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Quality Improvement & Patient Safety Section Newsletter - December 2007, Vol 9, #1

Quality Improvement & Patient Safety Section

circle_arrow The Chair’s Letter
circle_arrow Section Officers 2007-2008
circle_arrow QIPS Section Annual Report
circle_arrow QIPS Annual Meeting Minutes
circle_arrow A Lean Primer
circle_arrow Interesting Challenge
circle_arrow AMA 2007 Annual Meeting in Chicago
circle_arrow Historical Figures in Quality
circle_arrow National Patient Safety Goals
circle_arrow The ED Quality Course
circle_arrow Washington Update – Quality Measures
circle_arrow Welcome New Members!
circle_arrow Quality and Safety Articles

Newsletter Index

Quality Improvement & Patient Safety Section



The Chair’s Letter

Dickson Cheung, MD, MBA, MPH

Dickson Cheung, MD, MBA, MPHIf you are a member of the QIPS Section, you already know that these are exciting times to be involved in quality and patient safety in healthcare. And they will continue to be for many years to come.

The reason is not primarily because we are facing external pressure from organizations such as the Center of Medicare and Medicaid Services, the Institute of Medicine in their well publicized reports or even that it is a noble pursuit that is finally finding its rightful place in the agendas of important meetings. Healthcare quality will continue to a major issue for decades to come mainly because of worldwide economic forces: businesses cannot afford to continue to pay for healthcare services at its current rate. Large automotive corporations are going bankrupt, towns are shriveling up as companies fold and Americans are losing jobs as globalization because more of a reality with each passing day. The survival of the American economy is contingent upon our collective ability to provide better healthcare at lower costs for our country to remain competitive.

The cynic will say that the whole PQRI movement is just to cut payments to hospitals and providers. There certainly is some truth to that sentiment but I’d rather take advantage of this opportunity to finally highlight the overdue need to increase quality, standardization and to decrease waste and inefficiency in our operations. The importance for a Section such as ours will only increase with time. The rest of our careers will be dominated by this demand to provide better and more services for less and with less while still keeping our patients safe from harm. The only question is whether we are up to the task. I think we are.

We have a reason to be incredibly proud of our Section. And not just because we have accomplished the hat trick of ACEP Section awards: the Outstanding Web Page 1207chairAward, the Outstanding Newsletter Award and the Promoting Section Membership Award. This trifecta represents a complete sweep of all the Section awards we were eligible for this year. Quite impressive! I can honestly say though that I am not surprised. The dedication of the members within our group is inspiring. Personally, I know of several people that flew to Seattle this year just to participate in our Section meeting. This community we have built over the past few years has become the place to network with others committed to Quality Improvement and Patient Safety. I have only been a part of the group for a short three years but I have witnessed an incredible amount of dedication put forth to make projects like the QTIPS, the CCBQI (chief complaint based quality indicators grant), the Quality Course and the Quality Improvement and Patient Safety Curriculum become reality. Each project has taken an enormous amount of effort from an equally large number of Section members. As much enrichment as we get from the Section meeting at the Annual Meeting, most of the work in our Section occurs during the year in the form of conference calls, writing assignments and advocacy for various core measures and ACEP resolutions. And most if not all of us do this in our spare time, for no pay and often no recognition.

As the new leader of our Section, I have spent some time thinking about how to build upon the momentum sparked by my predecessors. Clearly, we need to continue to develop the CCBQI project (which will likely be resurrected this year) and the Curriculum project. The Curriculum project in particular will receive a lot of attention this year as it represents the natural evolution of QIPS. This project will help us build a framework in which to build a research agenda, an educational platform and an avenue for members to get plugged into specific areas of quality improvement and patient safety.

One area that I want to concentrate on this year is to further build QIPS as a community. We have an incredibly talented group. Looking around the Seattle conference room, I noted many national experts in our field including government agents, group administrators, academic researchers, educators, business leaders and full-time clinicians. As individuals, we are often the only ones at our respective institutions that are committed to safety and quality from emergency medicine. There are relatively so few of us across the nation that we need to stick and work together. Only when we can harness the resources of everyone’s diverse skills and perspectives can we make the most impact. Otherwise, we will be subject to those with less experience, less expertise and less at stake than ourselves to make decisions for us and our patients.

I am proud to represent our Section. And we should all be proud to be a part of it. QIPS truly represents the best of Section membership… even if we didn’t get all the awards. But it sure is nice!




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Section Officers 2007-2008

Chair/Alternate Councillor: Dickson S. Cheung, MD, FACEP

cheungDr. Cheung was born and raised in Chicago. He attended MIT for undergraduate degree in mechanical engineering, returning to Chicago for medical school and emergency medicine residency at Northwestern. He has lived in Boston, Chicago, Denver, San Francisco and currently resides in Baltimore where he is an Assistant Professor at Johns Hopkins School of Medicine. His research and administrative focus is on patient quality, safety and operational efficiency.

Dr. Cheung served as the Newsletter Editor of the QIPS Section in 2005. He was Co-leader of the Syncope subsection for the Chief Complaint-based Quality Indicator grant. He also served ACEP as the emergency medicine representative for the Sinusitis Guideline Panel sponsored by the Academy of Head and Neck Surgeons.


