Vol. 17 No. 10
October 2008
—InSIDE—
Medical errors
Discover how to meet the
emotional needs of staff
members after a medical
error on p. 4.
Recruitment and retention
Use these new recruitment
and retention ideas for staff
development on p. 7.
Use HIPAA when
safeguarding PHI
Secure protected health
information by complying
with HIPAA electronic health
record standards on p. 8.
Avoid patient disparities
A Joint Commission report
finds a link between patient
demographics and quality of
care on p. 9.
Medical identity theft
Educate your staff to protect
patients and your facility from
the challenges of medical
identity theft on p. 11.
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New research suggests RFID devices
could interfere with ICU gear
A study and accompanying editorial in the June 25 Journal of the
American Medical Association
(JAMA) found that radio-frequency
ID (RFID) devices can interfere with
critical ICU gear and possibly put
patients in danger.
about potential hazards in your ICU
that might warrant investigation.
RFID is a common technology that
transmits radio waves and is used
for ID badges and medical equipment tracking.
That risk is doubled if your hospital is planning to purchase a new
RFID system. Find out whether it’s
possible to perform testing before
you buy the equipment or try to
get confirmation from the manufacturer that it won’t, for example,
throw your facility’s brand of ventilators out of whack.
Although it’s unlikely that your gear
is in immediate danger from RFID
devices, the research is a warning
Battle royal in the air
The JAMA research reinforces
> p. 2
the idea that hospitals
California hospital team takes on VTE
Patients with venous thromboembolism, which includes deep vein
thrombosis and pulmonary embolism, account for 600,000 hospitalizations and 200,000 fatalities each
year, the National Quality Forum
estimates.
A three-year study led by Greg
Maynard, MD, MS, a clinical professor of medicine and division
chief of hospital medicine at the
University of California San Diego
(UCSD) Medical Center, has made
waves in reducing this number.
Not only did Maynard and his team
analyze years of data about deep
vein thrombosis (DVT) and pulmonary embolism (PE), but they
also developed a mentor program
and toolkit to help other facilities
combat venous thromboembolism
(VTE).
“It really started out of recognition
that DVT is a national problem,
and it’s been shown that there are
proven pharmacological measures
that are underutilized,” Maynard
says. The National Quality Forum
(NQF) estimates that less than 50%
of patients diagnosed with DVT
receive appropriate prophylaxis.
UCSD Medical Center had a similar
prophylaxis rate when it applied to
be a part of a grant from the Agency
for Healthcare Research and Quality
(AHRQ) in 2005.
> p. 3
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RFID devices
< p. 1
should designate people to track devices releasing
signals in the airwaves, said John Collins, FASHE,
HFDP, engineering and compliance director at the
American Society for Healthcare Engineering.
In a corresponding editorial in JAMA, Donald Berwick
MD, MPP, FRCP, president of the Institute for Healthcare
Improvement in Cambridge, MA, wrote that it’s not yet
time to discard RFID devices.
“Outside the hospital, the [government] rules the airwaves,” Collins said. “When stuff comes inside the hospital, it’s a free-for-all … The more products that come
into the hospital, the more possibility that there may
be a problem.”
Instead, hospitals need to promote safety and define
the local hazards to their hospital environments. That
would include testing RFID devices before introducing them in the ICU—employing failure modes and
effects analysis—with the understanding that manufacturers develop RFID systems in isolation, far from your
hospital where many devices are already broadcasting
signals, Berwick said.
Collins likened the concern to having a conversation
at a party: When it’s only a few people, you can talk
with another person at a normal volume. As more
people enter the room and the ambient noise level
increases, you need to raise your voice to compensate. At some point, you typically must watch the
other person for visual clues in addition to listening
to continue the conversation.
“Even though a lot of this [electronic equipment] is
low power, it all contributes to a noise level to the
point where a device is going to have to generate a
little more power to communicate,” Collins said.
Study measures interference
In the JAMA study, researchers tested two particular
brands of RFID tags near 41 medical devices (e.g.,
defibrillators, dialysis machines, cardiopulmonary
bypass devices, and pacemakers). In 123 laboratory
tests, they catalogued 34 incidents of interference,
with 22 of them classified as hazardous enough to
harm a patient.
The Dutch Ministry of Health funded the study,
which was conducted at the 1,002-bed University
of Amsterdam Academic Medical Centre and led by
researcher Remko van der Togt, MSc.
“The intensity of electronic life-supporting medical
devices in this area requires careful management of
the introduction of new wireless communications,
such as RFID,” van der Togt and his colleagues
wrote.
