INQRI Researcher Patti Hamilton Explores Why the "Weekend Effect" is Putting Patients at Risk

With studies showing that nearly a quarter of the leading causes of deaths in hospitals happen to patients admitted at night or on weekends, INQRI researcher Patti Hamilton is using an RWJF grant to explore the reasons—and finding answers that may help guide staffing committees.

Click here to read about Dr. Hamilton's work.

Click here to visit "Life in the Trenches," a blog about nurses who work on the nights and weekends.

This story was published in the Robert Wood Johnson Foundation's September edition of the e-newsletter "Sharing Nursing's Knowledge."

Our next webinar is NEXT WEEK... Sign up now!

Next Webinar: Wednesday, October 7

Examining the Impact of Nursing Structures and Processes on Medication Errors

Speaker: Linda Flynn, University of Maryland

Date: October 7, 2009: 3:30 p.m. - 4:30 p.m. EST

Each year, INQRI offers a series of webinars designed to educate grantees and inform the public about our work. Grantee teams are polled to identify topic areas they would like covered. This fall, we have already featured a presentation on the Robert Wood Johnson Foundation's Initiative on the Future of Nursing, at the Institute of Medicine. Special thanks to Sue Hassmiller and Lori Melichar for leading this presentation. We have another webinar planned for November which will focus on the use of subject incentives in research.

We are also continuing to explore issues surrounding medication management. In 2007, INQRI worked with the Gordon and Betty Moore Foundation to plan a day-long convening which brought researchers together with stakeholders to discuss the impact of medication errors. We will continue this investment with a series of webinars that begin this October.

In the coming months, we will release the "save the dates" for our spring series. Look for a continuation of the medication management series as well as a new series focused on translating research into practice. The translation series will be co-sponsored by the Donaghue Foundation and will continue the work we begun with the Funders Forum.

Please contact Heather Kelley with any questions or to RSVP.

INQRI General Series

The Robert Wood Johnson Foundation's Initiative on the Future of Nursing, at the IOM
Speakers: Sue Hassmiller and Lori Melichar
Date: September 22, 2009: 12 p.m. EST - 1 p.m. EST
If you missed this presentation, click here to either download the slides or view the presentation at your desktop.

Subject Incentives in Research
Speaker: Connie Ulrich, the University of Pennsylvania School of Nursing and Christine Grady, National Institutes of Health
Date: November 18, 2009: 2 p.m. - 3 p.m. EST

Medication Management Series

Examining the Impact of Nursing Structures and Processes on Medication Errors
Speaker: Linda Flynn, University of Maryland
Date: October 7, 2009: 3:30 p.m. - 4:30 p.m. EST

Nursing, Technologies and Medication Management: New Multidimensional Measures of Cost and Quality
Speaker: Pascale Carayon, Bentzi Karsh and Joy Rivera, University of Wisconsin-Madison
Date: December 11, 2009: 3:00 p.m. - 4:00 p.m. EST

Missed Yesterday's Webinar? Check it out Online

Special thanks to Sue Hassmiller and Lori Melichar for yesterday's presentation on The Robert Wood Johnson Foundation's Initiative on the Future of Nursing, at the Institute of Medicine. If you missed the webinar, please take a look at the slides or view the presentation right from your desktop.

PowerPoint Presentation
Webinar Recording

Keep your eyes on this space - we will be posting the rest of our fall webinar calendar this week.

JOIN NOW - Webinar on the Initiative on the Future of Nursing

Topic: INQRI - IFN
Date: Tuesday, September 22, 2009
Time: 12:00 pm, Eastern Daylight Time (New York, GMT-04:00)
Meeting Number: 574 746 816
Meeting Password: INQRIweb1


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To join the online meeting (Now from iPhones too!)
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1. Go to https://rwjf.webex.com/rwjf/j.php?ED=130456777&UID=0&PW=NY2E5ZWQ5N2Vj&RT=MiMxMQ%3D%3D
2. Enter your name and email address.
3. Enter the meeting password: INQRIweb1
4. Click "Join Now".

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To join the audio conference only
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To receive a call back, provide your phone number when you join the meeting, or call the number below and enter the access code.
Call-in toll-free number (US/Canada): 866-469-3239
Access code:574 746 816

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For assistance
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1. Go to https://rwjf.webex.com/rwjf/mc
2. On the left navigation bar, click "Support".

You can contact me at:
hkelley@nursing.upenn.edu

It's TOMORROW: the first INQRI webinar of the fall!

Tomorrow is the day! Sue Hassmiller and Lori Melichar will be discussing the Robert Wood Johnson Foundation's Initiative on the Future of Nursing, at the Institute of Medicine from 12:00 p.m. - 1:00 p.m. Please take the opportunity to join Sue and Lori to share your thoughts and get your questions answered.

