

and patient safety. As a leader, we will:

• Identify and advance best practices

• Promote professional development

• Influence industry trends

Values• Excellence

• Integrity

• Diversity

• Collaboration

• Professional Growth

• Continuous Improvement

MissionThe mission of the California Association for Healthcare

Quality is to develop and promote the healthcare quality

professional through:

• Education and Resources

• Networking

• Leadership in the Industry


Table Of ContentsMessage From The President

Julie Harmata Booth MS, CPHQ, RHIA•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 6

Messages From The Co-EditorsKathleen Tornow Chai MSN, PhD, CPHQ, FNAHQ & Pat Lucken RN, MSN, FNP-C, CPHQ•••••••••••••••••••••••• 6

Welcome to New CAHQ Members•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 9

The Business Case for Patient SafetyHighlights the benefits of an investment in patient safety initiatives, as well as presents the consequences of not placing

enough emphasis on patient safety.

Fabio Sabogal, PhD., Lumetra, Allison Snow, MHA, Lumetra & Linda Sawyer, PhD., RN, Lumetra••••••••••••••••••••10

NAHQ UpdateThe latest information on NAHQ, including info on the new officers for 2008 and the NAHQ Fellowship Program.

National Association for Healthcare Quality••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 16

Bridging the Gap in Emergency Cardiac CareDiscusses the advances in emergency cardiac care from as far back as twenty years ago.

Brian Hendrickson, EMT-P•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••17

Rapid Response Teams—Run, Don’t Walk...The Rapid Response Team at St. Mary’s Medical Center is an excellent model for other RRTs.

Pat Lucken RN, MSN, FNP-C, CPHQ•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••22


Rapid Response Teams—Another Organization’s ExperienceDiscusses the Rapid Response Team at Kaiser Permanente West Los Angeles.

Kathleen Tornow Chai MSN, PhD, CPHQ, FNAHQ• •••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••25

Destination Quality—Take The Ride!Spring Conference 2008 Brochure. Includes presenter biographies, registration information, conference hourly agenda and

conference registration form.

March 10–12, 2008•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••35

The bottom Line: Gifts That Keep GivingThe heartwarming story of the events surrounding Christmas at st. Mary’s Medical Center.

Pat Lucken RN, MSN, FNP-C, CPHQ•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••46

Authors BiographiesBiograhies for the authors who contributed to this issue of the journal as well as inadvertently omitted biographies from

previous journal.• •••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••48

California association for Healthcare Quality 2007 Author/Article Index A guide to to the authors and articles for the four CAHQ journals from 2007.•••••••••••••••••••••••••••••••••••••••••••49

Save These Dates!Upcoming CAHQ event dates and information.•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••56

CAHQ Membership Application•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••57


A Message from the President:

Always Striving

Messages from the Co-Editors:

Julie Harmata Booth MS, CPHQ, RHIA

Those of us working in health care

quality have some of the most fascinat-

ing and yet challenging jobs in the

world. We deal with issues that abso-

lutely need more oversight and attention

for the betterment of all who need care.

Take, for example, our past issue of

the Journal. There, a reader could find

articles on EMS Grand Rounds, Pain

Management, Dealing with Pressure

Ulcers, and the Health Care Quality

of Older Women. We’re dealing with

it all, striving to improve the care that

our family, friends, and neighbors may

experience within their local setting.

During my year as president, I’ve

been able to meet many new people,

and incorporate many ideas and in-

novations in the way quality issues

are handled at my own organization.

In thinking about this past year, I’ve

recalled all the wonderful times when

I’ve had an “aha” experience, whether

it was at a Harvard colloquium or chat-

ting over coffee with a colleague in a

local café.

THIS IS THE LAST ISSUE of the CAHQ Journal during my year as president. I will miss being part of this fine group of individuals who, as our vision states, work toward identifying and advancing best practices, promoting professional deve-lopment, and influencing industry trends.

Kathleen Chai

I’ve also been disheartened this year

over the many challenges to the good

work that’s already been done in the

quality arena. The greatest challenges

perhaps has been the increasing alarm

over methicillin-resistant staphylococ-

cus aureas (MRSA) infections, venous

thromboembolism (VTE), diabetes and

kidney disease . All of these will take a

uniformed team process to control.

In my new role as past-president, I’ll

look forward to continue the effort we

are all putting forward, always striving.

Excelsior!

✦

I am not sure how many of you

remember my last editorial but I wrote

it a few days before leaving on a long

cruise in Asia with my Mom. I was

excited and frantic over what had to be

done before leaving, but looking back,

I am very happy I made the decision I

did.

21 days included trips to Bangkok,

Singapore, Hong Kong, Viet Nam,

Nagasaki, Shanghai, and Beijing.

What a trip! It was my first cruise,

and I am now convinced it’s the only

way to travel. I spent almost 10 hours

with my daughter in Shanghai. I will

never regret spending time with my


mom, even though it was not always

easy in a 12X12 room. We laughed,

hit the bars together, played Bingo and

had a once in a lifetime vacation. I felt

overwhelmed when I returned to work

and the feeling still has not subsided.

But, the holidays came and went and

I have not panicked. Things at work

go on as they always have, always too

much to do and too little time. One

thing that surprised me

about the trip was how

much my medical and

nursing skills came in

handy. The first day of

the cruise, I heard an

overhead emergency call

at 5am that told me we

had a medical emer-

gency. From what I saw

after that, it seemed that

someone had a cardiac

arrest and we were 12

hours from port. I don’t know what

happened but did find out that the

medical crew was with the patient until

we got to port. The same day it became

apparent that there was an effort to

control the spread of infection. All of a

sudden you saw waiters with gloves on.

Unfortunately as I watched them I no-

ticed that they were going from clean to

dirty and dirty to clean. I felt like I was

prepping someone for JCAHO again!

I spoke with the steward and within

24 hours the practice changed-and that

was a very big ship. I found out later

that we had the dreaded Norovirus

that occasionally affects ship and crew.

Hand sanitation was required prior

to each meal (yes, they watched) and

frequent handwashing was encour-

aged. One of our tablemates told us of

her 48 hour confinement to her cabin

on the first 2 days of the cruise. It was

enlightening.

I saw multiple people with black

eyes, stitches and splints, and even

casts throughout the cruise. I could not

believe all of the medical emergencies

I saw or saw the results from. I decided

that from now on, I

need to travel when I

am fit and able to do

so. Two final experi-

ences made that my

motto. The first was

as we were going into

port in Singapore. We

were all lined up on

the stairs; waiting to

disembark and one of

the ladies in front of me

fell down 2 stairs and

lay on the landing. Her husband and I

rushed to her and as he lifted her flaccid

leg, I could tell her leg was broken. I

asked him to put it down, called 911

on the ship phone and waited for help

to arrive. Crew members were standing

around by that time and I asked them

to get some ice, but they did not re-

spond. I found out later that the cruise

line had recently been sued, and the

current protocol was not to intervene

until a medical person was available.

This reminded me of what sometimes

happens in healthcare organizations.

The last episode took place the day

we were leaving, on our way to the

airport. We were in Beijing, and as a

group was walking out through the

automated door of the hotel, one lady

who had been using a cane during the

cruise, was caught by the automatic

door and fell. As the crowd gathered, I

knelt down and spoke to her. She knew

she had broken a hip, but really wanted

to go home. I told her that would not

be possible and also shared that my

daughter received medical treatment in

Beijing and it was excellent.

All of this has a number of lessons

for me: 1. Take the time to experience

things that you may never experience

again. 2. Nursing is never far away-

whenever you need the information,

it comes back and you remember how

good it is to have that information. 3.

Do what you can do while you are still

able. There is no time to waste! Those

of us who know we will be retiring in

a few years, owe it to the profession of

nurses and other quality managers to

impart what we know and share the

benefit of our experience.

Thanks for listening. Kathy Chai

[email protected]

✦

My daughter and I


In the quest to attain great

quality outcomes, one cannot afford to

lose sight of the need to also create more

humane, holistic and caring centers of

healing.

St Mary Medical Center, Apple Val-

ley, CA, is a ministry of the St Joseph

Health System (SJHS) of Orange Cali-

fornia. One of our three system-wide

strategic goals are, Perfect Care. Perfect

Care means that every patient receives

the care they need every single time.

Another goal is focused on healthi-

est communities. A priority focus is

addressing childhood obesity. Finally,

we strive to create every encounter as

a sacred encounter. Sacred encounters

include the following traits as de-

scribed by the St Joseph Health System

(McPherson, 5/17/2007).

“S Sensitive and open to the sacred in

our midst

A Attentive to the needs and concerns

of others

C Compassionate interactions distin-

guishes our community

R Respectful and open to the differ-

ences and similarities of all people

E Engaged and enthused employees

and physicians

D Dignity-our core value-is embod-

ied by all within the St. Joseph Health

System.”

This movement is yet a ripple and

hope of what the future may be. Some

of those early ripples are having our

support group participants share their

stories with each other at our an-

nual holiday lunch with staff, who also

shared stories. One shy patient con-

fessed later to me that she felt guilty not

sharing with the crowd of 165 people. I

told her she had already shared because

I used her thoughts in a story to the

group that day. We encouraged her to

journal her thoughts and later received

a beautiful letter from her.

One of our cardiac rehab patients

with Parkinson’s disease also cares for

his elderly wife. His legs have recently

become too weak to attend cardiac

rehab and his doctor is recommending

physical therapy. He just purchased a

new car. He most likely will be unable

to return to cardiac rehab. He has

come to us for years. Each Wednesday

is donut day and he brings us donuts

without fail. He told staff it was okay

to share his condition with others with

just one stipulation, that they share

his phone number with them so he

could hear from those he usually saw at

exercise. I would describe each of these

touching moments as sacred encounters.

I recall a story from my past when

I cared for a woman in the ED who

experienced a miscarriage. Years later by

chance, I met that patient’s aunt. The

aunt had kept my name written on a

little piece of scrap paper in her wallet

all those years to remember my kind-

ness to her niece. The feeling of that

moment she shared with me will remain

with me forever. I felt so humbled that

the care received was remembered by

a family member years later and long

after I could recall any specific details. I

call that a sacred encounter.

I am interested in hearing how your

agencies are improving the quality of

care received and also the recipient’s

perception of care. Are you finding

innovative ways to connect to your

patients and their loved ones? I hope

2008 is a year for CAHQ to collaborate

and to partner more with our member-

ship body. I hope you will reach out

and share.

I hope to see many of you at our an-

nual CAHQ Spring Conference

✦

A Revolution of CaringPat Lucken, RN, MSN, FNP-C, CPHQ

Pat Lucken


Annette Adams

Phyllis Adams

Amy Ando

Carla Balog

Connie Benson

Kathleen Billingsley

Lori Ellen Brown

Kathleen Burger

Cynthia Cadwell

Veva E. Caldera

Chrysi Canerday-January

Shirley Chaney

Rick Coate

Jennifer Collins

Emesilia Daco-Cueallo

Martha Delgado

Deborah Doherty

Mary Ann Doran

Melanie Eller

Myra Enloe

Mary Ferguson

Rachel Fujii

Andrea M. Galante

Debra Garduno

Pamela George

Sandra L. Gradillas-Spaich

Linda Gregg

Crystal Haenggi

Elizabeth Haren

Rami Hasan

Carlos Hernandez

Sandra Hernandez

Carolina Hiranand

Arlene Ison

Anna Jaffe

Patti James

Cara Jenson

Angela Johnson

Janet Johnson-Yosgott

Betty Jones

Gauri Joshi

Shela Kaneshiro

Darina Kavanagh

Paula Keiser

Sarna Kolvan

Rose Krantz

Lynne Langholz

Kristi Larsson

Susan Lasota

Pamela Loo

Kris Ludington

Cornelia Malicse

Anne Marder

Julie Martin

Diana Matthews

Brian McAlister

Vickie Medlen

Gail Mercer

Yvette Million

V.S. Mitchell

Cashmere Monroe

Charmaine M. Mosher-Carbiener

Lisle Mukai

Kathy Murray

Dana Palacio

Mary Rose Palma-Samela

Martin F Peavey

Barbara Pelletreau

Anne Peterson

Rogene Pinasco

Robert Porath

Paula Radell

Gloria Redden

Blaire Richardson

Mary G. Ross

Connie Rowe

Lori Ruiz

Cristina Salas

Deborah J. Scaife

Janet Schmitt

Terry Schroeder

Yali Shu

Kathy Simmons

Holly Smith

Cindy Snelgrove

Jaspreet Sodhi

Melody Soles

Darlene L. Solis

Heather Van Housen

Tamera Vingino

Kathleen M. Wannemacher

Gay Wayland

Susan White

Valerie Winter

Robin Zudell

Welcome, to all of the new CAHQ members!


The Business Case for PaTienT safeTy

Fabio Sabogal, PhD. Allison Snow, MHA Linda Sawyer, PhD, RN

LumetraInvesting in patient safety initiatives makes good business sense. Proactively investing in error-reduction initiatives provi-des a hospital with a strategic business position to compete in the marketplace. Demonstrating the case for patient safety helps California hospitals to prioritize investments that foster the delivery of safe, efficient, and high quality care. This ar-ticle presents the dramatic costs of patient safety violations, shows the benefits of patient safety interventions, and high-lights the directions where safety leaders are investing in cost-effective, evidence-based patient safety solutions.

1. The Economic Burden of Patient Safety Violations and Medical Errors

Medical errors are prevalent, expen-

sive, and often preventable. Consider

this case: “A Denver hospital gave a

newborn infant a tenfold overdose of

penicillin in case it had been infected

with syphilis from its mother. Nurses

balked at giving the baby five injec-

tions so administered the medicine in

what turned out to be an unusual and

improper way—intravenously. The baby

died, and the autopsy showed it did

not have syphilis and never needed the

treatment in the first place.”1, 2

Medical errors affect a hospital’s

bottom line. Accidental deaths and

serious injuries compromise patient

care, increase economic burden, im-


pair profitability, and weaken organi-

zational performance and staff morale.

Hospitals suffer substantial personnel,

regulatory, marketing, and legal costs

because of medical errors and patient

injuries. It is estimated that within

U.S. hospitals, medical errors could

unnecessarily cost the healthcare

system between $17 to $29 billion

annually causing up to 98,000 deaths

per year.3, 4

Costs of adverse drug events are

a major economic burden to hospi-

tals. Patient injuries resulting from the

medication process alone are one of the

most common types of medical errors.

Nationwide, at least 1.5 million prevent-

able adverse drug events occur in the

United States each year causing 106,000

deaths annually.2, 5, 6 In the hospital

setting, between 380,000 to 450,000

patients experience a preventable

adverse drug event adding about $3.5

billion per year to total hospital costs.2

Medication errors occur throughout the

entire process, but are most common in

the ordering and administration phases.

This is especially true among pediatric

care in hospitals.

Adverse drug events increase risk

of injury and mortality. Adverse drug

events (ADEs) double the risk of death.7

Serious ADEs are the fourth leading

cause of death.8

Preventable adverse drugs events

increase length of hospital stay.

