Category Archives: Health Care Quality
Minoo Sarkarati, BA, is a third-year medical student and Robert Wood Johnson Foundation (RWJF) Health Policy Scholar at Meharry Medical College. She completed her undergraduate degrees of psychology and integrative biology at the University of California, Berkeley. Learn about the RWJF Briefings @ the Booth at the APHA Annual Meeting on Monday, November 17 and Tuesday, November 18.
What determines your health? Is it your zip code? Is it the clinic or hospital you go to? Is it the physician you see? Or is it you?
I could not say that the answer to this critical question is solely any one of these. However, understanding how each component plays a role in one’s health, as well as exploring further determinants, is vital to building healthier communities.
This year’s American Public Health Association (APHA) Meeting theme is Healthography. It is an opportunity to explore how our environment—whether it is access to clean air, safe housing, transportation, healthy foods, safe places to exercise, jobs, or quality health care—plays a role in our health.
As a medical student training in a safety-net hospital, I have seen how each of these elements plays a role in one’s health. Without addressing these factors, a large part of medical care is lost. Encouraging regular exercise is not so simple when you do not have sidewalks or green spaces, or you do not feel safe being outside in your neighborhood. Writing a prescription to treat diabetes becomes meaningless if your patient cannot fill it because he/she does not make enough income to purchase the medication.
Eileen Lake, PhD, RN, FAAN, and Jeannette Rogowski, PhD, are co-principal investigators of a study, supported by the Robert Wood Johnson Foundation (RWJF) Interdisciplinary Nursing Quality Research Initiative, that generated evidence linking nurse staffing and work environments to infant outcomes in a national sample of neonatal intensive care units.* A new documentary, “Surviving Year One,” examines infant mortality in Rochester, N.Y. and nationwide. It is being shown on PBS and World Channel stations (check local listings). Read more about it on the RWJF Culture of Health Blog here and here.
Are some premature babies simply born in the wrong place? Premature babies are fragile at birth and most infant deaths in this country are due to prematurity. It is well established that blacks have poorer health than whites in our country, but the origin of these disparities is still a mystery. It’s possible that the hospital in which a child is born may tell us why certain population groups have poorer health.
A new study by University of Pennsylvania and Rutgers investigators that I led shows that seven out of ten black infants with very low birth weights (less than 3.2 lbs.) in the United States have the simple misfortune of being born in inferior hospitals. What makes these hospitals inferior? A big component is lower nurse staffing ratios and work environments that are less supportive of excellent nursing practice than other hospitals. Our study, which was funded by the RWJF Interdisciplinary Nursing Quality Research Initiative, indicates that the hospitals in which infants are born can affect their health all their lives.
A Brighter Future
What can be done to make these hospitals better? A first step would be to include nurses in decisions at all levels of the hospital, as recommended by the Institute of Medicine to position nursing to lead change and advance health. Laws in seven states require hospitals to have staff nurses participate in developing plans for safe staffing levels on all units.
Erin Krebs, MD, MPH, is the women’s health medical director at the Minneapolis VA Health Care System and associate professor of medicine at the University of Minnesota Medical School. She is an alumna of the Robert Wood Johnson Foundation (RWJF) Physician Faculty Scholars program and the RWJF Clinical Scholars program.
How can we create a Culture of Health that effectively serves veterans? We can put veterans in charge of their pain care.
Chronic pain is an enormous public health problem and a leading cause of disability in the United States. Although 2000-2010 was the “decade of pain control and research” in the United States, plenty of evidence suggests that our usual approaches to managing chronic pain aren’t working. Veterans and other people with chronic pain see many health care providers, yet often describe feeling unheard, poorly understood, and disempowered by their interactions with the health care system.
Evidence supports the effectiveness of a variety of “low tech-high touch” non-pharmacological approaches to pain management, but these approaches are not well aligned with the structure of the U.S. health care system and are often too difficult for people with pain to access. Studies demonstrate that patients with chronic pain are subjected to too many unnecessary diagnostic tests, too many ineffective procedures, and too many high-risk medications.