For more information, email Heather Kelley.

The Robert Wood Johnson Foundation's Initiative on the Future of Nursing, at the IOM

A Presentation by Sue Hassmiller and Lori Melichar

Date: September 22, 2009

12:00 p.m. - 1:00 p.m. EST

Handwashing - It's Not Just for the OR

Yesterday, Pauline Chen, M.D. posted a terrific blog post about the importance of handwashing by medical professionals. In her piece "Why Don't Doctors Wash Their Hands More?" Dr. Chen outlines the important lesson she learned as a medical student...

"Within seconds the circulating nurse, the anesthesiologist and an operating room technician had hustled me over to a corner of the room. Standing in a semi-circle around me, they clucked their reprimands: You’ve got to be careful! Remember the sterile field! Just step away if you’re contaminated! Didn’t you pay attention? And, perhaps most humiliating: You medical students never learn!

If I hadn’t known it before, I knew it then. Hand hygiene and sterile technique are so successfully maintained in operating rooms not because of the reminders that hang over scrub sinks, but because it is part of the culture and identity of those who work there. No self-respecting surgeon, nurse, anesthesiologist or technician would ever dream of breaching those sterile protocols in the surgical suites. Or of allowing any deviation from the aseptic norms to simply pass."

But she continues to say that such dedication to handwashing does not continue outside of the operating room and wonders "Why Don't Doctors Wash Their Hands More?"

Click here to read the piece.

A team of INQRI researchers has found that handwashing is key to reducing infections. This team, at Johns Hopkins University, has conducted the first randomized-control trial to reduce central line associated blood stream infections among ICU patients. There are some 80,000 catheter-induced bloodstream infections each year, causing up to 28,000 deaths. This study has shown that substantial reductions in infections can be widely achieved, particularly when nurses lead the infection control efforts. Their study builds on the well-known work of Dr. Peter Pronovost, creator of the line-insertion “checklist.” What makes the INQRI-funded work unique is that nurses drive the program in ICUs and they have achieved better results than have previous studies. Some of the components of the program include back-to-basics reminders such as having everyone who touches a central line wash their hands with soap and water; or ensuring that patients be fully covered by a sterile drape (except for a small hole where the line is inserted); or removing unnecessary lines from patients that can spawn infections. ICUs that have embraced this nurse-driven protocol have in many cases completely eliminated bloodstream infections among their patients for several months at a time.

RWJF Awards $1.5 Million to Identify Ways to Keep Patients Safe and Improve Quality

INQRI's newly awarded fourth cohort of grantees will examine the role of nurses and better care in settings outside the hospital and in specific areas of health. For example, one project will examine a community-based diabetes prevention program where nurses visit patients in subsidized housing units; another will focus on reducing pressure ulcers in long-term care facilities; and another will focus on how to help back surgery patients better manage pain on their own.

Please click here to read about the new grantees.

Initiative on the Future of Nursing - Editorial

This month's American Journal of Nursing features an editorial about RJWF's Initiative on the Future of Nursing at the IOM. Initiative chairperson Donna Shalala and vice chairperson Linda Burnes Bolton have co-authored the piece which outlines the ways that nursing care is transforming American health care. The authors explain concerns about the effect of the nurse shortage on health care reform.

Click here to read the editorial.

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Donna E. Shalala is the former secretary of the U.S. Department of Health and Human Services and the president of the University of Miami and chairperson of the Robert Wood Johnson Foundation (RWJF) Initiative on the Future of Nursing at the Institute of Medicine. Linda Burnes Bolton is the chief nursing officer at Cedars-Sinai Medical Center, Los Angeles, and the vice chairperson of the RWJF Initiative on the Future of Nursing. The authors acknowledge the contribution of Gina Ivey, communications director at the RWJF Initiative on the Future of Nursing, in the writing of this article.

The Effect of Magnet Hospitals on Quality

INQRI National Advisory Committee member Linda Aiken, PhD, FAAN, FRCN, RN, the Claire M. Fagin Leadership Professor in Nursing, Professor of Sociology, and Director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania has a piece featured in the July/August edition of The American Journal of Nursing. Co-authored by Donna Havens, PhD, RN and Doug Sloane, PhD, "The Magnet Nursing Services Recognition Program: A Comparison of Two Groups of Magnet Hospitals" discusses the effect of magnet hospitals on patient care quality and the delivery of nursing care.

Please click here to download a PDF of the article.

For more information on Linda's work, please click here.