Patients who experience ADEs are

hospitalized an average of 8 to 12 days

longer than patients who do not suffer

these events, and their hospitalization

costs $16,000 to $24,000 more. The

ADE Prevention Study estimates that

the additional length of stay associated

with a preventable ADE is 4.6 days,

with an increase in total cost of $8,750

in 2006 dollars.2, 9 The annual costs

attributable to preventable ADEs for a

700-bed teaching hospital result in an

additional $2.8 million per year.9

Hospital admission costs related to

a previous ADE increases economic

burden. Hospital admissions due to a

previous ADE are expensive, mostly se-

vere, and often preventable.10 A study in

one tertiary care hospital found that 1.4

percent of admissions were caused by a

previous ADE with estimated costs of

$16,177 per ADE, $10,375 per prevent-

able ADE, and $1.2 million per year for

preventable ADEs.10

Emergency room costs related to

a previous ADE are considerable. A

cost analysis of drug-related illnesses

associated with visits to a 560-bed

teaching hospital emergency depart-

ment found an estimated 66 percent of

preventable ADEs with $391,342 in an-

nual Emergency Department (ED) and

hospital costs in 1994.11 The previous

costs of treatment among those with a

preventable ADE were $308 for those

who were not hospitalized and $2,752

for those who were.11

Emergency department adverse

drug events are preventable and

costly. In a study of preventable

medication-related emergency depart-

ment visits, of the 253 patients inter-

viewed, 71 patients (28.1 percent) had

a medication-related visit.12 Of the 71

patients, 50 (70.4 percent) were prevent-

able with an average cost of $1,444 per

each preventable medication-related

visit.12

Hospital-acquired infections are

substantial and compromise the bot-

tom line. About two million people

annually acquire an infection at U.S.

hospitals at a total cost of more than

$4.5 billion.13, 14, 15 Mortality associated

with hospital-acquired bloodstream

infections is 23.8 percent to 50 percent

and 14.8 percent to 71 percent for

pneumonia.14 The excess length of stay

due to these infections is one to four

days for urinary tract infections, 7 to

8.2 days for surgical site infections, 7

to 21 days for bloodstream infections,

and 6.8 to 30 days for pneumonia.14

The estimated average cost is $2,734 for

each surgical site infection, $3,061 to

$40,000 for each bloodstream infection,

and $4,947 for each pneumonia.14 Hos-

pitals lose from $583 to $4,886 for each

hospital-acquired infection.14 MRSA, a

type of bacteria (Staphylococcus aureus)

resistant to many antibiotics, is a major

healthcare-acquired infection. In fact,

26.6 percent of patients with MRSA are

hospital-onset associated.16

Medical errors have major financial

impact. Hospitals are major targets

of personal injury lawsuits. Patient

safety initiatives mitigate medical errors

preventing financial losses associated

with these events. Patient safety viola-

tions consume additional resources

since hospitals have to pursue litigation

defense, paying awards and settlements.

The average claim related to liability

for an adverse drug related event is

estimated to be between $376,00017 and

$668,000.18 A study found that claims

for ADEs were in excess of $19 million

for the 10-year period of the study.17 In

an ADE study of the Veterans Adminis-

tration (VA) facilities, 37 percent of tort

claims resulted in payments that aver-

aged $138,800.19 Another study found

40 cases of wrong-site surgery among

1,153 malpractice claims.20

Malpractice litigation affects

hospitals, providers, and patients.

Malpractice litigation has substan-

tial effects on hospitals and providers

including lost practice time, damage to

reputation, emotional stress, and insur-

ance losses.17 Providers may perceive

malpractice litigation as a barrier for

reducing errors.21, 22 Similarly, patients

suffer financial, physical, and emotional

consequences because of medical errors

and litigation.

Organizational Benefits of Investing in Patient Safety Initiatives

Areas Impact of Patient Safety Violations Impact of Patient Safety InitiativesFinancial Decrease profit margins•

Increase direct and indirect costs•

Threat to organizational survival•

Decrease costs•

Prepare for pay-for-performance •

Increase capacity and infrastructure•

Clinical Compromise quality of care•

Reduce organizational performance•

Promote variability in service delivery •

Increase inappropriate care•

Promote costly duplication of services•

Improve clinical quality indicators•

Increase adherence to care guidelines•

Provide better patient care•

Increase workflow efficiencies•

Enhance process design•

Technological Use paper-based patient chart that was •

developed over 100 years ago

Write illegible and incomplete orders fraught •

with errors

Decrease medication errors •

Support coordinated care management•

Optimize access to clinical data•

Increase ability for electronic ordering•

Culture Promote a “blame” culture •

Increase fear of error disclosure•

Foster a culture of safety •

Maximize error interception•

Legal Consume additional resources pursuing •

litigation defense, paying settlements and

awards

Avoid exposure to liability•

Increase documentation accuracy•

Reduce insurance premiums•

Legislation Potential sanctions and litigation• Comply with patient safety standards•

Human

Resources

Increase recruitment costs of scarce human •

resources

Compromise employee morale•

Reduce patient and family satisfaction•

Increase provider and patient satisfaction•

Increase provider-patient communication•

Higher productivity with efficient process•

Ease provider recruitment•

Measurement Threaten transparency and accountability•

Reduce provider and system feedback•

Delay patient safety improvement•

May compromise HIPAA requirements•

Enhance surveillance and monitoring•

Prepare for public reporting•

Enhance benchmarking and goal settings•

Increase patient confidentiality•

Marketing Tarnish reputation and brand identity•

Decrease public confidence•

Decrease new business initiatives•

Build good will and reputation•

Elevate brand image and differentiation•

Increase revenue by bringing new patients•

Accreditation

Stakeholders

Increase regulatory costs •

Duplication of efforts and messages•

Uncoordinated safety requirements•

Maintain accreditation•

Simplify HIPAA compliance•

Align with other organizations•


2. Patient Safety Interventions Make Good Business Sense

Hospitals that are investing in patient

safety decrease costs, improve clinical

quality indicators, increase workflow

efficiencies, and avoid exposure to mal-

practice litigation. The following table

presents a summary of organizational

costs and potential benefits of patient

safety practice initiatives over multiple

organizational areas.

The benefits of creating safe operation

of systems and processes that mini-

mize errors and accidental injury are

substantial:

Patient safety initiatives increase

efficient workflow redesign and

provider time for patient care. Safety

culture and workflow redesign initia-

tives streamline clinical processes and

decrease administrative time. Health-

care providers and patients often report

positive satisfaction levels in highly

efficient healthcare systems. Increased

workflow efficiencies result in less time

for administrative and redundant tasks,

and more time for patient care.

Patient safety and quality improve-

ment interventions make good busi-

ness sense. A pilot project conducted

by Virginia Health Quality Center

(VHQC)-RAND for the Centers for

Medicare & Medicaid Services (CMS)

concluded that electronic health

records, patient registries, reminder sys-

tems, and standing orders save money

and improve clinical outcomes.23 These

quality improvement interventions can

decrease costs, increase revenues, and

lead to increased profitability.

Patient safety initiatives establish

infrastucture to facilitate evidence-

based care. Research has documented

considerable savings from adherence

to evidence-based quality and patient

safety guidelines. Clinicians are more

likely to promote evidence-based care

and achieve better clinical outcomes

and patient satisfaction. Systems

improvement increases a hospital’s

bottom line, reduces staff turnover, and

produces better care.

Safer practices foster better com-

munication, care coordination, and

patient outcomes. Safer clinical proce-

dures improve provider-patient com-

munication, reduce fragmentation of

care, and produce better clinical health

outcomes. Also, higher patient satisfac-

tion is associated with perceptions of

safer procedures, physician communica-

tion, and team coordination.30, 31, 32

The Business Case for Quality and Patient Safety in Hospitals: A Pilot Study

Patient Safety and Quality Improvement Pilot ProjectSystem Change Strategies are Cost-effective in Hospitals. Standing orders, clinical pathways, fast track protocols, and •

comprehensive case management systems reduce the average length of stay, improve clinical outcomes, increase patient

satisfaction, and produce annual savings that range from $15,000 to $187,000.23

Standing Orders and Clinical Pathways. A large, acute-care hospital invested $3,674 to develop and implement a set •

of standing orders and clinical pathways for its 400 acute myocardial infarction (AMI) patients each year. This process

change has reduced the average length of stay, resulting in a financial benefit of $53,000 annually.23

Fast Track Protocol. Heavily publicizing a new fast track protocol for patients with chest pain allowed an acute care •

hospital to admit additional patients while reducing average length of stay (ALOS), increasing patient profits by nearly

$135,000 annually and reducing the hospital’s exposure to denials of payment for unnecessary admissions.23

Clinical Pathways. Creating a set of clinical pathways allowed one hospital to ensure that its pneumonia patients receive •

antibiotics more quickly. This intervention resulted in a sizeable average length of stay reduction and staff efficiencies,

saving the facility more than $30,000 annually.23

Comprehensive Case Management System. One urban medical center developed a comprehensive case management •

system for pneumonia patients, involving standing orders, physician reminders, and patient education resulting in

$187,000 in annual cost savings as a result of an average length of stay reduction.23

Source: Virginia Health Quality Center. Quality Makes Good Business Sense. Key Findings From

The Making the Case For Business Benefits of HCQIP Projects.” Special Study, 2003.


Savings from Adherence to Evidence-Based Quality and Patient Safety Guidelines

Condition Reported Cost SavingsHeart Failure In patients with a diagnosis of heart failure, exposure to angiotensin converting enzyme (ACE) •

inhibitor therapy is associated with fewer hospitalizations and lower total costs (mean $2,397) than

no ACE inhibitor therapy.24

Pneumonia Effective pneumonia treatment - early initiation of antibiotic therapy in the emergency department and •

the use of a case manager responsible for evaluating adherence to practice guidelines - resulted in a

cost savings of $267,410 in a sample of 143 patients.25

Surgical

Complications

Patients who develop surgical site infections have longer and costlier hospitalizations than patients •

who do not develop such infections. They are twice as likely to die, 60 percent more likely to spend

time in an intensive care unit, and more than five times more likely to be readmitted to the hospital. The

median direct costs of hospitalization were $7,531 for infected patients and $3,844 for uninfected

patients. The excess direct costs attributable to surgical site infections were $3,089.26 Programs that

reduce the incidence of surgical site infections can substantially decrease morbidity and mortality and

reduce the economic burden for patients and hospitals.26

Acute

Myocardial

Infarction

As a result of the paper-based reminder system stressing CMS quality performance measures for •

AMI, including early administration of aspirin and beta blockers, smoking cessation counseling, and

administration of ACE inhibitors and aspirin on discharge - one facility was able to decrease the

average length of stay for AMI patients by 0.51 days and improve its quality performance measures.

Assuming a hospital can save approximately $450 in incremental costs for each day subtracted from

the end of a stay, this change saved the facility $1,607 per month due to the average length of stay

reduction.23

Reducing Staff

Turnover

Staff turnover compromises patient safety. In fact, the Joint Commission has concluded that actions •

taken to increase nurse retention improve the business case for patient safety interventions.27 The

Advisory Board estimated an annual $800,000 savings for a 500-bed hospital that reduced staff

turnover rates from 13 percent to 10 percent.28 In addition, the Voluntary Hospital Association (VHA)

has estimated that an average hospital spends $5.52 million per year on turnover costs and that a

reduction in turnover of 20 percent to 15 percent would result in an average savings of $1.38 million

per year. Organizations with high turnover rates (≥ 21 percent) had a 36 percent higher cost per

discharge when compared to those hospitals with a lower turnover rate (>≤ 22 percent). Hospitals

with lower turnover rates (4-12 percent) had a 6 percent higher return on assets when compared to

hospitals with higher turnover rates (> 22 percent).29

Safer hospitals enhance reputation

and protect brand name. Hospitals

can capitalize on an improved reputa-

tion and enhanced community image

by showing superior quality perfor-

mance. Proactively investing in patient

safety enhances prestige and protects

brand names. Hospitals that empha-

size the provision of high-quality,

safety, and efficient healthcare services

attract new patients generating better

revenues.33, 34 They increase reputation,

community image, and have satisfied

patients.35 Organizations can capitalize

on reputation by disseminating superior

quality performance.35 Therefore, proac-

tive investing in patient safety could

enhance prestige, protect brand names,

improving patient volume and high-

quality providers.35

Investing in safety culture im-

proves human capital, which

improves provider and patient satis-

faction. Safer hospitals improve patient

volume, retain high-quality providers,

and enhance satisfaction generating

increased revenues. Hospitals that in-


vest in safety cultures are more likely to

recruit and retain high-quality employ-

ees. Because patient safety culture and

office-redesign initiatives can stream-

line clinical processes, reduce medical

errors, and decrease administrative

time, healthcare providers and patients

frequently report positive satisfac-

tion levels with use of such systems.36

Increased patient safety standardization

and efficiencies can result in less time

for administrative and redundant tasks,

more time for patient care, and increase

patient satisfaction.

On the other hand, unsafe hospi-

tal practices make it more difficult

to recruit clinical staff. Unsafe work

environments and inefficient clinical

processes are unattractive for health-

care workers. Patient safety violations

increase recruitment costs, affect

employee morale, and reduce provider

satisfaction. Medical errors also make

it more difficult to attract high-quality

staff. Turnover compromises coordina-

tion of care, increases stress on exist-

ing staff, and negatively affects patient

safety and outcomes. Not surprisingly,

there is public dissatisfaction with

healthcare safety and quality. In a 2004

national survey, half of patients are wor-

ried about the safety of their care, and

55 percent said that they are currently

dissatisfied with the quality of health-

care.37 Forty percent believe that the

quality of healthcare has “gotten worse”

in the past five years, whereas only 17

percent think it is better.37

Investing in patient safety technol-

ogy reduces serious medical errors

and produces positive return on

investment. “Wired hospitals” have

higher productivity, better control of

expenses, and more efficient utiliza-

tion management than non-wired

hospitals. Electronic healthcare record

systems maximize access to informa-

tion, increase workflow efficiencies,

support fully-integrated patient care,

provide population management, sim-

plify HIPAA compliance, and prepare

for pay-for-performance initiatives.

Health information technology return

on investment is positive with increas-

ing gains depending on the level of

functionalities. Consider the following

statistics:

Clinical Decision Support Systems Increase Healthcare Quality and Patient Safety

Condition Reported BenefitsReduce Medication

Errors

A clinical decision support system in conjunction with a CPOE produced a 83 percent reduction

in serious medication errors at an academic medical center.33, 40

Improve Preventive

Care

Computerized reminder systems increase the use of preventive services and are more cost-

effective than non-computerized reminders. Two meta-analyses showed that reminder systems

improve clinicians’ use of blood pressure assessment, Papanicolaou tests, vaccinations, and

colorectal and breast cancer screenings exams.41, 42

Improve Management

Care and Quality

Clinical information systems are effective in supporting provider and patient reminders and in

assisting with patient education and treatment planning. A review of 98 randomized clinical

trials to assess the clinical value of computerized information services found that provider

prompts and patient reminders, and computer-assisted patient education and treatment planning

were significant interventions to improve clinical outcomes.43

Reduce Drug Cost Because physicians have access to evidence-based information through Electronic Health

Record systems, they can reduce medication costs. In a study, researchers estimated that

6-month savings from new prescriptions and refills were about $3,450 per clinician.44

Improved Drug

Administration

In a 650-bed community teaching hospital during a 6-month period, a computer alert

system fired 1,116 times: 596 were true-positive alerts (53 percent).45 These alerts identified

opportunities to prevent injury at a rate of 64 per 1,000 admissions. A computer alert system

can effectively prevent injury from adverse drug events.45

Other Benefits Decision support systems can also reduce length of stay and decrease time needed for ordering

appropriate treatment.34, 46


A study estimated a net benefit ••

from using an EHR system for

a five-year period at $86,400 per

provider.38 The financial benefit of

implementing an EHR system was

positive in the long run.

A study of a 40-physician ambula-••

tory care medical group found an

estimated net present value for the

EHR system of $279,670.39 Finan-

cial benefits come from savings in

drug expenditures (33 percent),

improved utilization of radiology

tests (17 percent), improvements

in charge capture (15 percent),

and decreased billing errors (15

percent).38

Other clinical support technolo-••

gies in conjunction with a Com-

puterized Physician Order Entry

(CPOE) system produced an 83

percent reduction in serious medi-

cation errors with savings of $5

million to $10 million annually.33, 40

Investing in patient safety initia-

tives improves performance measure-

ment and public reporting. Safer

hospitals improve performance mea-

sures and incident reporting systems.