He also called for manufacturers to perform more extensive safety testing to determine how their gear interacts
with other equipment and to design better ways to shield
vulnerable equipment from offending RFID waves.
Outside prompting could help
Hospitals shouldn’t necessarily be solely responsible
for pressuring manufacturers, Berwick said. Regulators
could provide an additional push and should eventually determine how RFID devices, cell phones, Bluetooth
devices, wireless computers, and PDAs interact.
Neither Collins nor Berwick support bans of RFID devices; instead, they advocate watching their interactions
and taking action when interference is demonstrated.
“Any technology you introduce—even if it’s designed
to do something good, which they all are—always
brings new forms of hazards or errors with them,”
Berwick said. He suggested safety managers meet with
ICU physicians and nurses, hospital engineers, and
facility directors to discuss interference issues they’ve
seen and means of testing gear for potential hazards.
“This calls for multidisciplinary conversation and study,
in which no one person is going to have all the information they need,” Berwick said. “The safety manager
should be the convener [of the meeting].”
Cataloging known issues and near misses over time
could reveal patterns of interference, Collins said. ■
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VTE
< p. 1
Part of the goal of applying to the AHRQ was to create a toolkit that other hospitals could use. To achieve
this, Maynard had to first fashion a risk assessment
system that was different from the existing pointbased systems requiring addition. So Maynard and
his colleagues created a “bucket” model that separated all inpatients into three categories: low, medium, and high. Each bucket was linked to a certain
level of prophylaxis, and every inpatient was given
a risk assessment at admission. This model was built
into the computerized physician order entry system,
allowing caregivers to see what the appropriate level
of prophylaxis was for each risk level.
“Our model had a high level of reliability and agreement,”
Maynard says. “It also monitored effectiveness of how
often patients are getting appropriate prophylaxis.”
Gathering the data
Maynard’s team started collecting data on every case
of DVT and PE at UCSD Hillcrest, a 300-bed hospital, between 2005 and 2006 using the risk assessment
model. Two main methods were employed: digital
scans and random sampling. Inpatient digital reports
were scanned each day for DVT. Any positive outcomes were followed up to see whether any clots
present were community- or hospital-acquired. Those
who had hospital-acquired VTE and had followed the
suggested prophylaxis regimen were considered preventable cases. Additionally, each day, patients were
chosen at random to monitor for 48 hours to see
whether they were on appropriate VTE prophylaxis
and had been adequately assessed.
During the early stages of the program, UCSD
Medical Center’s rate of adequate prophylaxis hovered around 55%. Maynard says it took another year
to get that number up to 70%. The first year was
spent educating staff members about the initiative.
Next, the risk assessment model was incorporated
into an order set so that every patient admitted got
evaluated, which helped raise the adequate prophylaxis rate to 90%.
“But what about that 10% not on adequate prophylaxis?” Maynard says. “After we started getting reports
of who was not on prophylaxis that should be and had
a smaller pool, we asked the nurses to help us.”
The nurses prompted doctors to evaluate the remaining patients for DVT and PE and give the correct prophylaxis. Since mid-2007, the adequate prophylaxis
rate has been approximately 98%.
The NQF recently endorsed a new set of consensus
standards for hospitals, which include 48 new standards, six of which address VTE. This is the second
set of standards that have been endorsed. The first set
from 2006 had two VTE performance measures.
“NQF is suggesting that all patients should be evaluated,
based on the number of risk factors there are and the
fact that most patients who come into the hospital will
have one or more of those risk factors,” says Melinda
Murphy, RN, MS, CNA, a consultant at the NQF who
has been working on the VTE project since 2005.
A toolkit and a mentoring program
One of the outcomes of UCSD Medical Center’s VTE
project is direction for other facilities that need help
setting up a program.
As the first recipient of the Society of Hospital Medicine’s
(SHM) Team Approaches in Quality Improvement
Award, Maynard’s team has worked with the SHM to
publish a toolkit and mentoring program on the SHM
Web site.
To date, the VTE Prevention Collaborative (the mentoring program) has 30 sites with longitudinal interaction.
Hospitals that sign up for the program are provided
mentors to reinforce via phone the concepts posted
to the SHM Web site, and they receive instructions
on successful implementation for more than one year
from Maynard and his team. ■
Editor’s note: Go to http://tinyurl.com/6bhzj3 to visit the
SHM’s VTE Prevention Collaborative Web site.
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© 2008 HCPro, Inc.