IHI Implementation Map

During the 100,000 Lives and 5 Million Lives Campaigns, health care providers told the Institute for Healthcare Improvement that they wanted help making sense of the many complex and competing demands hospitals face. In response, IHI has launched the IHI Improvement Map, an online tool that distills the best knowledge available on the key process improvements that will lead to better outcomes for patients.

Click here for more information.

Follow the Map on Twitter.

Announcing our First INQRI Webinar of the Fall

Each year, INQRI offers a series of webinars designed to educate grantees and inform the public about our work. Next week, we will announce all of our dates for this fall's series of webinars.

In the meantime, please SAVE THE DATE for our first presentation:

The Robert Wood Johnson Foundation's Initiative on the Future of Nursing, at the IOM

A Presentation by Sue Hassmiller and Lori Melichar

Date: September 22, 2009

12:00 p.m. - 1:00 p.m. EST

Sue and Lori want to hear from you! Do you have questions about the initiative? Submit them to Heather Kelley by next Wednesday, September 16th and don't forget to join us on September 22 to get your questions answered!

Josie's Story: Turning Tragedy to Triumph

This morning, INQRI grantee team member Peter Pronovost joined Sorrel King on WYPR's Maryland Morning to talk about Sorrel's new book and patient safety issues. In her book, Josie's Story: A Mother's Inspiring Crusade to Make Medical Care Safe, Sorrel writes about Josie, the medical errors that led to her death, the family's struggles with grief, Sorrel's development as a patient safety advocate and the safety improvements that have come about in Josie's memory.

Click here to listen to the interview.

Click here to learn more about the Josie King Foundation.
Click here to learn more about Dr. Pronovost.

Dr. Peter Pronovost is a member of an INQRI grantee team at Johns Hopkins University and serves as the director of the Quality and Safety Research Group at Johns Hopkins University.

Forum on the Future of Nursing: Acute Care

Registration has opened for the Forum on the Future of Nursing: Acute Care. This meeting, the first of the three nationwide forums convened by the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine, will be held in Los Angeles, CA at the Cedars-Sinai Medical Center on October 19, 2009.

The topic of discussion at this forum will be nursing across acute care settings. Please view the agenda for more information.

Webcast
If you are unable to attend the meeting in person, you are welcome to take part in the meeting via a live webcast. On the day of the meeting, a link to it will be posted on the project webpage. After the meeting takes place, the webcast will be archived for viewing. Please note that there is no need to register to view the webcast.

Invitation to Submit Testimony
To inform the discussion at the forum and the committee's deliberations, the committee is inviting individuals and organizations to submit written testimony--which might include innovations/models and barriers/opportunities--in the following three areas: quality/safety, technology, and interdisciplinary collaboration. You may submit testimony in any or all of these areas. All testimony received prior to Monday, October 5 will be considered in the development of the forum discussion. Please note that you are welcome to submit testimony whether you plan to attend the meeting or not.

Future Forums
Subsequent forums will cover the topics of community health, public health and primary care in Philadelphia on December 3 and nursing education in Houston on February 22. We hope that you will be able to attend and ask that you save these dates below. These forums will also be webcast.

• Forum on the Future of Nursing: Primary Care, Community Health, and Public Health - December 3, 2009 - Philadelphia, PA
• Forum on the Future of Nursing: Education - February 22, 2010 - Houston, TX

More Information
For more information on the Initiative and members of the committee, please visit www.iom.edu/nursing or www.thefutureofnursing.org. You may also wish to sign up for updates on the Initiative via email. If you have questions, please contact us at nursing@nas.edu.

From Reuters: "Quality focus reduces deaths in US hospitals-report"

Better quality could save 47,000 lives a year

Quality control could prevent 92,000 complications

By Maggie Fox, Health and Science Editor

WASHINGTON, Aug 10 (Reuters) - Hospital systems that focus on quality care lower death rates and have healthier patients, according to an analysis released on Monday.

The analysis from Thomson Reuters TRIL.TO looked at 252 U.S. health systems and found the best-performing 20 percent had 25 percent fewer deaths, 19 percent fewer complications, and 13 percent fewer patient mishaps than the 20 percent worst performers, even though their patients were sicker.

The study, released in Modern Healthcare, shows that higher-quality healthcare is possible if hospital systems make it their primary focus, instead of profits, for example, said Jean Chenoweth, Thomson Reuters senior vice president for performance improvement, who led the research.

The analysis can also inform healthcare reform efforts -- the signature policy of U.S. President Barack Obama and the focus of considerable negotiations in Congress, Chenoweth said.

"The legislation that is pending will be restructuring the healthcare industry to drive higher value. That will affect insurance companies, health systems and all of us as patients," Chenoweth said in a telephone interview.