There is a national movement toward

incident reporting systems, publicly

reported measures, and pay-for-perfor-

mance initiatives that is accelerating the

implementation of patient safety initia-

tives. The core of this movement is the

concept of transparency, accountability,

and measurement.47 The process of

developing, validating, standardizing,

reporting, and providing feedback to

healthcare providers is creating mo-

mentum among hospitals, purchasers,

providers, safety organizations, and the

general public.47

Hospitals that accelerate incident re-

porting systems and performance-based

measures using the following principles

designed by the Institute of Medicine

will be successful in patient safety stan-

dard reporting requirements:

Comprehensive measurement••

Evidence-based goals and measures••

Longitudinal measurement••

Supportive of multiple uses and ••

stakeholders

Measurement intrinsic to care••

Patient and population level ••

measurement

Shared accountability••

Independent and sustainable learn-••

ing system

Greetings, NAHQ members!

The beginning of a new year brings a

fresh start for new officers, volunteer

opportunities, and continuing steps

toward NAHQ’s vision of being univer-

sally recognized as an essential connec-

tion and leading resource for healthcare

quality professionals.

NAHQ 2008 OfficersWe are pleased to welcome NAHQ’s

2008 Officers:

President: Thomas M. Smith, MA ••

RN CPHQ

President-Elect: Catherine Munn, ••

MPH RHIA CPHQ

Immediate Past President: Heidi ••

Benson, MS RN CPHQ FNAHQ

Secretary-Treasurer: Sandra ••

Grinder, MSN RN CPHQ

Professional Development Direc-••

tor: Linda Scribner, BA CPHQ

Member Services Director: ••

Lenard L. Parisi, MA RN CPHQ

FNAHQ

HQCB Chair: David S. Loose, ••

MSN CNAA RN CPHQ

Executive Director: Stacy ••

Sochacki, MS (ex-officio).

The deadline for nominations for

2008 was January 18, 2008.

FellowshipThe NAHQ Fellowship Program was

developed by the Healthcare Quality

Foundation both to recognize NAHQ

members who have made outstanding

contributions to the field of healthcare

quality and to act as a blueprint for an

ideal career path in the healthcare qual-

ity profession.

Consideration of an applicant for

fellowship includes review of the appli-

cant’s credentials, employment back-

ground, and education. The NAHQ

NAHQ Update

See Patient Safety on pg. 27

http://www.nahq.org/email/link_redir/19461/www.nahq.org/about/board.htm

http://www.nahq.org/email/link_redir/19415/www.nahq.org/awards/fellow.htm


Fellowship Review Board (FRB) deter-

mines the granting of Fellowship based

on an evaluation of the applicant’s

contributions to the field of healthcare

quality in the following categories:

Leadership and Service••

Published Works••

Lectures and Presentations••

Mentorship.••

We strongly urge you to set aside

some time to review the NAHQ Fel-

lowship application before you apply;

changes occur from year to year. De-

clare your intent to apply by sending a

letter to the NAHQ FRB Chair, Sandra

Robinson, by January 15, 2008. This

can be sent via e-mail and should be

addressed to [email protected].

NAHQ is proud to offer the Fellow-

ship program. Recognition of outstand-

ing leaders in the association benefits

not only those honored but also those

who seek role models in the healthcare

quality field.

For more information, please visit

the NAHQ Web site or contact NAHQ

headquarters at (800)966–9392. Best of

luck with the application process!

NAHQ. Together we define excel-

lence in healthcare quality.

NAHQ also awards grants in a num-

ber of categories throughout the year.

To see what is available, click here for

more information.

A message from the NAHQ Office

National Association for Healthcare

Quality

4700 W. Lake Avenue, Glenview, IL

60025-1485

Toll Free: (847)375–4720;

(800)966–9392

Fax: (877)218–7939

[email protected]

www.nahq.org

According to the Centers for

Disease Control and Prevention

(CDC), the number one lead-

ing cause of death in the United States

is heart disease (National Center for

Health Statistics [NCHS], 2007). Even

if we as individuals take a proactive

approach to fight our own battle against

cardiovascular disease, there is no

guarantee that someday we will not suc-

cumb to a heart attack. What can we

expect if that day comes? Take a brief

journey back in time and explore the

treatment and outcome that might have

awaited us just twenty short years ago.

An advanced life support (ALS) am-

bulance would respond to your house.

That unit would be staffed with a well-

trained paramedic without the ability to

perform a 12 lead EKG. They had the

ability to provide minimal treatment

and transportation to the nearest hospi-

tal. They might be able to provide you

with temporary relief, but the bottom

line is the need for timely diagnostic

and therapeutic intervention. You may

have received thrombolytic therapy

at the receiving facility, or you maybe

were fortunate enough to end up at a

hospital that had the ability to perform

cardiac catheterization and if needed,

heart bypass surgery. Your chances for

survival would be fair. If you did not ar-

Bridging the Gap in Emergency Cardiac CareBrian Hendrickson, EMT-P


http://www.nahq.org/email/link_redir/19419/www.nahq.org/

http://www.nahq.org/awards/grants.htm


http://www.nahq.org/


rive at an interventional site, this might

entail another ride to another hospital

with diagnostic and open heart surgical

abilities. Delays in care result in delays

to coronary reperfusion and time is

muscle. Today’s call for assistance in a

cardiac emergency reveals a difference

with improved patient outcomes. In

2008, a 911 call for chest pain runs like

this:

A 76-year-old male has an episode of

chest pain and activates the 911 system.

Approximately five minutes after

the call, a well equipped and trained

paramedic arrives and begins the

assessment. The findings point consis-

tently to a myocardial infarction (MI).

The paramedic recognizes the need to

perform a 12 lead EKG. The findings

are ST elevation in 1, AVL, and V-1

through V-6 with reciprocal changes in

II, III and AVF (Antero-lateral wall MI)

pictured below. The paramedic decides

that the patient must go to a hospital

that is capable of percutaneous coro-

nary intervention (PCI). This patient is

fortunate that his heart attack occurred

in 2008.

There is currently a push to develop

what is known as STEMI (ST Eleva-

tion Myocardial Infarction) centers.

These hospitals specialize in reducing

the time that a patient must wait to

receive definitive intervention such as

angiography and angioplasty. The pa-

tient was immediately transported to a

“STEMI” center, and while en route he

receives care with oxygen, nitroglycer-

ine, and morphine and two intravenous

lines. Upon arrival at the hospital, the

emergency room physician confirmed

the suspicions of the paramedic. Within

forty-eight minutes of the patient’s ar-

rival at the emergency room, the patient

receives balloon angioplasty to the left

anterior descending coronary artery

which was 99% occluded. The patient

tolerates this procedure well and is dis-

charged with a good prognosis within

seventy-two hours of the procedure.

When we look at a case such as this,

it is evident that we are on the right

track making a tremendous impact

on the survival rates of heart attack

victims. The new and emerging tech-

nologies such as pre-hospital 12 lead

EKG, are just one facet of improving

outcomes and survival rates. In order

for us to continue on this path, it is

imperative that we build a solid bridge

between Emergency Medical Service

crews, the Emergency Room, and the

Cardiac Catheterization lab. A shared

vision is needed.

One such vision is the American

College of Cardiology’s (ACC) Door

to Balloon Alliance (D2B). The project

was introduced at the November 2006

American Heart Association’s (AHA)

National Meeting. The goal of the

D2B is to achieve a PCI time equal to

or less than ninety minutes in 75% of

Pre-hospital EKG: Acute Antero-lateral Wall MI


STEMI cases. The project is a collabo-

ration between the ACC, AHA and

the National Heart, Lung and Blood

Institute (NHLBI). A list of participat-

ing California Hospitals is provided at

the end of the article (D2B, 2007).

Counties across the country are

developing pre-hospital 12 lead EKG

protocols with rapid transport protocols

to a STEMI center. Most protocols

involve the bypassing of other facili-

ties if within a thirty minute response

time in order to transport STEMI

patients to the closest STEMI receiving

center. Some remote regions also use air

transport to expedite care for STEMI

patients. Several counties in Southern

California have already developed

STEMI centers including, Los Ange-

les, Orange, Riverside, San Diego, and

Ventura counties. The Inland County

Emergency Medical Agency (ICEMA)

recently finished presenting a draft 12

lead EKG policy and chest pain desti-

nation policy for public commentary

(ICEMA, 2007).

One may draw parallels for STEMI

centers from the golden hour of trauma

and use of EMS to transport those in

need of trauma care to the most appro-

priate centers. STEMI centers deliver

expeditious coronary reperfusion with

onsite surgical back-up teams. Progress

continues as counties work within their

regional emergency medical agencies

to improve emergency cardiac care by

a collaborative effort between EMS

and hospital staff and EMS regulatory

bodies.

There are still many areas in need of

improvement, those areas include; early

recognition of the signs and symptoms

of a heart attack and activation of the

EMS system. According to the National

Institute of Health and the National

Heart, Lung and Blood Institute,

(NIH, NHLBI, 2001) over one million

people die of a heart attack nationally

each year. Of those who die, nearly half

die before ever reaching the hospital.

Often STEMI patients arrive by private

vehicle and do not benefit from the

advanced care initiated in the field.

Healthcare professionals can teach the

signs and symptoms of cardiac emer-

gency and encourage basic life support

training for lay persons and early activa-

tion of the Emergency Medical System

(EMS).

An exciting endnote to this discus-

sion of early reperfusion to save lives is

the American College of Cardiology’s

D2B Alliance includes enrollment of

many International participants as well

as National participants. They include

Spain, Canada, Brazil, United Arab

Emirates, India, Saudi Arabia, Thai-

land, Poland and Taiwan (D2B, 2007).

We are bridging the gap in emergency

cardiac care and the gap is closing.

ReferencesAmerican College of Cardiology, ❖

D2B an Alliance for Quality. Re-

trieved January 19, 2007, from www.

d2balliance.org

Inland County Emergency Medical ❖

Agency (ICEMA), Retrieved January

19, 2007, from http://www.sbcounty.

gov/icema/

National Center for Health Statistics ❖

(2007, Deaths-Leading Causes. Re-

trieved January 2, 2008, from www.

cdc.gov/nchs/fastats/lcod.htm

National Institute of Health, ❖

National, Heart, Lung and Blood

Institute (NHLBI). Act in Time to

Heart Attack Signs. Retrieved Janu-

ary 19, 2008, from http://www.nhlbi.

nih.gov/actintime/index.htm

Brian can be contacted at hendrick-

[email protected]

✦

D2B Participating California HospitalsAnaheim Memorial Medical Center Anaheim

St Mary Medical Center Apple Valley

Methodist Hospital Arcadia

Bakersfield Heart Hospital Bakersfield

Mills Peninsula Health Services Bulingame

Providence St. Joseph Medical Center Burbank

Mercy San Juan Medical Center Carmichael


Enloe Medical Center Chico

Sharp Chula Vista Medical Center Chula Vista

John Muir Medical Center, Concord Campus Concord

Citrus Valley Medical Center Covina

Scripps Memorial Hospital Encinitas Encinitas

Palomar Pomerado Health Escondido

Fountain Valley Regional Hospital Fountain Valley

Washington Hospital Healthcare System Fremont

Community Regional Medical Center Fresno

Saint Agnes Medical Center Fresno

St. Jude Medical Center Fullerton

Glendale Memorial Hospital and Health Center Glendale

Marin General Hospital Greenbrae

John F. Kennedy Memorial Hospital Indio

Irvine Regional Hospital Irvine

Sharp Grossmont Hospital La Mesa

Saddleback Memorial Medical Center Laguna Hills

Lakewood Regional Medical Center Lakewood

Lancaster Community Hospital Lancaster

Los Alamitos Medical Center Los Alamitos

Cedars-Sinai Medical Center Los Angeles

Good Samaritan Hospital Los Angeles

UCLA Medical Center Los Angeles

USC University Hospital Los Angeles

Providence Holy Cross Medical Center Mission Hills

Mission Hospital Mission Viejo

Doctors Medical Center of Modesto Modesto

Beverly Hospital Montebello

Garfield Medical Center Monterey Park

El Camino Hospital Mountain View

Queen of the Valley Medical Center Napa

Hoag Hospital Newport Beach

Northridge Hospital Medical Center Northridge

Alta Bates Summit Medical Center Oakland

Tri-city Medical Center Oceanside

St. Joseph Hospital Orange

University of California, Irvine Medical Center Orange

St. John’s Regional Medical Center Oxnard

Desert Regional Medical Center Palm Springs


Huntington Hospital Pasadena

ValleyCare Medical Center Pleasanton

Pomona Valley Hospital Medical Center Pomona

Eisenhower Medical Center Rancho Mirage

Shasta Regional Medical Center Redding

Riverside Community Hospital Riverside

Mercy General Hospital Sacramento

Sutter Medical Center Sacramento Sacramento

University of California, Davis Medical Center Sacramento

Alvarado Hospital San Diego

Scripps Mercy Hospital San Diego

Sharp Memorial Hospital San Diego

University of California, San Diego San Diego

California Pacific Medical Center San Francisco

O’Connor Hospital San Jose

Sierra Vista Regional Medical Center San Luis Obispo

San Ramon Regional Medical Center San Ramon

Santa Barbara Cottage Hospital Santa Barbara

Dominican Hospital Santa Cruz

Santa Rosa Memorial Hospital Santa Rosa

Stanford Hospital and Clinics Stanford

St. Joseph’s Medical Center Stockton

Encino-Tarzana Regional Med Ctr Tarzana

Twin Cities Community Hospital Templeton

Los Robles Hospital & Medical Center Thousand Oaks

Little Company of Mary Hospital Torrance

Torrance Memorial Medical Center Torrance

San Antonio Community Hospital Upland

Community Memorial Hospital Ventura

John Muir Medical Center, Walnut Creek Campus Walnut Creek

Presbyterian Intercommunity Hospital Whittier


St., Mary Medical Center

(SMMC) is a one-hundred and

eighty-eight bed acute care

hospital located in the Mojave Desert of

Southern California. SMMC is part of

the St Joseph Health-system (SJHS) of

Orange, California. In 2005, SJHS sys-

tem began developing Rapid Response

Teams (RRT’s) at each of their minis-

tries. The AIM of the SJHS RRT is to

decrease overall codes occurring outside

the ICU 50%, to increase the use of

the medical response over time and to

decrease the number of inpatient deaths

non-severity adjusted (Kassab, 2006).

Tricia Kassab RN, MS, CPHQ is the

AVP for Quality and Patient Safety for

SJHS. Tricia began leading the teams in

2005, providing monthly training and

now quarterly WebEx calls for all the

ministries. Each facility tracks processes

and outcome measures, and reports to

the health system monthly. Recently,

Kathy Duncan a Director at the Insti-

tute for Healthcare Improvement (IHI)

joined one of the conference calls. She

emphasizes the importance of focusing

upon increasing RRT call volumes to

20-25 calls per 1,000 discharges in or-

der for teams to sustain their gains and

realize mortality reductions. Addition-

ally, the IHI has set goals for RRT’s,

one to decrease inpatient non-risk

mortality 25% and the other to reduce

risk adjusted mortality 20% (Duncan,

2007).

SMMC began pilot testing their

RRT in October 2005 on their West

Medical Surgical Unit. The team is

composed of a critical care RN team

leader/break nurse and a respiratory

care practitioner. Administrative coor-

dinators serve as back-up for the team.

Tools from the IHI website (IHI.org)

provided sample documentation records

as well as trigger tools for activating an

RRT call. SMMC educators assist with

educating staff about the RRT and help

to develop competencies for team mem-

bers. SMMC developed a Standardized

Protocol for emergency RRT orders

following the first year of RRT calls.

The Medical Staff accepts use of

the emergency orders and have also

called the RRT themselves when they

required additional assistance. The last

leg of the project will roll out in spring

2008 that is the Pediatric RRT. The Pe-

diatric Advanced Cardiac Life Support

R.N., from the emergency department

will staff the pediatric team along with

a dedicated respiratory therapist.