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The second victim: Help staff members after a medical
error with peer-support programs and education
It has been almost a decade since Linda Kenney went
into surgery to have her ankle replaced and ended up
going into cardiac arrest and having her chest opened.
Since then, she’s handled a range of emotions, from
shock to depression to thankfulness for being alive.
It wasn’t until she had made it through the seemingly impossible first year after the incident that she
began to consider how those involved in her case
might be feeling. Kenney’s specific case involved an
error during anesthesia. “I was thinking, ‘If I’m this
emotionally distraught, I can just imagine how [the
anesthesiologist] must be feeling,’ ” she says, adding
that her medical error was barely discussed with her
while she was in the hospital, highlighting the stigma
regarding such events.
In 2002, Kenney founded a support group, Medically
Induced Trauma Support Services (MITSS), due to
the lack of support for all parties involved in medical
errors. Part of what MITSS does is provide support to
caregivers who have been involved in a medical error
or near-miss event.
“In the beginning, I was focused on patients and families, but I kept hearing from [hospital staff members],
and they are equally isolated and alone,” Kenney says.
As an industry, healthcare has stressed personal responsibility for patient care. It has only been in the past
few years that the idea of supporting staff members
involved in an error or near-miss event has even been
discussed. Thomas Gallagher, MD, associate professor of medicine at the University of Washington, says
this idea of personal responsibility has led to today’s
unsupportive attitude toward those staff members
involved in a medical error.
“The implication is, if you’re acting in the patient’s
best interest, you wouldn’t do anything to harm them,”
Gallagher says. “If you did make a mistake, somehow
this was a breach of your professional duty. At the same
time, there was a professional ethos that developed
that the physician was the unruffled professional who
can handle any stressful situation. So this means that as
a doctor, you shouldn’t make mistakes and, if you do,
you should just let them bounce off of you.”
The toll errors can take on staffs
Gallagher has coauthored several reports on this topic,
including an Agency for Healthcare Research and
Quality–commissioned study that appeared in The Joint
Commission’s August 2007 Journal on Quality and
Patient Safety article, “The Emotional Impact of Medical
Errors on Practicing Physicians in the United States and
Canada,” and another article, “Supporting Health Care
Workers After Medical Error: Considerations for Health
Care Leaders,” which appeared in the May Journal
of Clinical Outcomes Management. In his studies,
Gallagher has uncovered some interesting statistics.
For example, after being involved in an error, many
caregivers report feeling self-doubt (96%), disappointment (93%), self-blame (86%), shame (54%), and fear
(50%). Caregivers expressed the need to talk to someone about the mistake (63%), reaffirm their competence (59%), validate their decision-making processes
(48%), and reassure their self-worth (30%).
Ninety percent of caregivers say there is inadequate
support available to them after an error has occurred.
More than 33% of caregivers involved with a near-miss
event reported that errors had negatively affected their
anxiety about future errors, professional confidence,
job satisfaction, and their ability to sleep.
Gallagher says many of these statistics were brought to
light from the Institute of Medicine’s 1999 publication,
To Err is Human.
“The fact is, errors are distressing for healthcare workers,” Gallagher says. “We’ve known that for a long time.
I don’t think if you asked someone if errors bugged
them 10–20 years ago that they would say no, but there
was not a lot of conversation about providing support
for physicians.”
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Today, the focus is on moving away from a culture of
blame, which may be the correct thing to do. However,
it creates a conundrum, Gallagher says.
If errors are due to a system breakdown and not personal responsibility, that leaves little room for acknowledging the need for physician support after an error.
Sigall Bell, MD, an instructor of medicine at Harvard
Medical School and staff physician at Beth Israel
Deaconess Medical Center (BIDMC) in the division of
infectious diseases in Boston, has found in her research
that errors are usually the result of systems malfunctioning and providers making mistakes. It’s important
to create a system that addresses these issues.
“I think if you’re going to be comprehensive in your
approach, you need to have mechanisms to address
both,” Bell says. “There are a lot of ways to recognize
the benefits to providing support to [staff members]. If
you have formalized methods to support them after an
error and provide a forum for normalizing discussions
to these errors, promoting a nonpunitive culture will
facilitate these discussions. Sometimes, you just need
to give [staff members] permission to talk about their
experiences.”