Physician assistants (PAs) received high marks from patients in a recent survey conducted by Harris Poll for the American Academy of Physician Assistants (AAPA). Among 680 Americans (out of more than 1,500 surveyed) who have interacted with a PA in the past year, 93 percent see PAs as part of the solution to the nation’s shortage of health care providers; 93 percent regard PAs as trusted health care providers; and 91 percent agree that PAs improve health outcomes for patients.
“The survey results prove what we have known to be true for years: PAs are an essential element in the health care equation and America needs PAs now more than ever,” AAPA President John McGinnity, MS, PA-C, DFAAPA, said in a news release. “When PAs are on the health care team, patients know they can count on receiving high-quality care, which is particularly important as the system moves toward a fee-for-value structure.”
The AAPA points out that more than 100,000 PAs practice medicine in the United States and on U.S. military bases worldwide. A typical PA will treat 3,500 patients in a year, the association says, conducting physical exams, diagnosing and treating illnesses, ordering and interpreting tests, prescribing medication, and assisting in surgery.
New guidelines from the American Association of Medical Colleges (AAMC) are intended to close the gap between expectations and the reality of what medical students are prepared to do at the start of their residencies.
Known as the Core Entrustable Professional Activities for Entering Residency, the guidelines include 13 activities—such as performing physical exams, forming clinical questions, and handing off patients to other physicians when residents go off duty—that all medical students should be able to perform, regardless of specialty, in order to be better prepared for their roles as clinicians. In August, AAMC launched a five-year implementation pilot with 10 institutions.
Ensuring that the nation’s medical school graduates “have the confidence to perform these activities is critical for clinical quality and safety,” AAMC President and CEO Darrell G. Kirch, MD, said in a news release earlier this year. “These guidelines take medical education from the theoretical to the practical as students think about some of the real-life professional activities they will be performing as physicians.”
In the last 15 years, the availability of high-fidelity simulation has slowly begun to transform the clinical education of the nation’s nursing students. Schools that once relied on the combination of classroom education and hands-on experience in a clinical environment began to mix in time in a simulation lab, where nursing students could work with highly sophisticated mannequins able to display a range of symptoms and react in real-time to treatment.
Such simulation labs offer many advantages to nurse educators, including the ability to replicate a range of patient situations, thus allowing students to practice specific nursing skills without having to practice their budding skills on actual patients.
But how effective are simulators at training the next generation of nurses? That’s a question that the National Council of State Boards of Nursing (NCSBN) has a particular interest in answering, because the state boards it represents are asked with increasing frequency to permit nursing schools to replace on-the-ground clinical time with simulation.
In pursuit of an answer, NCSBN conducted a full-scale study, tracking 666 nursing students for two academic years, beginning in Fall 2011, and then for six months longer as they began their work in the nursing profession. During their nursing school experience, one-quarter of the students had traditional clinical experiences with no simulation, another quarter had 25 percent of their clinical hours replaced by simulation, and the remaining half had 50 percent of their clinical hours replaced by simulation. At various points during their training and subsequent work as nurses, all study participants were assessed for clinical competency and nursing knowledge.
Charles D. Scales Jr., MD, MSHS, an alumnus of the Robert Wood Johnson Foundation/VA Clinical Scholars program (UCLA 2011-2013), is a health services researcher at the Duke Clinical Research Institute and assistant professor in the division of urologic surgery at Duke University School of Medicine. He is also assistant program director for quality improvement and patient safety for the urology residency training program at Duke University Hospital.
Young doctors training to become surgeons, also called surgical residents, are increasingly caring for patients in an environment that links quality, safety, and value to patient outcomes. Over a decade ago, the Institute of Medicine highlighted the need for improving care delivery in the landmark report, Crossing the Quality Chasm, suggesting that high-quality care should be safe, effective, patient-centered, timely, efficient (e.g., high value), and equitable. Just this week, the Institute of Medicine followed with a clarion call for training new physicians to participate in and lead efforts to continually improve both care delivery and the health of the population, while simultaneously lowering costs of care.