Rapid Response Teams— Run, Don’t Walk…Pat Lucken, RN, MSN, FNP-C, CPHQ


Lessons Learned:Some fifty percent of adult calls involve

a hypoxic patient (oxygen saturation less

than 90% despite oxygen). Some fifty

percent of calls are transferred to the

ICU for further care.

We encourage calls to RRT even

when the physician has been con-

tacted by staff as often the patient may

deteriorate quickly especially with

airway emergencies. The standardized

procedure allows the critical care nurse

to transfer the patient into the intensive

care unit if condition warrants.

All out of unit codes are reviewed to

see if staff may have missed an oppor-

tunity for calling the RRT (missed trig-

gers). We recognized some late calls &

missed triggers that resulted in a code

blue with some of our temporary per-

sonnel. We worked with our temporary

agency to ensure that their staff know

that they can call the RRT anytime

while at our facility.

We learned that we were using a lot

of reversal agents for opiate reversal

from a review of the RRT documenta-

tion. One person survived a respiratory

arrest after receiving three milligrams

of Dilaudid by IV push. Luckily, the

nurse on the ward noticed failing

respirations and called the RRT and

the patient survived. Our pain manage-

ment nurse, Sheri King, RN, helped to

coordinate both nursing and medical

education and our reversal use has di-

minished significantly. We were able to

immediately place a warning sign into

our medication dispensing unit that

cautioned staff that one milligram of

dilaudid is equivalent to five milligrams

of morphine sulfate.

One patient returned from the GI lab

and looked like she had white powder

on her face. She had experienced a

rare reaction to the topical anesthetic

spray used to anesthetize her throat.

It is called methemoglobenemia and

basically the medication binds with the

oxygen transporting cells and prevents

proper oxygen exchange. The reversal

agent used is intravenous metheyline

blue. She was transferred to the inten-

sive care unit and survived. The team

responded to a pneumonia patient that

was short of breath. The med neb failed

to work and an EKG showed an acute

myocardial infarction. This patient

went to cath lab and received a stent to

a completely occluded coronary artery.

Along with knowing your call data,

implementing process changes based

upon the what the call’s tell you, it is

helpful to perform a mortality review

of the last fifty inpatient deaths (closed

records). The tools are available on

the IHI website. The tools include the

global trigger tool for assessing patient

harm as well instructions on how to

perform the 2x2 matrix. The goal is to

identify potentially avoidable deaths

and implement strategies to improve

care processes and mitigate patient

harm. We are dedicated to performing

this exercise at least annually to assess

for leading cause of death and potential

harm, failures to plan, communicate or

rescue.

The emergency department team will staff

the pediatric RRT beginning in spring

2008


SMMC Registered Nurses and Respiratory Therapists respond to RRT calls

Baseline 1.8% in 2005, 1.5% in 2006 and

1.2% in 2007. 34% reduction in non-risk

mortality from 05–07

Baseline 1.05 in 2005, 0.70 in 2006 and

0.75 in 2007. 30% reduction in risk mor-

tality HSMR from 05–07

SMMC Rapid Response Team Percentage Raw Mortality

All Cause Inpatient MortalitySMMC Rapid Response Team

Risk Adjusted Mortality


SMMC presented a Poster-board at IHI’s National Quality Forum in Decem-

ber 2007 at Orlando, Florida. Contrary to some of the negative press perpetuated

against the effectiveness of RRT’s, our team prefers to run, not walk!

✦

Baseline 10.4 codes per 1,000 discharge in 2005, 6.4 codes per

1,000 discharge in 2006 and 4.25 codes per 1,000 discharge in

2007. 60 % reduction codes per 1,000 discharge from 05–07.

RRT began fall 2005, as a pilot unit. Global to adult inpa-

tient 2006. Including outpatient areas 2007.

2008 final roll-out to pediatric unit.

SMMC Rapid Response Team Number of Codes per 1,000 Discharge

Includes all Inpatients

SMMC Rapid Response Team Annual Number of Calls to the RRT

Not every organization has had

the same experience with Rapid Re-

sponse Teams (RRT). Kaiser Perma-

nente West Los Angeles initiated RRT

mid 2005, rolling out the process on

two units and then spreading it to

others over the next several months.

This was the first Kaiser in Southern

California to implement the program.

From the beginning, staff was eager and

ready to participate. There was some

concern about the extra utilization of

resources, however with the excep-

tion of an already identified need for a

respiratory care practitioner, the plan

was to implement the program in a cost

effective way.

On the other hand, a number of

physicians had a problem with the

lack of comparative research done on

outcomes from RRTs. Also, as reported

Rapid Response Teams—Another Organization’s Experience Kathleen Tornow Chai MSN, PhD, CPHQ, FNAHQ


in an article published in the Journal

of the American Medical Association

(JAMA), only 10 studies had been

published evaluating RRT implementa-

tion that provided adequate compari-

sons of outcomes between control and

intervention groups. Of these, 8 were

observational and 2 were randomized

(Winters, Pham & Pronovost, 2006).

The article, “Rapid Response Teams-

Walk Don’t Run” went on to discuss

that the implementation of RRTs may

not be for every organization. Knowing

physician practice and training is based

on evidence, it seemed reasonable that

they had reservations. However, the

plan continued.

Initially, it was difficult to determine

what the goals of RRT implementation

should be. While the literature focuses

on decreased mortality, decreased cardi-

ac arrests (Kenward, Castle, Hodgetts,

& Shaikh, 2004) there were additional

reasons that we at KP-WLA wanted to

bring this process forward. Our initial

goals were to:

Identify patients who may fall into

the “failure to rescue” category and

provide support prior to the need for

code blue.

Reduce the rate of Code Blues out-

side of CCU.

Increase knowledge and skill of

nurses related to identification of “fail-

ure to rescue.”

Increase nurse satisfaction.

Provide RRT support with minimal

additional resources.

Reduce mortality rate.

After two and a half years of imple-

mentation, we have learned a lot about

our organization and improved many

things. Initially, we identified that there

had previously been an inadequate

process for identifying the number of

Code Blue calls, which also became the

case with the initial RRTs. Historically,

the organization relied on the number

of completed forms that were submit-

ted to identify the number of Code

Blues. One of the first things the project

manager facilitating the RRT data

noticed was that the number of post-

RRT completed forms was not the same

as the number called as evidenced by

her own tracking of the calls while she

was there. After several permutations,

KP-WLA now uses the Communica-

tion Department’s Emergency Process-

ing Transaction Log. This is the same

process used for tracking Code Blues.

The log information is reviewed and as-

sessed to make sure each entry resulted

in a response before it is included in the

denominator.

The number of RRTs called was

relatively stable until recently, when it

has decreased slightly. The time is right

for a refresher education process that

will be taking place soon. Our mortal-

ity rate has decreased slightly, however

there is no way to directly attribute this

finding to the initiation of RRT. The

number of Code Blues outside the ICU

fluctuates, and no definitive trend has

been seen. However, after the process

had been implemented and was stable

organization wide, we measured the

perceptions of our nurses and found

something exciting.

Seventy-six nurses responded to the

Zoomerang survey and 55% of the

respondents had initiated an RRT. 60%

of the nurses felt that the RRT call

went as they expected it would. Over

80% felt confident that if they called an

RRT, the team would be supportive of

them. 90% of the staff felt that RRTs

had been positive for patient safety.

90% of the staff felt that the implemen-

tation of RRTs made them feel more

comfortable in their practice while 80%

felt that their clinical assessment skills

had improved. Ninety-three percent felt

that patient outcomes had improved

due to the implementation of the RRT

process.

These numbers have been a signifi-

cant driver in the ongoing implemen-

tation of RRTs at West Los Angeles.

While they are just a snapshot, and will

be repeated, they show us the level of

impact this patient safety tool has made

for our nurses. Nursing staff who inter-

view for positions at KP-WLA ask if we

have implemented a Rapid Response

Team and we have been happy to share

the information with them. KP-WLA

is significantly feeling the nursing

shortage and staffing is no easy task. It

is important that our nurses feel that

there is support for care when the need

arises.

The plan is to revitalize our RRT

processes and re-energize staff in this

implementation. We are an organiza-

tion with many initiatives and do not

see that slowing down in the future.

RRTs have become a way of life, a spe-

cial tool that we use to support patients

and staff. In the near future, we hope

to embark on the patient and family

initiated RRT for a specific segment of


our population. Our goal is to improve

patient care and outcomes while at the

same time support our staff as they

provide the most difficult care.

ReferencesKenward, G. , Castle, N., Hodgetts, ❖

T., & Shaikh, L. (2004). Evaluation

of an emergency medical team one

year after implementation. Resuscita-

tion, 61, 257-263.

Investing in patient safety ini-

tiatives prepares for pay-for-per-

formance and publicly reporting

initiatives. Purchasers and leading

insurers are putting more attention to

patient safety and healthcare quality

using quality measures.35 Initiatives that

reduce errors by adopting health infor-

mation technology (HIT) and other

strategies can provide hospitals with

improved reimbursement rates and pre-

pare for pay-for-performance initiatives.

For example, the Leapfrog Group—a

consortium of companies and health

purchasers—is providing incentives for

hospitals to implement HIT to reduce

medical errors. Hospitals that develop

valid and reliable incident reporting

systems, educate healthcare providers in

medical errors, and adopt technology

and other related strategies to enhance

patient safety, are preparing for pay-

for-performance initiatives. Also, the

PCMS Premier Hospital Quality Incen-

tive Demonstration initiative showed

that hospitals participating in this proj-

ect had significantly higher composite

quality scores in each indicator of the

study (AMI, pneumonia, heart failure),

accelerating the adoption of evidence-

based practices.48

Numerous public and private entities

have begun posting publicly accessible

and searchable indices of a hospital’s

performance in quality care:

CMS Hospital Quality Measures••

Premier Hospital Quality Safety••

US DHHS Hospital Compare••

California Hospital Compare••

National Voluntary Hospital Re-••

porting Initiative

PacifiCare Quality••

Health Scope Hospital Ratings••

California Healthcare Foundation, ••

Patients’ Evaluation of Perfor-

mance in California

The LeapFrog Group••

Health Grades••

Investing in patient safety provider

education and system improvement

are cost effective strategies. Collabora-

tive learning increased patient safety

medications. A quality improvement

project designated to reduce ADEs

within the Veterans Affairs (VA) system

using the Institute for Healthcare

Improvement collaborative methods

avoided between 589 and 740 serious

or potentially life-threatening medica-

tion errors at an estimated direct care

cost savings between $3.47 million

and $12.13 million for the six months

of the study.19 At six month follow-up,

the team remained intact, continued

to collect data, and maintained their

gains.19 A program to reduce injuries

to caregivers in handling patients at

the Veterans Health Administration

(VHA) that involved an ergonomic

assessment protocol, patient handling

technology, decision algorithms to se-

lect equipment, and guidelines for safe

patient handling, decreased incidence

and severity of injuries, produced satis-

faction with the equipment, decreased

workers’ compensation claims $200,000

per year, and a payback of 4.30 years.49

Also, having a pharmacist participating

in patient rounds with the Intensive

Care Unit (ICU) team, Brigham and

continued from pg. 16

Patient Safety

Winters, B.D., Pham, J., & Pro- ❖

novost, P.J. (2006). Rapid Response

team-Walk don’t run. Journal of the

American Medical Association, 296,

1645-1647.

✦

http://www.cms.hhs.gov/HospitalQualityInits/25_HospitalCompare.asp

http://www.premierinc.com/

http://www.hospitalcompare.hhs.gov/Hospital/Home2.asp?version=alternate&browser=IE%7C6%7CWinXP&language=English&defaultstatus=0&pagelist=Home

http://www.calhospitalcompare.org/

http://www.hospitalcompare.hhs.gov/hospital/home2.asp

http://www.pacificare.com/commonPortal/application?origin=mp_leftnav.jsp&event=bea.portal.framework.internal.portlet.event&pageid=mp_MemberQualityIndex&portletid=QIIndex&wfevent=link.viewarticle&navnode=ToolsServices.4

http://www.healthscope.org/

http://www.calhospitals.org/

http://www.leapfroggroup.org/for_hospitals

http://www.healthgrades.com/


Women’s Hospital reduced the ADE

rate in its ICU from 33.0 to 11.6 per

1,000 patient day.50, 51


tives helps reduce deficient hospi-

tal care and persistent healthcare

disparities. 52 A broad body of research

has documented deficiencies in patient

safety and healthcare quality: only

50 percent of patients receive recom-

mended preventive care;53 persistent

healthcare disparities across a range of

illnesses and healthcare services has

been found;54 55 and more than half of

patients are worried about the safety of

their care and the quality of healthcare

they receive.37 Researches have found

a major association between a patient’s

health literacy, healthcare provider

communication, and patient safety.56,

57 Investing in patient safety initiatives

that increase healthcare provider-patient

communication, cultural competency,

and language access are valuable patient

safety strategies that help reduce health-

care disparities and improve patient

satisfaction and clinical outcomes.

Consider the high costs of not having

proper communication and linguistic

access:

A 22-year-old, non-English-speaking

man was awarded a lifetime settlement

of $71 million because the emergency

department failed to detect a stroke.

His mother used the Spanish word “ in-

toxicado” but the ED staff understood

that he had a drug overdose.58 Like in

this case, medical errors are prevalent,

expensive, and often preventable. It is

estimated that within U.S. hospitals,

medical errors could unnecessarily cost

the healthcare system between $17 and

$29 billion annually causing up to

98,000 deaths per year.3, 4

The family of a deceased 36-year-old

Low English Proficiency (LEP) woman

received $900,000 in a settlement after

her flu-like symptoms turned out to be

a fatal case of bacterial meningitis. This

hospital ED staff treated and dis-

charged her, using one of the patient’s

semi-fluent friends as an interpreter.

Key symptoms were never interpreted,

leading to misdiagnosis and the pa-

tient’s death.58

Investing in safer patient initiatives

facilitates accreditation and partner-

ships with stakeholders. Stakehold-

ers, accreditation agencies, and patient

safety organizations are working togeth-

er to create an environment that fosters

safety measures. Aligning with patient

safety stakeholders will bring strategic

benefits to California hospitals promot-

ing a unified message, common goals,

and standard measures. CMS’s quality

improvement initiatives; Institute of

Medicine’s reports on patient safety and

medical errors; Institute for Health-

care Improvement’s Five Million Lives

campaign; National Quality Forum’s

“Never Events”; and the Agency for

Healthcare Research and Quality’s

patient safety and quality initiatives, to

name a few, are aligned with the Joint

Commission 2008 National Patient

Safety Goals.


tives moves a hospital toward achiev-

ing the Joint Commission’s 2008

National Patient Safety Goals. Proac-

tive investing in patient safety initia-

tives provides a hospital with a strategic

position to more rapidly achieve the

Joint Commission’s 2008 National

Safety Goals, which are to:

Improve the accuracy of patient ••

identification.

Improve the effectiveness of com-••

munication among caregivers.

Improve the safety of using ••

medications.

Reduce the risk of healthcare-asso-••

ciated infections.

Accurately and completely ••

reconcile medications across the

continuum of care.

Reduce the risk of patient harm ••

resulting from falls.

Reduce the risk of influenza and ••

pneumococcal disease in institu-

tionalized older adults.

Reduce the risk of surgical fires••

Encourage patients’ active involve-••

ment in their own care as a patient

safety strategy.

Hospital acquired pressure ulcers ••

(decubitus ulcers).

Hospitals that invest in error-

reduction initiatives now are better

prepared for patient safety legisla-

tion requirements. Legislation is a

contributing force to adopt patient

safety initiatives in hospitals. About

one-third of the states have established

mandatory reporting of errors following

recommendations from the Institute

of Medicine’s To Err is Human and in

part because of fear of litigation.60 Cali-

fornia legislation mandating a plan to

substantially reduce hospital medication

errors has generated an unprecedented

amount of patient safety activity.61


Examples of state error reduction

legislation are:

The approval of legislation •• SB 1875

in 2002 that required hospitals, as

a condition of licensure, to create

medication error reduction plans.62,

63

The •• Patient Safety and Quality

Improvement Act of 2005, which

mandates the creation of Patient

Safety Organizations (PSOs) to

collect, aggregate, and analyze

confidential information reported

by healthcare providers.