Providing support improves patient safety
Bell says she has found a parallel between the feelings of the patients and families who have been the
victims of medical errors and the feelings of those
involved. These sentiments are manifested in guilt,
fear, and isolation. “When you take a step back, in
the aftermath of an error, the [caregiver] is going
through exactly the same things [as the patient]—
they feel horribly guilty about the harm caused to the
patient and family, they feel extremely fearful about
what this will mean for their license, job, reputation,
respect from colleagues, never mind litigation. And
then if a caregiver feels so isolated that they can’t talk
about it to their colleagues and others in the hospital,
it can be extremely damaging,” Bell says.
workers experiencing unmet distress after an error
won’t be providing the best care to their patients. So
the idea is that to really be a safe and effective [caregiver], you need support after an error.”
If providers are given the proper support and don’t feel
guilty about being involved in a medical error, they are
more likely to discuss any future errors they might be
involved in, says Steven Parker, MD, WebMD’s pediatric and parenting expert and a professor at Boston
University’s School of Medicine.
“Also, being able to talk about errors will make [staff
members] less likely to make future mistakes because
they will have learned from a process that is nonthreatening and as supportive as possible,” Parker says. “It’s
much easier to go forward and change your practice,
admit you made a mistake, and not do it again if you’re
not constantly defensive about it and feeling guilty.”
When Parker was a resident more than 30 years ago,
he had an intern who was involved in a near-miss situation. That experience helped Parker see how poorly
supported caregivers were at that time.
He says it also helped him realize that those involved
in a near miss or medical error shouldn’t have to ask
for help; it must be part of the system, not a makeshift
situation.
“The elephant in the room is the fear of lawsuits, and
that’s a hard one,” Parker says. “Maybe admitting your
error will cause you to be sued but, in the long run,
many patients don’t get as mad when you have disclosed, aside from the fact it’s the right thing to do
ethically.”
Gallagher makes a case for support by making the connection to patient safety.
Creating a safe space to talk about errors
Being sued for malpractice is one of many caregivers’
biggest fears. When facilitating support for caregivers,
it is vital to enforce the notion that anything said to
a counselor or psychologist is something that will be
kept private. Many involved in a medical error might
want to discuss it with colleagues but don’t for fear of
implicating themselves.
“There’s not any empiric evidence yet—the correlations are more theoretical,” Gallagher says. “Healthcare
“The peer support model is very effective,” Kenney
> p. 6
says. She references a pilot program MITSS
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Medical error
< p. 5
helped create with Brigham and Women’s Hospital in
Boston that involves self-identification. “One peer says,
‘There has been an incident,’ and there is already a system in place so that another peer can trigger the leaders to step up and acknowledge that there is a need to
support the staff member involved,” she says.
Gathering input for support systems
Gallagher recommends that facilities trying to begin
their support program start by engaging their staff members. It’s important to get their opinions about what the
current support system comprises.
“One of the key steps is to have conversations [with
everyone] about the current state of affairs and what
they think should be included in an effective support
system,” Gallagher says. “Without this, your program is
not likely to be successful.” Leadership needs to embrace
the concept to show true commitment, he adds.
Kenney, who receives calls from hospitals nationwide
about support needs, says she often sees hospitals rushing to create a support system for staff members before
having an adequate disclosure system in place.
Including an education component is key
Education is perhaps the most critical part of creating a support system for caregivers, Bell says. Learning
how to disclose an error is a major part of working in
a healthcare facility today. She says training on how to
respond to a medical error should begin in the earliest
years of medical school.
When surveyed, 85%–90% of medical school students
said they have at least observed a medical error, Bell
says. “It’s a little bit of operating in a vacuum if those
same students are not equipped with the tools and
knowledge about how to best orchestrate a response
in that setting,” she explains.
It’s not only students who should be educated, but all
caregivers. Each staff member interacts with patients
in a different way. Bell recommends that disclosure
training should be a part of every new-employee orientation. In addition, this training should be interactive,
perhaps using role-playing rather than simply lecturing
to students and staff members, she says.
BIDMC has taken this approach with its staff members
and has garnered favorable reactions. “The very notion
of the education needs to be a leveler in the sense
that we’re all in this together, we’re all committed
to a policy of open disclosure, and we’re all here to
support each other. And education plays that role as
linking everyone together,” Bell says.
Wellpoint to stop paying for 11 preventable errors
Following in the footsteps of CMS, Wellpoint, one of
the country’s largest health insurers, will stop paying
for 11 medical errors that it considers preventable in
October.
CMS announced in 2007 that it will also not pay for
certain preventable errors starting in October.
Wellpoint, which insures 35 million people nationally, has decided to start with the same list that CMS
is using. This includes not paying for three types of
surgical errors: wrong-site surgery, wrong-patient surgery, and the wrong type of surgery on the correct
patient.