To support this imperative, the Accreditation Council for Graduate Medical Education, which accredits all residency training programs in the United States, mandates that all doctors-in-training receive education in quality improvement. Despite this directive, a number of substantial barriers challenge delivery of educational programs around quality improvement. Health care is increasing complex, driving residents to focus on learning the medical knowledge and surgical skills for their field. Patient care demands time and attention, which can limit opportunities to learn about quality improvement within the context of 80-hour duty limits. This barrier particularly challenges surgeons-in-training, who often spend 12 or more hours daily learning surgical skills in the operating room, leaving little time for a traditional lecture-format session about quality improvement. Finally, many surgical training programs lack faculty with expertise in the skills required to systematically improve the quality, safety, and value of patient care, since these skills were simply not taught to prior generations of surgeons.
Health care worker fatigue was a factor in more than 1,600 events reported to the Pennsylvania Patient Safety Authority, according to an analysis in the June issue of the Pennsylvania Patient Safety Advisory. Thirty-seven of those events, which occurred over a nine-year period, were categorized as harmful, with four resulting in patient deaths.
“Recent literature shows that one of the first efforts made to reduce events related to fatigue was targeted to limiting the hours worked,” Theresa V. Arnold, DPM, manager of clinical analysis for the Authority, said in a news release. “However, further study suggests a more comprehensive approach is needed, as simply reducing hours does not address fatigue that is caused by disruption in sleep and extended work hours.”
In the Pennsylvania analysis, the most common medication errors involving worker fatigue were wrong dose given, dose omission, and extra dose given. The most common errors related to a procedure, treatment, or test were lab errors. Other errors included problems with radiology/imaging and surgical invasive procedures.
More information on health care worker fatigue and patient safety is available here.
Kathy Apple, MS, RN, FAAN, is CEO of the National Council of State Boards of Nursing and an alumna of the Robert Wood Johnson Foundation (RWJF) Executive Nurse Fellows program (2006-2009). She received the Ben Shimberg Public Service Award from the Citizen’s Advocacy Center.
Human Capital Blog: Congratulations on receiving the Ben Shimberg Public Service Award from the Citizen’s Advocacy Center! What does the award mean for you and for your work at the National Council of State Boards of Nursing (NCSBN)?
Kathy Apple: It is quite an honor for both NCSBN and myself, as this recognition comes from an independent, objective organization that advocates for the public interest, effectiveness, and accountability of health care licensing bodies. It confirms that NCSBN is on the right track in supporting its members, the nurse licensing boards in the United States.
HCB: The award is named for a man who is considered the “father” of accountability in professional and occupational licensing. How are you carrying out his mission at NCSBN?
Apple: Dr. Shimberg was an expert on competency testing and challenged all licensing boards to ensure competence assessments meet the highest psychometric and ethical standards. He urged licensing boards to continuously examine how to improve testing procedures. Dr. Shimberg challenged licensing boards to improve communication to applicants and consumers, to keep data and accurate records on all board business, and be accountable for their own performance. He advocated for licensing boards to conduct research in all aspects of regulatory functions. He encouraged collaboration between and among licensing agencies. He challenged all regulators to have and follow their own code of ethics. Dr. Shimberg really was incredibly insightful and visionary regarding the role and work of licensing boards.
Brendan Carr, MD, MA, MS, directs the Emergency Care Coordination Center and is on the faculty of the Perelman School of Medicine at the University of Pennsylvania. He is an alumnus of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program (2008-2010).
Human Capital Blog: The Emergency Care Coordination Center (ECCC) was created in 2006 by presidential directive in response to pressing needs in the nation’s emergency medical care system. Can you describe those needs?
Brendan Carr: I’ll try my best. While the landmark Institute of Medicine (IOM) report on the future of emergency care really brought much of this into focus in 2006, the story of the emergency care system’s struggles extends back well before that. The IOM reports on the health care system’s response to injuries (Accidental Death and Disability in 1966 and Injury in America in 1985) really foreshadowed the shortcomings of acute care delivery. At the time, we understood that rapid intervention in trauma was lifesaving and that our delivery system wasn’t keeping pace with the science of emergency care.
Over the last few decades, we’ve really come face to face with this reality on a broader scale. Our growing appreciation for the importance of early diagnostics and intervention, combined with increased awareness about the importance of creating a patient-centered health care system, have highlighted the mismatch between the demand for care and the product that we deliver. The emergency care system’s crisis is really the health system’s crisis.