California Legislation Requires ••

Quality Assurance Programs in

Pharmacies, the California passed

Senate Bill 1339 in 2000, which

requires pharmacies to establish

quality assurance programs to

reduce the frequency of medica-

tion errors and requires the Board

of Pharmacy to adopt a regula-

tion specifying the requirements

of a pharmacy quality assurance

program. A goal of the legislation

was to move the quality improve-

ment process away from blaming

individuals and move towards

improving systems to minimize

future occurrences of medication

errors.

SB 797•• , that establishes a prescrip-

tion-monitoring program in the

Department of Health and Senior

Services.

Selected Organizations Accelerating the Patient Safety Movement

Organizations DescriptionJoint Commission Requires organizations to establish quality and patient safety standards and monitor

performance.

CMS Services Implements quality and safety improvement initiatives in hospitals and other clinical

healthcare settings.

Institute of Medicine Calls for mandatory reporting of medical errors in the U.S.

OSHA Occupational Safety and

Health Administration

Requires reporting of all occupational injuries and illnesses.

National Patient Safety

Foundation

Acts as a resource for improving the safety of patients by bringing together diverse

stakeholders, and holding annual congresses on patient safety.

Agency for Healthcare Research

and Quality

Promotes research in the areas of patient safety and quality improvement.

The Commonwealth Fund Releases a report presenting 10 case studies of healthcare organizations that have

designed and implemented patient safety initiatives.

Institute for Healthcare

Improvement

Accelerates change in healthcare quality and patient safety initiatives.

Leapfrog Group Promotes safety measures: CPOE adoption, evidence-based hospital referral, ICU

staffing by physicians trained in critical care medicine.

United States Pharmacopeia Standards-setting organization for all prescription and over-the-counter medicines,

dietary supplements, and other healthcare products manufactured and sold in the

United States.

National Quality Forum “Never Events” are errors that should never, ever happen such as medication errors

and wrong-site surgery. Never events are clearly identifiable, largely preventable,

and serious adverse events for patients and healthcare organizations.59 NQF

identified 27 adverse events in six major categories: Surgical events, product or

device events, patient protection events, care management events, environmental

events, and criminal events.


SB 1301•• , that requires DHS to

conduct onsite investigations of

adverse events and complaints

involving general acute care, acute

psychiatric, or special hospitals

within specified timelines, and

requires the department to conduct

periodic unannounced inspec-

tions not less than once per year of

health facilities that have reported

adverse events.

Patient Safety Organizational Needs AssessmentLumetra has developed a patient safety

needs assessment that helps healthcare

organizations identify organizational

needs regarding patient safety issues.

Patient safety POTENTIAL ORGANIZATIONAL GAPS – Which areas represent possible areas for improvement in your organization?

Check all that Apply (√ )

Leadership—Involve senior leaders, CEO, and Board on patient safety issues

Systems—Create patient safety systems, policies, procedures, and processes

Requirements—Fulfill patient safety directives and regulatory requirements

Culture—Establish a culture that makes patient safety a top priority

Education—Conduct house-wide staff training on patient safety principles

Communication—Increase communication between individuals and teams

Quality Improvement—Develop and implement patient safety interventions

Technology—Integrate health information systems and data management

Medication—Implement effective systems to reduce medication errors

Patients—Involve patients, families, and caregivers in patient safety

Coordination—Maintain patient safety that spans the continuum of care

Evaluation—Monitor effectiveness of the overall patient safety program

Other:

Patient safety IMPROVEMENT AREAS – Which areas would be most helpful to improve patient safety in your organization?

Check all that Apply (√ )

Leadership engagement with patient safety initiatives

Process design, implementation, and human factors improvement

Evaluation of current compliance with National Patient Safety Goals

Organizational culture change assessment and improvement

Education and training in patient safety culture, improvement, and results

Situation communications, teamwork training, and Team STEPPS

Identification of patient safety risks and design of improvement interventions

Evaluation of opportunities to integrate information systems and use data well

Medication reconciliation strategies, and prevention of adverse drug events

Patient and family education techniques and programs

Coordination at time of transfer between care settings or providers

Program assessment and evaluation methodology

Other:


Please review it with your leadership

team to discuss patient safety priorities

and action areas.

Conclusion

Evidence and expert-based patient safety solutionsCurrently, California hospitals are

searching for cost-effective patient

safety strategies. Many are implemented

evidence- and expert-based patient

safety solutions in the areas of:

Linking incident reporting with

provider education and quality

improvement. Incident reporting and

continuous performance measurement

have been successfully used in conjunc-

tion with collaborative learning and

practitioner feedback to educate provid-

ers and organizations in patient safety

culture and improvement.

Systems improvement and process

redesign patient safety solutions.

System-wide patient safety initiatives

such as organizational design, pro-

cess improvement, reminder systems,

clinical pathways, and standing orders

streamline processes, save money, and

improve clinical outcomes.

Creating a patient safety culture.

Hospitals are creating a culture in

which healthcare providers feel respon-

sible for the safety of every patient,

every time. Hospitals are changing

from a culture of blame to a culture of

safety so that providers can report errors

freely. Systems are changed, and staff

are accountable for behavior choices.

Patient safety technology. Health

information technology - including

computerized physician order entry,

decision support systems, electronic

health records, and bar code medication

administration - improve the quality,

safety, and efficiency of hospital care.

Provider’s cross-cultural com-

munication and patient activation.

Hospitals are investing in patient safety

initiatives that focus on the develop-

ment of provider’s cultural competency

including effective provider-provider

and provider-patient cross-cultural

communication to reduce medical er-

rors. Such patient safety strategies are

directed to create effective communica-

tions systems among providers, improve

the accuracy of patient identification,

increase language access, and promote

patients’ active involvement in their

own care.

A growing national movement is

raising the bar for patient safety. Pa-

tient safety organizations, accreditation

agencies, and stakeholders are making a

national call to work together to create

an environment that fosters increased

safety. Investing in patient safety solu-

tions and aligning with stakeholders

will bring strategic benefits to Califor-

nia hospitals promoting a unified mes-

sage, common goals, and standardized

measures.

The benefits of investing in patient

safety initiatives are considerable.

The benefits of creating safer operating

systems and processes that minimize

the likelihood of errors and accidental

injury are substantial: protect the bot-

tom line, provide better patient care,

improve patient satisfaction, increase

employee productivity, prepare for pay-

for performance and public reporting,

build goodwill and reputation, avoid

exposure to litigation, maintain ac-

creditation, and comply with legislation

requirements.

For author biographies see page 48.

References1. Fox M. Drug Mistakes Injure 1.5

Million in US Every year. Reuters

Health Information. 2006.

2. Institute of Medicine. Preventing

medication errors. Washington:

National Academies Press; 2006.

3. Institute of Medicine. To Err is Hu-

man: Building a Safer Health Sys-

tem. Washington, D.C.: National

Academy Press; 1999.

4. Kaushal R, Jha AK, Franz C, et al.

Return on investment for a comput-

erized physician order entry system.

J Am Med Inform Assoc. May-Jun

2006;13(3):261-266.

5. Bates DW, Cullen DJ, Laird N, et

al. Incidence of adverse drug events

and potential adverse drug events.

Implications for prevention. ADE

Prevention Study Group. JAMA.

Jul 5 1995;274(1):29-34.

6. Perry D. When medicine hurts in-

stead of helps. Consultant Pharma-

cist. 1999;14:1326-1330.

7. Classen DC, Pestotnik SL, Evans

RS, Lloyd JF, Burke JP. Adverse

drug events in hospitalized patients.

Excess length of stay, extra costs,

Lumetra


and attributable mortality. JAMA.

Jan 22-29 1997;277(4):301-306.

8. Lazarou J, Pomeranz BH, Corey

PN. Incidence of adverse drug

reactions in hospitalized pa-

tients: a meta-analysis of pro-

spective studies. JAMA. Apr 15

1998;279(15):1200-1205.

9. Bates DW, Spell N, Cullen DJ,

et al. The costs of adverse drug

events in hospitalized patients.

Adverse Drug Events Prevention

Study Group. JAMA. Jan 22-29

1997;277(4):307-311.

10. Jha AK, Kuperman GJ, Rittenberg

E, Teich JM, Bates DW. Identifying

hospital admissions due to adverse

drug events using a computer-based

monitor. Pharmacoepidemiol Drug

Saf. Mar-Apr 2001;10(2):113-119.

11. Dennehy CE, Kishi DT, Louie C.

Drug-related illness in emergency

department patients. American

Journal of Health System Pharma-

cy. Jun 15 1996;53(12):1422-1426.

12. Tafreshi MJ, Melby MJ, Kaback

KR, Nord TC. Medication-related

visits to the emergency depart-

ment: a prospective study. The

Annals of Pharmacotherapy. Dec

1999;33(12):1252-1257.

13. Monitoring hospital-acquired infec-

tions to promote patient safety--

United States, 1990-1999. MMWR

Morb Mortal Wkly Rep. Mar 3

2000;49(8):149-153.

14. Jarvis WR. Selected aspects of the

socioeconomic impact of noso-

comial infections: morbidity,

mortality, cost, and prevention.

Infect Control Hosp Epidemiol. Aug

1996;17(8):552-557.

15. Martone WJ, Jarvis WR, Culver

DH, RW. H. Incidence and nature

of endemic and epidemic nosoco-

mial infections. In: Bennett JV

BP, ed. Hospital infection. Boston:

Little, Brown, and Company;

1992:577-596.

16. Klevens RM, Morrison MA, Nadle

J, et al. Invasive methicillin-resis-

tant Staphylococcus aureus infec-

tions in the United States. JAMA.

Oct 17 2007;298(15):1763-1771.

17. Rothschild JM, Federico FA,

Gandhi TK, Kaushal R, Wil-

liams DH, Bates DW. Analysis of

medication-related malpractice

claims: causes, preventability, and

costs. Arch Intern Med. Nov 25

2002;162(21):2414-2420.

18. Kinninger T, Reeder L. The

business case for medication

safety. Healthc Financ Manage. Feb

2003;57(2):46-51.

19. Weeks WB, Mills PD, Dittus RS,

Aron DC, Batalden PB. Using

an improvement model to reduce

adverse drug events in VA facili-

ties. Jt Comm J Qual Improv. May

2001;27(5):243-254.

20. Kwaan MR, Studdert DM, Zin-

ner MJ, Gawande AA. Incidence,

patterns, and prevention of

wrong-site surgery. Arch Surg. Apr

2006;141(4):353-357; discussion

357-358.

21. Gostin L. A public health approach

to reducing error: medical mal-

practice as a barrier. JAMA. Apr 5

2000;283(13):1742-1743.

22. Studdert DM, Mello MM,

Brennan TA. Medical mal-

practice. N Engl J Med. Jan 15

2004;350(3):283-292.

23. Virginia Health Quality Center.

Quality Makes Good Business

Sense. Key Findings From The

“Making the Case For Business

Benefits of HCQIP Projects.” Spe-

cial study. 2003.

24. Abarca J, Malone DC, Armstrong

EP, Zachry WM, 3rd. Angiotensin-

converting enzyme inhibitor therapy

in patients with heart failure en-

rolled in a managed care organiza-

tion: effect on costs and probability

of hospitalization. Pharmacothera-

py. Mar 2004;24(3):351-357.

25. Dempsey CL. Respiratory Infec-

tions - Optimizing Management

of Hospitalized Patients With

Community-Acquired Pneumonia.

Infect Med. 1999;16(10):670-684.

26. Kirkland KB, Briggs JP, Trivette

SL, Wilkinson WE, Sexton DJ. The

impact of surgical-site infections in

the 1990s: attributable mortality,

excess length of hospitalization, and

extra costs. Infect Control Hosp Epi-

demiol. Nov 1999;20(11):725-730.

27. JCAHO (Joint Commission on

Accreditation of Healthcare Or-

ganizations). Health Care at the

Crossroads: Strategies for Address-

ing the Evolving Nursing Crisis:

JCAHO; 2002.

28. Aiken L, Clarke S, Sloane D, Soch-

alski J. An international perspective

on hospital nurses’ work environ-

ments: The case for reform. Policy,

Politics, and Nursing Practice.

2001;2(4):255–263.


29. Kosel K, Olivo T. The Business Case

for Workforce Stability. Irving, TX:

VHA Inc. Center for Research and

Innovation; 2002. Volume 7: VHA

Research Series.

30. Beck RS, Daughtridge R, Sloane

PD. Physician-patient communica-

tion in the primary care office: a

systematic review. J Am Board Fam

Pract. Jan-Feb 2002;15(1):25-38.

31. Winter JA. Doctor, can we talk?

Physician-patient communication

issues that could jeopardize patient

trust in the physician. S D J Med.

Jul 2000;53(7):273-276.

32. Likourezos A, Chalfin DB, Murphy

DG, Sommer B, Darcy K, David-

son SJ. Physician and nurse satisfac-

tion with an Electronic Medical

Record system. J Emerg Med. Nov

2004;27(4):419-424.

33. Krohn R. In search of the ROI from

CPOE. J Healthc Inf Manag. Fall

2003;17(4):6-9.

34. Chaiken BP. Clinical ROI: not just

costs versus benefits. J Healthc Inf

Manag. Fall 2003;17(4):36-41.

35. Bailit M, Dyer MB. Beyond bank-

able dollars: Establishing a business

case for improving health care. Issue

Brief Commonwealth Fund. Sep

2004(754):1-12.

36. Lee F, Teich JM, Spurr CD, Bates

DW. Implementation of physi-

cian order entry: user satisfaction

and self-reported usage patterns.

J Am Med Inform Assoc. Jan-Feb

1996;3(1):42-55.

37. Altman DE, Clancy C, Blen-

don RJ. Improving patient

safety--five years after the IOM

report. N Engl J Med. Nov 11

2004;351(20):2041-2043.

38. Wang SJ, Middleton B, Prosser

LA, et al. A cost-benefit analysis

of electronic medical records in

primary care. Am J Med. Apr 1

2003;114(5):397-403.

39. Renner K. Cost-justifying electronic

medical records. Healthc Financ

Manage. Oct 1996;50(10):63-64, 66,

68 passim.

40. Bates DW, Leape LL, Cullen DJ, et

al. Effect of computerized physician

order entry and a team inter-

vention on prevention of serious

medication errors. JAMA. Oct 21

1998;280(15):1311-1316.

41. Hunt DL, Haynes RB, Hanna

SE, Smith K. Effects of computer-

based clinical decision support

systems on physician performance

and patient outcomes: a sys-

tematic review. JAMA. Oct 21

1998;280(15):1339-1346.

42. Shea S, DuMouchel W, Baha-

monde L. A meta-analysis of 16

randomized controlled trials to

evaluate computer-based clinical

reminder systems for preventive

care in the ambulatory setting. J

Am Med Inform Assoc. Nov-Dec

1996;3(6):399-409.

43. Balas EA, Austin SM, Mitchell

JA, Ewigman BG, Bopp KD,

Brown GD. The clinical value of

computerized information ser-

vices. A review of 98 randomized

clinical trials. Arch Fam Med. May

1996;5(5):271-278.

44. McMullin S LT, Rynearson C,

Doerr T, Veregge P, Scanlan

E. Impact of an evidence-based

computerized decision support

system on primary care prescription

costs. Annals of Family Medicine.

2004;2(5):494-498.

45. Raschke RA, Gollihare B, Wun-

derlich TA, et al. A computer

alert system to prevent injury from

adverse drug events: development

and evaluation in a community

teaching hospital. JAMA. Oct 21

1998;280(15):1317-1320.