The list also includes eight events for which Wellpoint will not pay additional costs if any of these
errors occur.
These events are:
• Objects left in the body postsurgery
• Air embolisms
• Blood incompatibility
• Catheter-associated bloodstream infections
• Pressure ulcers
• Vascular catheter–associated infections
• Chest infections after coronary artery bypass graft
surgery
• Injuries resulting from hospital care
Wellpoint’s decision to no longer pay for these medical
errors could be a sign of what is to come from other
insurers around the nation. ■
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The changing face of recruitment and retention
Respiratory care managers spend a lot of time predicting and planning for the future, but there are
more problems than solutions in hiring and retaining
employees. To retain RTs, hospitals must be places
where people want to work. But it is difficult defining
what those hospitals will look like.
Most experts agree that recruiting and retaining
enough employees will take a lot of change—something that healthcare isn’t always good at. So respiratory care managers need to change the way they
look at staffing.
Making it a point to talk about people—and not just
systems and processes—might be a good place to start.
Many healthcare professionals have changed the way
they talk about their staff members and how they hire.
The following statements are likely to be heard today
by a facility’s recruitment team: • “We don’t own our employees.” Gone are the
days when facilities could cage their staff members
in one place because they feared another facility would steal them. Today, smart facilities have
learned that they don’t own their staff; so if they
don’t offer experience and learning opportunities,
other organizations will. Some hospitals are offering their RTs travel and job-sharing opportunities.
For example, hospitals in cold-weather regions
might allow RTs to travel to Florida for the winter
months, then return to their jobs in the spring. Or
if a good employee at a community hospital leave
to try a job at a larger tertiary system, the community hospital might leave the door open for that
employee to return.
• “They don’t always have to be RTs.” How
many caregivers does it take to run a hospital? It
sounds like the start of a bad joke, but some organizations have discovered that they don’t need as
many RTs as they once thought. Forward-thinking
hospitals are using assistants, other staff members,
and even family to take on roles that don’t require
a degree.
• “Newspaper want ads don’t work.” Your next
good employee isn’t sitting home with a newspaper
and a highlighter. Today’s candidates are online,
on social networks such as Facebook, and writing
blogs, so that’s where your want ads should be.
• “Sign-on bonuses are a temporary fix.” Often,
when hiring becomes difficult, someone will say,
“What about sign-on bonuses?” But sign-on bonuses are only a temporary solution to recruitment
and retention needs, and they often annoy other
employees. If you want to attract good employees,
pitch your facility’s learning opportunities.
• “Turnover is good.” CEOs don’t want to retain
just anybody—even when faced with shortages—
so they’re committed to hiring only good employees and weeding out bad ones. They’ll even hire
the right person who has no experience before
they’ll hire the wrong person who has an impressive resume.
• “Who cares about the hospital next door?”
It’s no longer enough simply to emulate the hospital next door when finding and keeping good
employees. If you want recruitment and retention
to be effective, they must be based on the best
practices out there, regardless of whether they’re
found in healthcare. That is where many work
force changes are coming from. ■
Illustration by
David Harbaugh
“Obviously, you’re not ready for primetime smoking cessation.”
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Make your EHRs comply with HIPAA standards
If you’ve decided to start using electronic records at
your facility, you’ve probably spent hours researching
which software program to purchase and thinking
about how to train your staff. But how much time have
you dedicated to making sure the protected health
information (PHI) that will be stored in those records
is secure?
To comply with the HIPAA security rule, providers
need to establish safeguards to protect PHI from
breaches, such as hackers or unauthorized personnel
accessing PHI.
If you don’t invest the time up front to make sure that
the PHI in your electronic records is secure, you could
be exposing yourself to government fines, lawsuits,
and embarrassing public disclosures in the future.
“As time-consuming as it may be, someone really
needs to sit down and put the minimum requirements
in place that are required by the security rule,” says
Helen Oscislawski, an attorney at Fox Rothschild,
LLP, in Princeton, NJ, who has developed several
HIPAA assessment tools, checklists, and policies.
Understanding PHI
Without getting into the technical or legal definition,
PHI is any information that would allow the viewer
to identify or know confidential information about an
individual, says Darice Grzybowski, MA, RHIA,
FAHIMA, president of HIMentors, LLC. Names, medical record numbers, and Social Security numbers—any
self-identifying data—would be considered PHI.
The HIPAA security rule applies only to electronic PHI,
or ePHI, which also includes e-mails, Oscislawski says,
noting that the security rule doesn’t extend to paper
records.