Thomson Reuters, the parent company of Reuters News, also rated the hospital systems across the United States and released a top 100 list as part of its report. It did not look at whether raising quality lowered costs, although many experts say lowering patient complications can save billions.

"The lowest 20 percent of healthcare systems are significantly poorer performing than the top 20 percent on every metric -- patient mortality, complications, length of stay," Chenoweth said.

DRIVING QUALITY

The top 10 include for-profit and not-for-profit health systems, religious and secular organizations, large and small facilities across the country.

"This suggests that every type of health system has the potential to drive higher quality -- and health systems could become a powerful force for rapid improvement in hospital performance as the industry is restructured," Chenoweth said.

Chenoweth's team used data on 12 million Medicare patients using five measures: mortality, medical complications, patient safety, average length of stay, and whether hospitals followed standards of care published by the Centers for Medicare and Medicaid Services.

These standards include giving aspirin to heart patients, giving the right antibiotics and a pneumonia vaccine to patients with pneumonia, and giving antibiotics and blood thinners before surgery to prevent infections and blood clots.

Chenoweth's team calculated that if all Medicare patients received the same level of care as provided by the top 100 hospitals, more than 47,000 lives would be saved each year, 92,000 patient complications would be avoided each year and average patient stay would fall by half a day.

The top 10 hospital systems according to the study are:

• Advocate Health Care of Oak Brook, Illinois
• Catholic Healthcare Partners of Cincinnati, Ohio
• Health Alliance of Greater Cincinnati
• HealthEast Care System of Saint Paul, Minnesota
• Henry Ford Health System in Detroit
• Kettering Health Network of Dayton, Ohio
• OhioHealth of Columbus
• Prime Healthcare Services, Inc. of Victorville, California
• Trinity Health of Novi, Michigan
• University Hospitals Health System of Cleveland, Ohio.
  
  

(Editing by Eric Beech)


© Thomson Reuters 2009.

From the Wall Street Journal: "Pitching Patient Safety and Hospital Transparency on YouTube"

In this blog post, Laura Landro discusses TransparentHealth, a for-profit patient safety education company founded by Timothy McDonald, chief safety officer at the University of Illinois Medical Center at Chicago, and his colleague Dave Mayer, a cardiac anesthesiologist. McDonald and Mayer are producing a series of videos focused on patient safety which will outline improvements made after the disclosure of harmful patient events. The videos are being targeted as tools for hospital staff members to watch during patient safety education programs.

This YouTube video is the trailer for the first video, “The Faces of Medical Error: From Tears to Transparency,” which will debut September 24th at the University of Illinois.



Click here for Laura Landro's blog post.

From the News: Two Reports on Medical Errors in Hospitals

Design intended to reduce errors at new Mercy center
Des Moines Register - August 26, 2009

Demonstrating the patient lifts and video monitoring system, Mercy Medical Center-West Lakes Administrator Dan Aten beams with pride when he shows visitors the metro area's latest medical facility.

He's quick to point out that quality and safety were the main goals in designing the 83-bed facility.

"We have great opportunities when you're building something from scratch. We built it smaller and more efficient in many ways," he said.

The $100 million hospital, set to open Sept. 8, is the result of three years of design, discussion and research, Aten said. Mercy officials spoke with staff members and patients in addition to visiting sites throughout the country as part of a planning process focusing on "evidence-based design."

To read the rest of the article, click here.

Hospitals Own Up to Errors
Wall Street Journal: Informed Patient Blog - August 25, 2009

Kaelyn Sosa, 6, was crippled as a toddler by a medical error. Her mother, Sandy, now helps the hospital protect other patients from such accidents.

As often happens after medical accidents, the facility, Baptist Children's Hospital in Miami, settled with the Sosa family for an undisclosed sum. But the hospital went further. Administrators analyzed the chain of events that led to the tragedy. They put in place new measures aimed at preventing the mistakes that injured Kaelyn from recurring and to better respond when something does go wrong. The hospital then engaged the child's parents in educational efforts to underline to medical staff the critical importance of patient safety.

Now Sandy Sosa, Kaelyn's mother, serves as a community liaison on the hospital's quality-and-patient-safety committee. "We wanted something good to come out of what happened to our daughter," she says.

Medical errors kill as many as 98,000 Americans each year, according to the Institute of Medicine, a government advisory group. In an effort to improve this record, some hospitals like Baptist Children's are taking steps to admit grievous mistakes and to learn from them in order to overhaul flawed procedures. That represents a sharp departure from hospitals' traditional response when something goes terribly wrong—retreating behind a wall of silence to guard against potential lawsuits.

To read the rest of the article, click here.