46. Kuperman GJ, Gibson RF.

Computer physician order entry:

benefits, costs, and issues. An-

nals of Internal Medicine. Jul 1

2003;139(1):31-39.

47. Institute of Medicine. Perfor-

mance Measurement. Accelerating

Improvement. Washington: The

National Academies Press; 2006.

48. Grossbart SR. What’s the return?

Assessing the effect of “pay-for-per-

formance” initiatives on the quality

of care delivery. Med Care Res Rev.

Feb 2006;63(1 Suppl):29S-48S.

49. Siddharthan K, Nelson A, Tiesman

H, F. C. Cost Effectiveness of a

Multifaceted Program for Safe Pa-

tient Handling: AHRQ. Advances

in Patient Safety: From Research to

Implementation. Volume 3. Imple-

mentation Issues; 2005.

50. Leape LL, Cullen DJ, Clapp MD,

et al. Pharmacist participation on

physician rounds and adverse drug

events in the intensive care unit.

JAMA. Jul 21 1999;282(3):267-270.

51. General Accounting Office (US).

Adverse Drug Events: GAO/

HEHS-00-21; 2000.


52. IOM. Unequal Treatment: Con-

fronting Racial and Ethnic Dispari-

ties in Health Care. Washington,

DC: National Academy Press; 2002.

53. Schuster MA, McGlynn EA,

Brook RH. How good is the

quality of health care in the

United States? 1998. Milbank Q.

2005;83(4):843-895.

54. Gonzales R, Steiner JF, Sande MA.

Antibiotic prescribing for adults

with colds, upper respiratory tract

infections, and bronchitis by ambu-

latory care physicians. JAMA. Sep

17 1997;278(11):901-904.

55. Kressin NR, Petersen LA. Racial

differences in the use of invasive

cardiovascular procedures: review

of the literature and prescription for

future research. Ann Intern Med.

Sep 4 2001;135(5):352-366.

56. Peota C. Health literacy and

patient safety. Minn Med. Apr

2004;87(4):32-34.

57. Ross J. Health literacy and its influ-

ence on patient safety. J Perianesth

Nurs. Jun 2007;22(3):220-222.

58. California Academy of Family

Physicians and CAFP. Address-

ing Language Access Issues in Your

Practice A Toolkit for Physicians

and Their Staff Members 2005.

59. National Quality Forum (NQF).

Serious Reportable Events in

Healthcare: A National Quality

Forum Consensus. 2002.

60. Marchev M. The Malpractice

Insrurance Crisis: Opportunity for

State Action. Portland: National

Academy for State Health Policy;

2002.

61. Spurlock B, Jennifer E, Nelson M,

J. P. Using Legislation and Regula-

tion to Improve Patient Safety in

Hospitals: The California Experi-

ence. Paper presented at: Academy-

Health, 2003.

62. California HealthCare Foundation.

Legislating Medication Safety: The

California Experience. 2003.

63. California HealthCare Founda-

tion. Legislating Medication Safety:

Highlights of Findings. 2003.

✦

1

MCLE &

CEUs OFFERED!!

Patient Safety & Elder Care IssuesCAHQ Spring Conference March 10 – 12, 2008

conference objectivesStrategically leverage opportunities for integration and col-I.

laboration.

Integrate functions and data for efficient solutions for safer II.

patient care.

Describe changes in regulatory standards and California III.

law.

Network with others to stimulate creative problems solving.IV.

Presenter biograPhiesKathleen Billingsley, R.N.—“Using the CDPH Survey to Your

Advantage”

Kathleen Billingsley. R. N. is the Deputy Director of the Center

for Healthcare Quality within the Department of Public Health.

Having had a great deal of experience in health care admin-

istration and operations, Ms. Billingsley has worked extensively

in the regulatory environment as well as in the areas of quality

improvement. She is committed to working closely with consum-

ers, representatives of the industry and advocates.

Julie Braun J.D., LL.M., MD—“Patient Safety: Legal

Implications”

Julie A. Braun, a graduate of the University of Illinois with a

Master of Laws in Health Law from DePaul College of Law

(Chicago), is a Chicago-based attorney and writer. Ms. Braun,

dedicates her practice to health and elder law with an emphasis on

long-term care litigation. She teaches, writes, and lectures exten-

sively on health, elder law, and long-term care topics. Ms. Braun,

also a physician, is an internationally recognized expert in the field

of long-term care litigation, is a visiting professor at various legal

and medical institutions, including Emory University in Atlanta

and the Universities of Osnabrueck and Witten in Germany.

Steven Charles Castle, MD—“Falls and Restraints: What

Constitutes Abuse?”

Dr. Castle is board certified in Internal Medicine and Geriatric

Medicine. He is a Professor of Medicine at UCLA and the Clinical

Director of Geriatrics at the VA Greater Los Angeles. He has been

recognized with many awards, including Clinician of the Year by

the American Geriatrics Society, and One of LA’s Best Doctors

by Los Angeles Magazine. He has been the recipient of two grants

from the National Institute of Aging, and several teaching awards

at UCLA. He has published over 100 papers, abstracts and book

chapters and given nearly 300 invited lectures.

Alan Y. Endo, Pharm. D., FCSHP—“Black Box Warnings”

Alan Endo, Pharm.D. graduated from University of Southern

California School of Pharmacy in 1971 and has been a practicing

hospital pharmacist since then. He has worked in a number of dif-

ferent practice settings from small community hospitals to major

teaching institutions. He is currently past president and Chairman

of the Board of Directors for the California Society of Health-

System Pharmacists.

Charlene Harrington Ph.D., RN, FAAN—“Quality of Care in

Nursing Homes: Nursing Home Policy Issues”

Charlene Harrington, Ph.D., RN, FAAN, is Professor of Sociology

and Nursing in the Department of Social and Behavioral Sciences,

Identify and assess quality care and the lack thereof in the V.

elderly.

Distinguish the difference between elder abuse medical VI.

malpractice.

Identify legal strategies for protecting your patients, facili-VII.

ties, and staff.

Discover how the NEVER 28 will affect YOU!VIII.

Outline three ways you can use the CDPH survey process IX.

to your advantage.

List 3 things to do and not do during your deposition.X.

CAHQ Spring Conference March 10 – 12, 2008 Patient Safety & Elder Care Issues

School of Nursing, University of California, San Francisco. She

was appointed deputy director of the California Licensing and

Certification program, where she was instrumental in strengthen-

ing the regulation of nursing homes and hospitals in California.

Dr. Harrington served on the Institute of Medicine (IOM)

Committee on Nursing Home Regulation whose l986 report led

to the passage of the Nursing Home Reform Act of l987. She is

Associate Director of the John A. Hartford Center for Geriatric

Nursing Excellence and Director of the new doctoral program in

nursing and health policy at UCSF. She has before the US Senate

Special Committee on Aging, and has written more than 200 ar-

ticles and chapters and co-edited five books while lecturing widely

in the U.S. and the U.K.

Martha J. Hawkins, RN, BSN, CWOCN, GNC, CCM—

“Pressure Ulcers and Wound Care”

Marti Hawkins, is a certified wound, ostomy and continence

(WOCN) nurse, a certified geriatric nurse and a certified case

manager. She is a wound care consultant for St. Alphonsus

Regional Medical Center and Horizon Home Care and Hospice in

Boise, Idaho. Ms. Hawkins has presented nationally at conferences

on prevention and treatment of pressure ulcers and the associated

legal issues.

Mark Kleiman, Esquire—“Whistle-blower... To Be or Not To

Be?”

Mark Kleiman is the former Executive Director of the Consumer

Coalition for Health in Washington, D.C. As a trial attorney for

seventeen years, he has prosecuted doctors, hospitals, and nursing

homes for consumer fraud and malpractice. In the process he has

represented nurses, doctors, engineers as well as other whistleblow-

ers in the defense, construction, and education industries.

Mr. Kleiman has consulted with the U.S. Department of

Health and Human Services, the American Public Health

Association, and the American Cancer Society. He has served on

an FDA Advisory Panel and on the boards of state licensing agen-

cies and national health care organizations.

Mr. Kleiman has served as a Special Master during investiga-

tions of fraudulent medical-legal activities in cooperation with the

California Department of Insurance and the Los Angeles County

District Attorney’s Office.

Jeffrey Levine, MD—“Risk Management in Geriatric Care”

Dr. Levine is a physician with twenty years of clinical and adminis-

trative experience in geriatrics and long-term care. He received his

fellowship training in geriatrics at the Mount Sinai Medical Center

in Manhattan, where he spent much of his career on the clinical

faculty. He currently has a hospital-based wound care practice.

He is board certified in Internal Medicine, is a Certified Medical

Director, Certified Wound-care Specialist, and holds a Certificate

of Added Qualifications in Geriatrics. Dr. Levine’s professional

focus is improving the quality of care delivered to elderly persons.

Della Lin, M.D.—“Protecting Patient Safety During Handoff

Communication”

Della Lin, MD, is a frequent speaker and author in the field of pa-

tient safety, reliability and quality initiatives. She has been on the

National Patient Safety Foundation Annual Conference Faculty

for the last several years, was an inaugural Health Forums Patient

Safety Leadership Fellow in 2003, and is a member of the Estes

Park Institute Faculty. Dr. Lin has served as Department Chief of

Anesthesiology, on hospital MEC, Peer Review and Credentialing

committees, is the Executive Director of Continuing Medical

Education at Queen’s Medical Center in Honolulu and is currently

a board member at various health care entities.

Jones Loflin—“Success Without Getting Squashed”

Drawing on skills honed as an educator, business owner, and

speaker, Jones has created and conducted training programs for

groups ranging from international corporations and trade associa-

tions to governmental agencies and educational institutions. Jones’

insightful programs regularly include the use of humor, powerful

examples and frequent audience involvement and interaction. Jones

is co-author of the book, Juggling Elephants, which is available in


the US and in over 12 foreign countries. He is the author of Prime

Rib or Potted Meat?, a humorous and thought-provoking collec-

tion of his ideas on getting more out of life. Jones is also a member

of the American Society of Training and Development.

Debby Rogers, RN, MS, Vice President, Quality and

Emergency Services California Hospital Association—“New

Regulations and Legal Implications. Serious Reportable

Events: Reporting, Liability, and Press Releases”

Debby Rogers is the Vice President for Quality and Emergency

Services for the California Hospital Association. Debby has an ex-

tensive background in state service. She was the Associate Secretary

for Legislative Affairs for the California Health and Human

Services Agency where she was responsible for coordinating all

legislation within the agency. Ms. Rogers spent 10 years with the

Legislature as a consultant on Health and Human Services issues.

Marcia Ryder PhD MS RN—“Healthcare Acquired Infections”

As a national and international educator and instructor, Dr. Ryder

has conducted over 80 specialty nursing courses and presentations.

Her publishing credits include over 25 articles and book chapters

on topics including biofilm-related infections, vascular access

device selection, central venous catheter complications and other

vascular access device subjects.

Suzanne Williams, RN, CPHQ, FNAHQ

As a healthcare professional with over 25 years of hospital acute

care experience and 10 years plus in managed care, Ms. Williams

has acquired the expertise to develop, establish and lead perfor-

mance improvement, utilization and case management programs.

Elder Abuse Mock Trial Participants

Honorable Judge Bruce J. Einhorn

The Honorable Bruce J. Einhorn has served as a United States

Immigration Judge in Los Angeles since July 29, 1990. In that

capacity, he has presided over civil prosecutions initiated by the

U.S. Department of Homeland Security (DHS) against non-

citizens in the United States whose lawful presence here has been

placed into question by counsel for the government. He has also

received a Lifetime Professional Achievement Award from the

California State Bar. Since 1991, Judge Einhorn has served as an

Adjunct Professor of International Human Rights Law and War

Crimes Studies at Pepperdine University School of Law in Malibu,

California. In 1997, Judge Einhorn received the Law School’s

David McKibbin Excellence in Teaching Award. He is a member

of the Bar of the United States Supreme Court, and the American

Bar Association.

Henry P. Canvel, Esquire Gordon and Rees, LLP

Henry P. (“Rick”) Canvel is a litigation partner practicing exclu-

sively in the defense of elder abuse claims representing primarily

extended care, skilled nursing and residential care facilities, and

further defends hospital and nursing registries.

He received his B.A., summa cum laude, from University

California - Berkeley and his J.D. Degree from University of

California - Hastings. Mr. Canvel has extensive national speaking

experience on elder abuse topics before numerous groups includ-

ing American Baptist Homes of The West, Andrews Publications,

Lorman Educational Services and Covenant Care of California,

Inc. He is also a member of the California Association of Health

Facilities (CAHF), and the American Health Association.

Stephen Garcia, Esquire—The Garcia Law Firm

Stephen M. Garcia has specialized in civil trial practice since 1994,

following nine years of focusing on criminal trial advocacy. He

has served as lead counsel on behalf of disenfranchised consumers

in cases including, insurance bad faith, medical malpractice, elder

abuse and products liability.

Mr. Garcia was trial counsel in the matter of Muccianti vs.

Fountain View, Inc., et al. the largest nursing home verdict in

the history of Fresno County and the then second largest nurs-

ing home verdict in the history of the State of California. The

Muccianti punitive damage award was noted to be one of the ten

largest punitive damage awards in the State of California in the


year 2001. Mr. Garcia is one of the only attorneys in the State of

California to have tried to conclusion multiple matters based upon

theories of elder and/or dependent adult abuse issues. Mr. Garcia

is the only California attorney who has tried multiple elder abuse

actions to have not received a complete defense verdict in any elder

abuse trials.

Peter K. Levine, Esquire—Peter K. Levine Law Firm

Mr. Levine has been practicing law since 1978 and is a member

of both the New York and California Bar Associations. His firm

represents individuals and families in serious catastrophic injury

matters. Mr. Levine’s firm includes practice areas of Medical

Malpractice, Elder Abuse, Wrongful Death, Personal Injury,

Employment Law, Discrimination, and Sexual Harassment.

John Supple, Esquire—Gordon & Rees, LLP

John L. Supple is a litigation partner with the law firm of Gordon

& Rees LLP, and the leader of the firm’s Health Care Practice

Group. Mr. Supple, specializes in the defense of the health care in-

dustry including medical malpractice and all aspects of elder abuse

litigation. Mr. Supple has dedicated his entire career to the defense

of health care providers including physicians, hospitals, skilled

nursing and assisted living facilities.

Mr. Supple is a member of the California Association of Health

Facilities (CAHF), the Northern California Association of Defense

Counsel, the American Society of Hospital Risk Managers, the

California Society of Hospital Risk Managers and the California

Medical Legal Committee.

Mr. Supple was chosen as one of Northern California’s “Super

Lawyers” by his peers in the field of health care for 2006. Mr.

Supple’s successful defense of a nursing home sued for wrongful

death, elder abuse and fraud, was selected by the California Daily

Journal as one of the Top 10 Defense Verdicts for 2006. The plain-

tiffs sought $14 million in damages, and the jury rejected all claims

for compensatory and punitive damages.

Tricia West, R.N., BSN, MBA/HCM, PHN, LNC

CEO P.J. West and Associates, Inc. Medical Legal Consulting

Tricia West is founder and chief executive officer of P.J. West and

Associates, Inc., a medical legal consulting firm. Since 1980, Ms.

West is a legal nurse consultant supporting the legal profession

in all areas of practice, including medical malpractice, personal

injury, elder and dependent abuse, criminal, and billing fraud.

Ms. West is a Past President of CAHQ, past Editor of the CAHQ

Journal and current Education Co- Chair. She is a past President

of the American Association of Legal Nurse Consultants Los

Angeles. She is a member of the Los Angeles County and San

Fernando Valley Bar Associations, as well as an arbitrator for the

San Fernando Valley Bar Association. She is also a member of the

Lumetra Hospital advisory council. Ms. West has numerous publi-

cations as well as more than twenty years of teaching experience to

both professionals and patients.