How to protect PHI
The security rule identifies the minimum safeguards
that need to be in place to secure PHI. The ideal time
to begin addressing security issues with electronic
records is before you start using a new system,
Grzybowski says. She recommends that providers
who are responsible for protecting PHI take three
key actions to do a better job of securing PHI in an
electronic health record (EHR) environment:
• Make sure you have an up-to-date legal health
record inventory completed to understand where
all medical record documentation, or PHI, is maintained in your facility.
• Ensure that clinical information can be accessed
on a need-to-know basis only. This means that
only the relevant providers should have access
to clinical information. Create a bypass key for
emergency access to records, which leaves a trail
you can audit to determine whether accessing the
record was appropriate.
• Handle external release of information in a centralized manner, and use trial logs to make sure
information has been accessed appropriately.
Don’t go it alone
A common mistake providers who handle PHI make
is to assume that family members can access the
health records of a loved one without authorization,
Grzybowksi says.
“The rules of access can be quite complex and
should always be referred to a health information
management expert for proper release procedures,”
she says.
If you’re not familiar or comfortable with implementing
data safeguards, Oscislawski recommends hiring a consultant or an attorney to help you comply with HIPAA
and other security standards.
Consequences of not securing PHI
Failing to secure PHI can have major repercussions.
In July, the U.S. Department of Health and Human
Services (HHS) entered what it called a resolution
agreement with Seattle-based Providence Health &
Services.
Providence was required to pay HHS $100,000 after
the unencrypted PHI from more than 386,000 patients
within the Providence health system was lost or stolen.
The health system, which was required to safeguard
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that information under HIPAA, also had to agree to a
corrective plan of action to make sure that PHI stored
in its electronic records system will be protected in the
future, according to HHS.
In addition to HIPAA requirements, more than 30
states have security breach notification laws that
generally require that individuals be notified if protected information, which includes PHI, has been
accessed inappropriately.
If you fail to secure a patient’s PHI and the patient
can prove he or she has suffered damages as a result,
you could be sued for negligence, Oscislawski says.
Another consequence of a breach of PHI is the bad
publicity the event generates. “You don’t want to have
that headline, because you lose potential customer
trust and it’s bad for business,” Oscislawski says.
Although enforcement against providers who have
not secured PHI properly has been relatively rare
at this point—the Providence case was the first time
HHS entered a resolution agreement—that doesn’t
mean there won’t be more enforcement, Oscislawski
says, adding that as the healthcare community begins
to build the infrastructure for electronic records,
there will be more enforcement action in the future
to make sure those records are being protected.
“As we move toward using EHRs in the future, there’s
going to be more focus on making sure the individuals that are handling them are keeping them safe,”
Oscislawski says. ■
Experts urge hospitals to identify healthcare disparities
A report released by The Joint Commission calls on
hospitals to improve patient care by eliminating racial
and ethnic disparities.
In April, The Joint Commission (formerly JCAHO)
released One Size Does Not Fit All: Meeting the Needs
of a Diverse Population, a report that found that “racial
and ethnic disparities are linked to poorer health outcomes and lower quality care.” This report is one of a
few recent efforts that aim to decrease racial and cultural disparities in patient care by informing healthcare
providers of the importance of cultural and geographical awareness and its connection to patient safety.
The report is structured on four themes:
• Building a foundation
• Collecting and using data
• Accommodating the specific needs of patient
populations
• Creating internal and external collaboration
As hospitals become more aware of the relationship
between patient safety and patient demographics,
experts say there is urgency for policies to be put
into place so all patients are getting the care they
deserve.
“[Patient demographics] should be part of patient safety. It shouldn’t happen on the side,” says Romana
Hasnain-Wynia, PhD, director for healthcare equity
and associate professor at Northwestern University’s
Feinberg School of Medicine in Chicago. Hasnain-Wynia
also served as a project advisor and reviewer for the
Joint Commission report. Part of providing the best
quality of care is to understand patient backgrounds,
she says. The Joint Commission report discusses the
importance of understanding patients’ cultures without resorting to stereotypes.
“You can’t simply fix disparities; then everyone gets
poor quality care,” says Jonathan Skinner, PhD,
professor of community and family medicine at
Dartmouth Institute for Health Policy and Clinical
Practice in Hanover, NH. “Instead, set quality care at
100% for all races.”
Skinner and the Dartmouth Institute were involved
in the early stages of research of the Robert Wood
Johnson Foundation (RWJF) initiative, “Aligning Forces
for Quality,” which in June announced a $300 million
grant designed to reduce significant regional and ethnic care disparities in the United States by targeting 14
U.S. communities. The researchers behind
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Disparities
< p. 9
this grant examined Medicare claims for evidence of
racial and geographic disparities and found that both
were prevalent.
The best way to begin to reduce regional and ethnic
disparities in healthcare is to treat patients like customers, Skinner says. Facilities can do this by getting
feedback from patients and setting standards to fix
these problems.
Findings: Minorities often receive poorer care
The Agency for Healthcare Research and Quality and
the Healthcare Cost and Utilization Project released
Racial and Ethnic Disparities in Hospital Patient Safety
Events, 2005 in June. The report found that:
• Asian-Pacific Islanders had worse rates than whites
for nine of the 14 patient safety indicators included
in the report
• Blacks, compared to whites, had higher rates of
hospital complications and adverse events for five
of the 14 patient safety indicators
• Among Hispanics, only two of the 14 measures
were worse than the rates among whites
• In all but two states, black diabetics were less likely
than whites to receive annual hemoglobin testing
• Blacks with diabetes or vascular disease are nearly
five times more likely than whites to have a leg
amputated
• Women in Michigan are far less likely to have mammograms than women in Maine
The importance of physician education
Education needs to occur at all levels and should happen early, says Elizabeth Jacobs, MD, MPP, associate
professor of medicine at Rush Medical College/Cook
County Hospital in Chicago and one of the lead advisors for One Size Does Not Fit All. Jacobs trains medical
students, residents, and faculty members on this topic.
Jacobs says she believes the best way to do this is
through observation and discussion. She has students
talk about encounters in which there were language
or cultural barriers, which typically leads to teaching
points. She has been educating medical students on
the cultural, linguistic, and racial needs of patients for
15 years and says she’s seen improvement in organizations, but there’s still a long way to go. “I think it’s
definitely becoming something people are addressing
more, but not a lot of hospitals recognize it,” she says.
Those hospitals that recognize the problem might not
know how to create or implement a plan.
Effective communication methods are also essential to
creating good educational programs about cultural and
racial disparities in healthcare, Hasnain-Wynia says.
Skinner says he would like to see more facilities discuss disparities in their own institutions. “Let’s identify
hospitals that seem to be showing inadequate rates for
blacks and whites and see why this is going on,” he
says. “There needs to be more research on the why,
and then look at how we can change it.”
Resources to help lower disparities in care
For hospitals that want to improve patient safety by
addressing the needs of diverse populations, there are
resources available to get them started.
The Health Research and Educational Trust Toolkit team
has released a free Web-based toolkit that provides hospitals with information and resources for collecting race,
ethnicity, and language data from patients, which can
be found at www.hretdisparities.org. Hasnain-Wynia
was part of the project team that developed the toolkit,
which contains tips about how to collect data, how to
ask patients questions, methods for staff training, ways
to garner community involvement, and other features.
“The strongest programs engage in true dialogue with
the community in what their needs are and how they
can facilitate providing care,” Hasnain-Wynia says.
The Joint Commission’s report also showcases a selfassessment tool that facilities can use to incorporate
cultural issues into patient care. This tool provides the
questions to facilities that are starting to create policies. Visit www.jointcommission.org to read the Joint
Commission report. ■
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Dealing with the challenge of medical identity theft
Traditional identity theft is a familiar problem in the
United States. Victims of identity theft brace for its
effect on their finances and credit ratings.
they might hack into electronic health information
systems and take advantage of employee error or
misconduct.
Medical identity theft is less well-known, but it is just
as problematic for patients, facilities, and insurers.
There haven’t been a substantial number of criminal
cases involving healthcare staff members who intentionally commit medical identity theft, Roach says.
Protecting against medical identity theft is a tall order for
overburdened and understaffed facilities, but its importance can’t be overstated. Medical identity theft has significant short- and long-term implications for everyone
involved, so educating staff members is essential.
Generally, medical identity theft occurs when staff
members inadvertently publish PHI—employee error
being far more common than intentional misconduct.
Defining medical identity theft
Medical identity theft is “the theft of any information that
is personally identifiable with a patient,” says William
H. Roach Jr., MS, JD, a partner at McDermott Will &
Emery, LLP, in Chicago.
“HIPAA defines protected health information [PHI] to
include many identifiers, the theft of any of which I
would consider medical identity theft,” Roach says.