2008 cahQ education committeeCo-Chair: Tricia West, RN, BSN, MBA/

HCM, PHN, LNC

Co-Chair: Jada Salamatian, RN

Lauri Church, CPHQ

Jennifer Hoke, RN, MSN, RNC II

Tricia Kassab, RN, MS, CPHQ

Eliot Kreun, LVN, CPHQ

Pat Luken, RN, MN, CPHQ

Beverly Roberts,R.N. CPHQ

Debby Rogers, RN, MS, CPHQ


Pre-conference WorkshoP (Sponsored by the Healthcare Quality Certification Board)

Monday March 10, 8:00 AM – 12:00 Noon

Suzanne Williams, RN, CPHQ, FNAHQ

Competency Testing: The CPHQ Exam in Motion

Explore the absorbing process of writing exam items for the

Certified Professional in Healthcare Quality (CPHQ) examina-

tion. Gain valuable information about the process of assessing

competency in the workplace. Gain insight from the discussion of

test-taking philosophies and strategies and the experience of learn-

ing how questions are developed and sanctioned for the CPHQ

exam. Discuss the development of the CPHQ exam. State the com-

ponents of a clear, concise test question. Identify 3 cognitive levels

of thinking. Describe the elements of a valid competency examina-

tion. Discuss the use of this information in the workplace to assess

the competency of employees.

conference information

Who should attend?

Professionals responsible for quality management and/or organizational improvement in all areas of

health care delivery including: Compliance/Safety Officers, Nurse Leaders, Risk Managers, Healthcare

Administrators Consultants, QI/UR Professionals, Legal Nurse Consultants, Managed Health Care

Professionals, PI Professionals, Case Managers, Infection Control Practitioners, Medical Staff Leaders,

Attorneys, Legal Nurse Consultants, Paralegals and Judges dealing with medical related legal issues.

Continuing Education

This program is approved by the California Board of Registered Nursing, provider number 03370, for 20

contact hours. This activity will be submitted to the National Association for Healthcare Quality for 8.0

CPHQ CE credits. Approved for MCLE credits by the California State Bar Association.

Registration

Due to limited space, all registrations must be postmarked by March 1, 2008. You may pay by credit

card or by check, payable to CAHQ. Email confirmation will be sent to each participant – be certain to

provide us with your email address. Registration will only be guaranteed with receipt of payment. On-site

registrations will be accepted with full payment on a first-come, first-serve basis. As it is difficult to predict

room temperature, please bring a sweater or jacket.

Cancellation Policy

ALL CANCELLATIONS MUST BE MADE IN WRITING by mail or fax (see above for contact in-

formation). A $75 processing fee will be charged for cancellations and/or registration transfer. No refunds

will be provided for cancellations received after March 2, 2008. Registrants who are unable to attend may

send an alternate, provided they notify CAHQ in writing prior to March 1, 2008. In lieu of canceling for

a refund, you may transfer your credit to any other CAHQ educational function until July 30, 2008. A

transfer fee of $75.00 will apply.


Tuition

Pre Conference, March 10, 2008 8:00 – 12:00 pm • • • • • • • • • • • • • • • • • • • • • • • •$75.00

CAHQ Member Full Conference• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •$499.00

Conference and Join CAHQ• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •$575.00

Non CAHQ Members • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •$675.00

Mock Trial Only• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •$350.00

Mock Trial is on March 12, 2008

10% discount for groups of 3 or more people registering at the same time, in the same payment.

Accommodations

Sheraton Universal Hotel. Special Group Room Rate $189 +

tax. Includes free Internet access. Group rates available until

February 20, 2008. Subject to availability. Make reserva-

tions directly with the Hotel at (818) 980-1212 or through

Sheraton’s Central Reservation Office at 888-627-7186 on

an individual basis, identifying yourself as a member of the

CAHQ group. Visit CAHQ’s website for more information,

www.cahq.org or book your reservation online at

http://www.starwoodmeeting.com/Book/CHC09B

Universal Sheraton Hotel

333 Universal Hollywood Drive

Universal City, California 91608

United States

Phone: (818) 980-1212

Fax: (818) 985-4980

Parking Rates(charged by hotel)

Daily Rates:

$10.00 for self-parking

$14.00 for valet parking

Overnight Rates (with in and out

priviledges)

$16.00 for self-parking

$21.00 for valet parking

conference agendaMonday March 10th, 2008

7:00 – 8:00 am Registration

8:00 – 12:00 pmPre Conference Workshop

Terrace ACompetency Testing: The CPHQ ExamSuzanne Williams, RN, CPHQ

11:00 – 1:00 pm

Registration and meet our ExhibitorsStudio Suites

1:00 pm – 1:15 pmWelcome

Julie Booth, CAHQ President

1:15 pm – 2:45 pmKey Note Speaker: Success Without Getting Squashed—

Juggling ElephantsEast BallroomJones Loflin


2:45 pm – 3: 00 pmVisit our Exhibitors and Enjoy a Snack

Studio Suites

3:00 – 4:00 pm

Track AEast BallroomWhistle-blower…To Be or Not To BeMark Kleiman, Esquire

Track BProducer/Director/WriterRisk Management in Geriatric CareJeffrey Levine, M.D.

4:00 pm – 5:00 pmHealthcare Acquired Infections

East BallroomMarcia Ryder, PhD, MS, RN

Monday (cont’d)

7:00 – 8:00 am Registration and Continental Breakfast with our Exhibitors

Studio Suites

8:00 – 8:15 am Welcome

8:15 am – 9:45 am

Using the CDPH Survey to your AdvantageEast BallroomKathleen Billingsley, Deputy Director of Center for

Health Care Quality, CA Dept of Public Health, Licensing & Certification

9:45 am – 10:10 am Break with our ExhibitorsStudio Suites

10:10 am – 11:10 am

Quality of Care in Nursing Homes—Nursing Home Policy Issues

East BallroomCharlene Harrington, PhD. Professor of Sociology

and Nursing, Dept. of Social & Behavioral Sciences

Tuesday March 11th, 2008


11:10 am – 12:25 am

New Regulations and Legal Implications— A Panel Discussion

East BallroomKathleen Billingsley, R.N., Deputy Director of

Center for Health Care Quality, CA Dept of Public Health, Licensing & Certification

Debby Rogers, RN, MS, Vice President, Quality and Emergency Services California Hospital Association

Tricia West, R.N., BSN, MBA/HCM, PHN, LNC CEO P.J. West and Associates, Inc. Medical Legal Consulting

12:25 pm – 1: 30 pmLunch

Rooftop Garden TerraceAnnual Meeting

1:30 pm – 2:30 pm

Track AProducer/Director/WriterPatient Safety—Legal ImplicationsJulie Braun, J.D., LLM, M.D.

Track BEast BallroomBlack Box WarningsAllen Endo, Pharm. D.

2:30 pm – 3:30 pm

Track AProducer/Director/WriterFalls and Restraints Steve Castle, M.D.

Track BEast BallroomHandoff CommunicationDella Lin, M.D.

3:30 pm – 3:45 pm

Break with our Exhibitors Studio Suites

3:45 pm – 5:00 pmWounds and Wound Care

East BallroomMartie Hawkins, RN, BSN, CWOCN, GNC, CCM

5:00 pm – 8:00 pmCocktail Reception

Roof Top Garden Terrace

Tuesday (cont’d)


7:00 am – 8:00 amRegistration and Continental Breakfast with

our ExhibitorsStudio Suites

8:00 am – 8:15 am

Welcome and IntroductionsEast BallroomTricia West, R.N., BSN, MBA/HCM, PHN, LNC


8:15 am – 5:00 pm

Judge Bruce EinhornTricia West, R.N., BSN, MBA/HCM, PHN, LNC


Defense Counsel Rick Canvel, EsquireJohn Supple, Esquire

Plaintiff CounselStephen Garcia, EsquirePeter K. Levine, Esquire

* Due to the dynamic process of the mock trial these times are flexible. Breaks with our Exhibitors will be from approximate-ly 10:00 – 10:20 am and 3:10 – 3:30 pm. Lunch will be served in the Rooftop Garden Terrace from 12:15 – 1:20 pm

Wednesday March 12th, 2008

registrationName _______________________________Title ________Organization ______________________________Mailing Address ____________________________________________________________________________City __________________________________________________State _____________Zip _______________Telephone ( ________ ) ______________________E-mail __________________________________________Master Card Visa Number _______________________________Exp. Date _______________ADA/Dietary Requirements __________________________________________________________________ __________________________________________________________________________________________Registration _____________________________________$ ________________Total $ ________________

Mail to:

The California Association

for Healthcare Quality

P.O. Box 70819

Pasadena, CA 91117-7819

Please mail by March 1, 2008

Or Fax Credit Card Registrations to: (626) 793-7417

(If you fax this form, please do not mail the original)

For more information, contact CAHQ at 1-800-230-3163 or

(626)793-7125


SAVE THE DATE

THANKS TO OUR SPONSORS

2008 Healthcare Quality Overview and Certification Workshops

Offered by Janet Brown and CAHQ

Thursday and Friday July 24 – 25, 2008

Thursday and Friday October 16 – 17, 2008

Avatar Medmined

LifeStar

Peminic Mercy Air St. John’s


In the November 2007 issue of The Bottom Line, Donna Grant described

the use of “My Story.” This tool is used by both hospital staff at St Mary

Medical Centers ICU as well as the patients they serve. Each learns more

about each other and thus care is more holistic.

I learned that our local Apple Valley Fire Department (AVFD) finds a way

to also connect with those they serve. A few days before Christmas, AVFD

staff came to SMMC along with Santa. They planned to visit the pediatric

unit but ended up touring most of the hospital.

On one unit that we had not planned to visit, a patient’s wife greeted the

AVFD staff and asked which station they were from. She recognized them

from the 911 rescue call they responded to which brought her husband to

the hospital. Tears filled her eyes as she thanked them for the card they sent

to her home. Each crew member had signed the card. They do this routinely

not just at the holidays. She could not thank them enough as she had

obviously been very touched by this caring.

Santa and the firefighters went to her husband’s bedside and silently paid

their respects. He had suffered a massive stroke. One of the AVFD disaster

preparedness personnel had tears in her eyes. She was not aware that they

had done this before. I was also holding back tears. I took Santa and his

helpers to see the, “My Story Board,” inside our ICU. I showed the one of

Denise Nunez, (who was featured in the bottom line in November). It just

happened that Denise was steps away and got to greet the crew. The fire

chief received a copy of a My Story kit; he felt it was very nice. The crew

remarked that they should come to visit the folks that they rescue more often.

Gifts That Keep on GivingPat Lucken, FNP-C, CPHQ

What a lovely thought that these men & women who would give their

life to save you, who serve 24/7 for unforeseen disasters and everyday

emergencies could care so much.

Also, while touring the facility I noticed a woman hand gifts to a staff

member on the maternity ward. No fanfare, just a quick anonymous hand

off of the gifts. Later when I told our medical staff director Anna Beber

about the day’s events she told me of yet another story of caring. Anna

mentioned an anonymous physician who, is a member of the Cardiology

Division of Upland Anesthesia Group, comes in each Christmas to give gifts.

He cannot find a Santa suit to fit his daughter so he dresses her as an elf.

They are not of a Christian tradition but he wants his daughter to know the

values of compassion and giving.

Reflecting about cards sent to the home of a family in crisis, a visit to the

hospital by a rescue crew, a post discharge phone call from a staff member

or an anonymous gift left at the hospital during the holiday, one can see

the privilege of caring . How truly magnificent this sacred work could be if

spread throughout healthcare. One would have a revolution of caring.

Happy New Year

Pat Lucken



Authors’ BiographiesBiographies inadvertently

omitted from November 2007 issue

Martie Hawkins, RN, BSN,

CWOCN, CGN, CCM is a certified

Wound, Ostomy Continence Nurse

Consultant at St. Alphonsus RMC in

Boise, Idaho. She also consults with

Horizon Home Care and Hospice. She

has presented at several conferences

around the country on topics such as

prevention and treatment pressure ul-

cers and the legal issues associated with

pressure ulcers.

Martie can be reached at marti-

[email protected]

Susan Moss. Susan is a Quality Spe-

cialist for American Medical Response

(AMR).

Susan can be reached at Susan_

[email protected]

Donna Grant, RN. Donna is a

Registered Nurse and Supervisor of the

Intensive Care Unit at St. Mary Medi-

cal Center in Apple Valley, Ca. Donna

can be reached at Donna.Grant@stjoe.

org

February, 2008Kathleen Tornow Chai is an ener-

getic proponent for healthcare quality.

For the past two years she has been the

Director of Education and Quality at

Kaiser West Los Angeles. In this role

she currently oversees quality, patient

safety, risk management, medical staff

office, inpatient medical records, and

staff education. Prior to that Kathy

worked full time for her own consulting

firm, KTC Consulting, and traveled

nationally providing assistance to

organizations needing advice in quality,

accreditation and licensure and nursing

areas. As an educator, Kathy uses every

opportunity to use her educational

skills. She currently teaches in the

California State University Dominguez

Hills Masters and Bachelors in Nurs-

ing programs, the institution from

which she earned her MSN and BSN.

An energetic learner, Kathy completed

her Ph.D. in Education at Claremont

Graduate School. Her dissertation

focused on the impact of learning style

and computer and information literacy

on learning by nurses pursing post RN

degrees. Her commitment to the profes-

sional development of others frequently

extends beyond her formal professional

roles.

Kathy believes that one of the stron-

gest tools used by a quality professional

is networking and has held a number of

positions both locally with the Califor-

nia Association for Healthcare Quality

and nationally with the National Asso-

ciation for Healthcare Quality, includ-

ing Board positions. It keeps her head

filled with new ideas from the people

she meets and constantly searching for

new ways to meet the challenges in

today’s healthcare environment.

Brian J Hendrickson, EMT-P has

over 25 years of service in Public Safety

covering most all aspects related to

Emergency Medical Services (EMS).

His current positions include, Vice

President/Co-Founder – Immersive

Learning Technologies, Inc. Clinical

Coordinator/Instructor - Victor Valley

College Prem Reddy School of Health

Sciences Paramedic Academy. He is

active in Community Service and serves

with the following organizations. San

Bernardino EMS Officers Committee,

Inland County Emergency Medical

Authority Protocol Task Force, North

end (CA High Desert) EMS Q/I Com-

mittee, Member National Association

of EMS Educators

Brian can be reached at hendrick-

[email protected]

Pat Lucken, MSN, FNP-C, CPHQ

received her MSN/FNP from Azusa

Pacific University in Azusa Ca. She is

currently Director of Cardiac Service

Line at St Mary Medical Center, in

Apple Valley, Ca (part of the St Joseph

Health system of Orange, Ca). Pat

serves the Board of CAHQ as Journal

Co-editor for 07-08. She also serves on

the Board of Inland County Emergency

Medical Agency (ICEMA) as Secretary

for the North End Quality Committee

for 07-08.

Fabio Sabogal, PhD has more than

20 years of experience as a university

professor and researcher, and has writ-

ten more than 50 peer-reviewed journal

articles. He is a Senior Health Care

Information Specialist for the Scien-

tific Analysis Department at Lumetra,

responsible for synthesizing evidence-

based information for the Physician

Office, Health Information Technology,

Managed Care, Underserved, Hospitals,

and Home Health projects.

Fabio can be reached at Fsabogal@

caqio.sdps.org

Linda M. Sawyer, PhD, RN has

more than 30 years of expertise as a

Registered Nurse with clinical, re-


search, education, quality improvement

and administrative experience in diverse

healthcare settings. She is the Chief

Operating Officer at Lumetra.

Linda can be reached at Lsawyer@

caqio.sdps.org

Allison Snow, MHA is the vice

president for healthcare process

improvement at Lumetra, serving as

the organization’s chief quality and

performance improvement officer. She

provides strategic direction and opera-

tional and fiscal oversight for managers

and staff. Ms Snow represents Lumetra

to key organizations, customers, and

stakeholders to foster collaboration

at the state and national levels. She

also promotes visibility for Lumetra at

national meetings with key constitu-

ents. Allison can be reached at Asnow@

caqio.sdps.org

✦

2007 First Quarter Journal

Janet Brown, BA, BSN, RN, CPHQ, FNAHQ

Catherine Martin, BA, BSN, RN, CPHQ, FNAHQ

A Look Back Over the Past 30 Years for California Association of Healthcare Quality•••••••••••••••••••••••••••••••••• p 5

California Association of Healthcare Quality2007 Author/Article Index

CAHQ expresses gratitude for those whom have contributed articles,

press releases, reflections, book, conference and movie reviews over the past year.

A special thanks to our graphic designer Colin MacGregor!

thAnnive

rsary

thAnnive

rsary

Official publication of the California Association for Healthcare Quality

Volume 31, Number 1 1st Quarter, 2007

In this issue...

CAHQ Celebrates Years –

What is Complementary and Alternative Medicine

Physician Patient Communication and Self Management Support

In this issue...

CAHQ Celebrates Years –

What is Complementary and Alternative Medicine

Physician Patient Communication and Self Management Support


Tricia West RN, BSN, MBA, CHN, LNC

What is Complementary and Alternative Medicine•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 7

Pamela Simpson, RN, MSA, CPHQ

The Alexander Technique: A Better Way to Use Your Body•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 9

National Institute of Health Press Release

Older Americans Not Discussing Complementary and Alternative Medicine Use with Doctors• •••••••••••••••••••••• p 12

Nancy Lee, MS, BSN

Robin Diane Orr, MPH

The Patient Experience: Quality as a Dimension of Culture••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 13

Steven Hilles, DC, CPHQ

Lars Youngquist, DC, LAC, CPHQ

Applying Evidenced-Based Medicine to Complementary Healthcare•••••••••••••••••••••••••••••••••••••••••••••••••• p 16


Managing Quality in Massage Therapy••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 20

Sally Lett, DC, RN, LNC

Personal Injury: Chiropractic Medicine and Medical Legal Nurse Consultation••••••••••••••••••••••••••••••••••••••• p 22


Craniosacral Therapy: A Helpful Modality or a Waste of Money•••••••••••••••••••••••••••••••••••••••••••••••••••••• p 23


What is Six Sigma? A book Review••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 25

James Reason, Professor Emeritus, University Manchester

Beyond the Organizational Accident: The Need for “Error Wisdom” on the Frontline••••••••••••••••••••••••••••••••• p 26

The Institute for Healthcare Improvement Research Findings

IHI Press Release••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 31

Julie Booth, RN, MS, CPHQ, RHIA

Notes from Speech by JCAHO President Dennis O’Leary•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 31

Liz Augusta, RN, MSN, CPHQ, LNCC

Identification and Evaluation of one Organization’s Punitive Response to Error••••••••••••••••••••••••••••••••••••••• p 32


Julie Harmata Booth, RN, MS, CPHQ, RHIA

You: The Smart Patient an Insider’s Handbook for Getting the Best Treatment; A Book Review••••••••••••••••••••••• p 37

Marcie Cochran, RN, CPHQ

Setting the Table: The Transforming Power of Hospitality in Business; A Book Review• •••••••••••••••••••••••••••••• p 38

Tricia West, RN, BSN, CHN, LNC

Medical Errors and Medical Narcissism•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 40

2007 Second Quarter Journal

Jennifer Hoke, BSN, MSN, RN

Tricia West, RN, BSN, CHN, LNC

California Association of Healthcare Quality’s First Mock Trial a Success•••••••••••••••••••••••••••••••••••••••••••••• p 7

Kathleen Tornow Chai, MSN, PhD, CPHQ, FNAHQ

California Hospital Assessment and Reporting Taskforce•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 8

Debbie Rogers, RN, MS

Legislative Update••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 9


Learn More About National Association for Healthcare Quality•••••••••••••••••••••••••••••••••••••••••••••••••••••• p 10


Pandemic••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 11

Julia Slininger, RN, BS, CPHQ, Lumetra

Lessons Learned From California’s Surgical Care Improvement Collaborative••••••••••••••••••••••••••••••••••••••••• p 13

thAnnive

rsary

thAnnive

rsary

Official publication of the California Association for Healthcare Quality

Volume 31, Number 2 2nd Quarter, 2007

In this issue...

CAHQ’s First Annual Mock Trial A

Success!

Legislative Updates

Leasons Learned From California’s

Surgical Care Improvement Collaborative


Fabio Sabogal, PhD, Lumetra

Mindy Coots-Miyazaki, MSN, CPHQ, Lumetra,

James E Lett, MD, CMD, Lumetra

Ten Effective Care Transitions Interventions: Improving Patient Safety and Healthcare Quality••••••••••••••••••••••• p 15

Sharon Mass, PhD, ACM

Case Management A Collaborative Journey: Are we There Yet?••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 20

Debbie Buzzard, NPSGO

Pat Lucken, RN, MSN, FNP-C

The Bottom Line. Mr Hernandez, a reflection• ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 22

2007 Third Quarter Journal

Compiled by Catherine Carson, BSN, MPA, CPHQ

Modified by Kathleen Tornow Chai, MSN, PhD, CPHQ, FNAHQ

Surgical Care Improvement Project Compendium:

Operational Approaches to Improve Clinical SCIP Measure Results•••••••••••••••••••••••••••••••••••••••••••••••• p 10

Barbara Furry, RNC, MS, CCRN, FACCN

Acute Coronary Syndrome: Defining the Difference•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 14

Pamela, Simpson, RN, MSA, CPHQ

What is Managed Care and How is it Regulated?••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 15


Notes from NAHQ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 17


Earn CEUs for articles in this issue!

Supporting Care Management,

Improving Care Coordination:

�e Role of Electronic Health Records

Acute Coronary Syndrome: Defining the

DifferenceSurgical Care Improvement Project Compendium: Operational Approaches to Improve Clinical SCIP Measure Results

Volume , Number rd Quarter,



Ashley Antler, BA, Lumetra

Ana Perez, MSN, CDE, CPHQ, Lumetra

Physician-Patient Communication and self-Management Support:

Enhancing Quality of Care for the Hispanic Elderly•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 18

Dr Syed Raza, MD, FACC


In Search of Perfect Healthcare for Heart Failure••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 26


Joseph Scherger, MD, MPH, Lumetra

Ida Ahmadpour, MPH, CHES, Lumetra

Supporting Care Management Improving Care Coordination: The Role of Electronic Health Records•••••••••••••••• p 29

Brian Hendrickson, EMT-P

Lifeguard•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••p 44


The Bottom Line. Watercolors, a reflection•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 46

Tricia West, RN, BSN, PHN, MBA, HCM, LNC

Sicko a Review••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 47

2007 Fourth Quarter Journal

Susan Moss, Quality Specialist, American Medical Response

EMS Grand Rounds: Pre-Hospital Airway Emergency•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 11


�e Power of One: Impacting Patient Outcomes by Returning to the Basics

Pain Management

& Care of the Dying

Pressure Ulcers: Updated Definitions, Recognition & Treatment

�e Power of One: Impacting Patient Outcomes by Returning to the Basics

Pain Management

& Care of the Dying

Women’s Health Gaps: A Forgotten

Group

Women’s Health Gaps: A Forgotten

GroupPressure Ulcers: Updated Definitions, Recognition & Treatment

Volume , Number th Quarter,


Michael Pesce, M.D., J.D.

Pain Management and Care of the Dying••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 12

Kathleen Vollman, MSN, RN, CCNS, FCCM

The Power of One: Impacting Patient Outcomes by Returning to Basics•••••••••••••••••••••••••••••••••••••••••••••• p 15


Linda Sawyer, PhD, Lumetra

Saleema Hashwani, PhD, Lumetra

Older Women’s Health Gaps: A Forgotten Group••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 20

Notes from NAHQ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 29

Julie Harmata Booth, MS, CPHQ, RHIA

Harvard Colloquium••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 30

Martie Hawkins, BSN, CWOCN, CCM

Pressure Ulcers-Updated Definition Recognition and Treatment•••••••••••••••••••••••••••••••••••••••••••••••••••••• p 32

Office of the Governor: Press Release Legislative Update•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 56

Deborah Buzzard, NPSGO

Apple Pies•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 57

Donna Grant, RN

The Bottom Line. My Story a reflection••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 58

✦


Do you want to write an article for the CAHQ Journal?Article Submission Criteria

We at CAHQ are extremely interested in anyone who would be willing to write and share their articles with us for inclusion

in the Journal. Please submit your articles to the Co-Editors Kathy Chai at [email protected] or Pat Lucken at pat.lucken@stjoe.

org by the deadline dates of Oct 1, Jan 1, April 1, and July 1.

Article Length: Article submissions should be between 2,500 and 3,500 words.

Software: Submit articles as MicrosoftWord or CorelWordPerfect documents.

Margins: Set all margins at one inch, header and footer at 0.5 inches.

Font: Use Times New Roman or Ariel, 12 pt throughout (including title, headlines, subheadlines, etc.)

Titles: Make titles flush left and bold, in sentence format. The first word is capitalized, the rest lowercase, unless one of the

words is a proper noun.

Headlines: Make headines as short as possible and avoid punctuation. The first word is capitalized, the rest lowercase, un-

less one of the words is a proper noun.

Author: Include the author(s) name underneath the headline with all of the titles correlating to the author

Spacing: Set spacing for single space between lines of text; do not double space between paragraphs.

Alignment: Set for flush left throughout.

Paragraphs: Indent the first line of each paragraph one half inch using <Tab> instead of indent formatting or multiple

spaces. Indented quotation margins are one half inch on the left with the first line tabbed at one inch.

Bold, Italic and Underline: Do not underline anything. Make titles and first level headings bold, sentence format, no

periods. Make second level headings italic, sentence format. Avoid third level headings if possible. Use italic for emphasis

within the body of the article.

Bullet Points: If applicable, use round dark bullet points, flush left alignment.

Footnotes/Endnotes: In Microsoft Word (Windows) go to Insert > Reference > Footnote. In Microsoft Word (Mac) go to

Insert > Footnote. In Word Perfect go to Insert > Footnote/Endnote.

Graphics: If graphics are included in the article document for plaement, also submit the graphic file separately. Avoid using

graphics obtained from the internet as they are usually very poor quality. Any photographs and raster images should

be desired dimensions at 72 ppi. Accepted file formats include: JPEG, TIFF, BMP, Adobe Photoshop (PSD), PDF and

PNG. Illustrations and vector graphics (including tables and graphs) should be in one of the following formats: Adobe

Illustrator (AI), EPS, PDF or SVG.

Biography: Include a brief author’s biography of no more than 50 words at the end of the article (article authors only).

Article Summary: Include a 25-40 word summary description of your article for use on the Table of Contents.


Guidelines for Articles on Hospital Quality ProjectsStyle and Information SheetThe questions below can act as a guide in helping you write your article.

1) When did you start working on the project?

2) What was the purpose of the project? What were your goals?

3) What clinical measures did you work on improving?

4) Where is your hospital located?

5) What is the size of your hospital?

6) What is the size of the hospital staff? Quality improvement team staff (if applicable)?

7) What is the average patient to nurse ratio?

8) Did you or your team attend any training? Please describe.

9) Did you provide any training? To whom? Please describe.

10) What improvements did you experience and when? (Please be as specific as possible and use data, percentage points,

etc.) Provide graphs if possible.

11) Did your project result in any tools you can share? If so, please include.

12) Did you experience any other accomplishments?

13) Did you have any lessons learned that you are willing to share.

14) Who were the primary champions of the project (names and titles). Include a team picture if you can.

Save These Dates! Healthcare Quality Overview and Workshops

Janet A. Brown, BA, BSN, RN, CPHQ, FNAHQ

Janet Brown is well known in the

field of healthcare quality as a consul-

tant and educator. She is the author of

The Healthcare Quality Handbook:

A Professional Resource and Study

Guide, in its 22nd annual edition (July

2007), and has taught more than 95

Workshops nationally for healthcare

quality professionals preparing for the

CPHQ Certification Examination.

She is also co-author of Managing

Managed Care II: A Handbook for

Mental Health Professionals, in its

second edition, and a complementary

Casebook. Janet is owner of JB Quality

Solutions, Inc., and has been actively

involved with healthcare organizations

making strategic system changes for

quality improvement, resource and risk

management, and managed care. She

has served on the CAHQ Board, was

the first Chair of the National Health-

care Quality Foundation, received the

National Association for Healthcare

Quality’s National Distinguished Mem-

ber Award, and is a Past President and

current Fellow of NAHQ.

Thursday & Friday

7/24/08 – 7/25/08 &

Thursday & Friday

10/16/08 – 10/17/08


Thursday & Friday

7/24/08 – 7/25/08 &

Thursday & Friday

10/16/08 – 10/17/08

CAHQ, P. O. Box 70819, Pasadena, CA 91117-7819 800-230-3163 626-793-7125 FAX: 626-793-7417 www.cahq.org Tax ID #95-3647787

New Application Renewal Referred by: __________________ Date Mailed: _________

Regular Dues $85 Discounted Dues $75 (prepaid by 12/31 for next year) Organization Membership $300 Student Dues $45 (Submit copy of Student ID with application.) Student membership limited to a maximum of one year.

SAVE EVEN MORE with added discounts BY EXTENDING YOUR MEMBERSHIP FOR 2 OR 3 YEARS NOW: Prepay $140 for a discounted 2-year membership or $200 for a 3-year membership. Organizational members can save by

taking advantage of a $500 prepaid 2-year membership or prepay $720 for a 3-year membership.

Mail completed application and check payable to CAHQ to the address above or pay by credit card:

MC/Visa/Amer Exp ________________________________ _____________________________ _____________ (circle one) Credit card # Signature Exp. Date

Name:

Business: Facility Name:

Title

Address

City: State: Zip:

Home: Address:

City: State: Zip: Business phone: e mail address: Fax number: Home phone: For publication in the CAHQ Directory, use my business home address.

For mailings, use my business home address. Omit my name from lists CAHQ shares with non-affiliated organizations. (You will still receive all CAHQ mailings.) I hold active status as a Certified Professional in Healthcare Quality (CPHQ). I am a current member of the National Association for Healthcare Quality (NAHQ), a CAHQ affiliate. RN Calif. license #_______________ Registered Health Information Administrator (RHIA)_____________ MD/DO license #________________ Registered Health Information Technician (RHIT) ________________ Cert. Med. Staff Coord. (CMSC) #__________ Cert. Prof. Cred. Specialist (CPCS) #___________________ Certified Risk Manager Other professional license/certification/accreditation. Type_______________________ #_________________ Type_______________________ #_________________

In which type of organization/facility do you currently work? (Select the 1 most appropriate description)

Acute care hospital or medical center Outpatient clinical facility Home health/hospice Behavioral health facility Specialty healthcare facility (e.g., chemical dependency or rehab.) Long term care facility Corporate or network/system headquarters Government agency (non-hospital) Licensure or accreditation body Insurance company/PPO Managed care organization Consultant Private review organization Health maintenance organization None of these apply

What is/are your area(s) of expertise? (Check all that apply)

Quality management/improvement Risk management Care/case/utilization management Medical staff services Managed care Administration Information management Patient safety Corporate compliance Ambulatory/rehabilitative care Infection Control Long term care Home care Behavioral health Nursing

Which best describes your current position? Senior management Supervisory Middle Management Consultant Staff How many years of experience do you have in the healthcare quality field? ________________ Have you been a CAHQ member before? Yes No If yes, when? __________(year) 11/07

California Association for Healthcare Quality MEMBERSHIP APPLICATION

official publication of the california association for ... · official publication of the...

Documents