Chris Apgar, CISSP, president of Apgar & Associates
in Portland, OR, explains that identity theft is:
The theft of medical information that is used for the
gain of another, specifically to fraudulently obtain
medical treatment or treatment-related medication
(such as individuals seeking drugs for recreational/abuse purposes), obtain medical treatment and
avoid paying for treatment, use medical identity to
obtain insurance coverage (generally individual)
that could not otherwise be obtained or would be
too expensive because of a preexisting condition,
and to hide a medical condition that may prohibit
seeking certain types of employment (such as pilot,
police officer, etc.).
Traditional identity theft more often refers to the theft
of a Social Security number with the intent to commit
fraud, Roach says.
Perpetrators of medical identity theft use several
methods to steal patient information. For example,
However, the potential for medical identity theft to
occur as the result of malicious intent exists, and it is
a huge risk for providers, Roach says. “As more covered providers move to electronic health records for
their patients, the risks of inadvertent disclosures and
of intentional theft of information increase,” he says.
Why you should be concerned
A hospital’s ultimate concerns are its reputation and
its bottom line. Medical identity theft can adversely
affect both.
For example, a facility might inadvertently provide
services to someone using a false identity and have
little chance of receiving reimbursement for them.
And reconciling illegitimate medical records created as a result of a theft means more headaches.
Further, affected patients face a long, difficult road
as they try to restore their credit history. And the
hospital—particularly if it is directly at fault—faces
a PR nightmare.
“The theft of any protected health information, whether
it is personal identifiers, health information, or financial
information, is a serious problem for providers subject
to HIPAA and state health information laws, both of
which carry legal sanctions,” Roach says.
If a disclosure leads directly to a case of stolen identity, immediate action—such as revisiting and rewriting
current privacy policies pertaining to patient identification—is necessary to prevent further unlawful
disclosures. Facilities should also contact
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Identity theft
< p. 11
their legal counsel for advice on the best method of
notifying affected patients, Roach says.
The real victim
Your organization will face problems if it experiences a breach that leads to medical identity theft for
one or more of your patients. But they, not you, are
the real victims.
Apgar says a victim of identity theft could face the following problems:
• Civil and criminal action if an insurance company
attempts to collect bad debt associated with fraudulently obtained medical treatment and/or fraudulent
claims payment.
• Labeling as an individual who demonstrates drugseeking behavior.
• Creation of a medical record that is incorrectly
associated with the patient. The false record could
include conditions that cause problems with respect
to obtaining coverage.
• Employment discrimination if certain conditions
that can stigmatize their victims, such as alcohol
and/or chemical dependency and mental illness,
incorrectly become part of a patient’s medical
record.
What you can do
Facilities should consider adopting the following
big-picture strategies to minimize the likelihood that
medical identity theft will affect their organizations:
• Initiate comprehensive training that explains what
medical identity theft is and the extent of potential damage to affected hospitals and victimized
patients
• Conduct routine reviews of employee performance
to discover potential wrongdoing
• Reinforce an internal culture of compliance that
originates with the board of directors and CEO
Training should focus on fine-tuning patient identification tasks that staff members already perform.
Teach your staff to recognize potential warning signs,
such as a frequent visitor who uses different names,
and to report suspicious situations to administration. ■
Editorial Advisory Board
Contributing Editor:
Peg Behan, MPA, RRT, RCP
Cardiopulmonary Supervisor
Dominican Santa Cruz Hospital
Santa Cruz, CA
George G. Burton, MD
Medical Director, Respiratory Services
Kettering Medical Center
Kettering, OH
Bob Demers, RRT
Demers Consulting Services
Carmel, CA
Allan Saposnick, RRT, MS, FAARC
President, ABSCO Enterprises
Respiratory/Homecare Consultants
Newtown Square, PA
Judy Tietsort, RN, RRT, FAARC
Respiratory Consultant
MediServe Information Systems
Tempe, AZ
Dave Walsh, RRT
DRW & Associates, Inc.
Chicago, IL
How may we help you?
For news and story ideas:
Contact Associate Editor Emily Beaver
• Phone: 781/639-1872, Ext. 3406
• Mail: 200 Hoods Lane, Marblehead, MA 01945
• E-mail: [email protected]
• Fax: 781/639-2982
Executive Editor, Elizabeth Petersen
Group Publisher, Emily Sheahan
Web site resources:
• To get the latest breaking news, visit www.hcpro.com
• For free resources available from HCPro, please visit
www.hcmarketplace.com/free.cfm
Paul Mathews, PhD, RRT, FCCM
Associate Professor of Respiratory
Care and Physical Therapy Education
University of Kansas Medical Center
Kansas City, KS
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