Chair-Elect: Robert I. Broida, MD, FACEP

broidaDr. Broida is Chief Operating Officer of Physicians Specialty Limited, Risk Retention Group (PSLRRG), a South Carolina captive insurance company serving the Ohio-based Emergency Medicine Physicians, Ltd. group. He serves on the Board of Directors of PSLRRG, the Ohio Chapter of the American College of Emergency Physicians and of the Northeast Ohio Society of Emergency Medicine in Cleveland. Dr. Broida is a member of the national ACEP Medical-Legal and Quality and Performance Committees. He is also a member of the ACEP Sections on Quality Improvement / Patient Safety and Emergency Medicine Practice Management and Health Policy.


Immediate Past Chair/Councillor: John (Jack) Kelly, DO, FACEP

kellyDr. Kelly is Associate Chair and Director of Emergency Department Quality Improvement and Patient Safety, and Director of the Senior Resident Administration Rotation at Albert Einstein Medical Center (AEMC) in Philadelphia. He is Vice President of the AEMC Medical Staff Board and Chair of the Physician Advocacy Committee of the Medical Staff Board. He holds the rank of Associate Professor at Jefferson Medical College.

Dr. Kelly also is Chair of the AEMC Pneumonia Task Force and a member of the Hospital Board's Finance/Mission Resources Committee, Medical Leadership Executive Committee, Performance Improvement Council, Cath Alert QA Group, Stroke Task Force/JHS Stroke Workgroup, and Network Mission/Vision "Alignment" Leadership Group.

He is Vice President and Board Member of the Pennsylvania Chapter of the American College of Emergency Physicians (PaACEP), and is Board Liaison and member of the Education Committee.

Nationally, he Chairs the ACEP Academic Affairs Committee, and Chairs the ACEP Quality Improvement and Patient Safety Section. Dr. Kelly has published in peer reviewed journals on Quality of Emergency Care, Patient Safety, and Emergency Airway Safety/Assessment. Recently he was awarded the AEMC Physician Partnership Award.

Secretary / Newsletter Editor: Elaine A. Thallner, MD, MS, FACEP

thallnerDr. Elaine Thallner is an emergency physician at Cleveland Clinic Foundation. She has trained in healthcare quality with the National Veteran’s Administration Healthcare Quality Fellowship, has earned a MS in Organizational Development and Change at the Weatherhead School of Management of the Case Western Reserve University, and has received advanced training in executive coaching. Dr. Thallner is active at the state and national levels in emergency care quality issues as well as state and federal legislative efforts related to emergency care. She has led quality improvement efforts, taught residents how to design quality improvement projects and coached them through their projects, and done research in patient safety. She also serves as an executive coach for physician leaders and leads seminars on developing leadership through emotional intelligence.



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QIPS Section Annual Report

Quality Improvement & Patient Safety Section
AnnualReport 2006-2007

Officers for 2006-2007

Chair: John J. Kelly, DO, FACEP
Chair-elect/Councillor: Dickson S. Cheung, MD, FACEP
Secretary/Newsletter Editor: Robert I. Broida, MD, FACEP
Alternate Councillor: Helmut W. Meisl, MD, FACEP
Board Liaison: Cherri D. Hobgood, MD, FACEP
Staff Liaison: Angela J. Franklin, JD

Summary of Annual Section Meeting

October 8, 2007, Seattle, Washington

Dr. John J. Kelly, DO, FACEP, Chair, Dickson S. Cheung, MD, Chair-Elect; Helmut W. Meisl, MD, FACEP, Immediate Past Chair; Robert I. Broida, Secretary/Newsletter Editor; Dennis M. Beck, MD, FACEP, Chair; Quality and Performance Committee, and Angela Franklin, JD, Staff Liaison, and 30 additional members and guests were present.

Section activities for the prior year were discussed, including publication of four issues of the newsletter, Award for Service to College, completion of the Section Grant for the presentation of "The ED Quality Course" at ACEP’s Spring Congress, and plans to seek a new grant to fund work on development of a National QI/PS Curriculum.

Elections resulted in the following officers for 2007-2008:

Chair/Alternate Councillor: Dickson S. Cheung, MD
Immediate Past Chair/Councillor: John J. Kelly, DO, FACEP
Chair-Elect: Robert I. Broida, MD, FACEP
Secretary/Newsletter Editor: Elaine A. Thallner, MD, FACEP

Dr. Andrew Sama, MD, FACEP has been appointed as QIPS Board Liaison for 2007-2008; Angela J. Franklin, JD remains staff liaison.


The Section discussed its direction for 2007-08, including the pursuit of a section grant for the development of a National QI/PS Curriculum. Guest speakers for the meeting were Shari L. Welch, MD, FACEP, Quality Improvement Director of Intermountain LDS Hospital in Salt Lake City, UT, and Dennis Beck, MD, FACEP, Chair of the Quality and Performance Committee (QPC). Dr. Welch presented the group with innovations in improving the flow of patients in the ED, engaging the group in discussion of the various options. Dr. Dennis Beck discussed the new QPC objectives for 2007-08 and his vision of how the QPC and QIPS would work together in the coming year.

Section Activities for 2006-2007

  1. Production of four full Newsletters, with quality articles on QI topics, CMS PQRI measures, Patient Safety.
  2. Increase in membership from approximately 220 to about 235 members.
  3. Recipient of the Outstanding Web Page Award, Outstanding Section Newsletter Award, and the 2007 Promoting section membership award.
  4. Successful completion of a section grant for "The ED Quality Course". This was the result of the successful grant application by the QIPS Section under the direction of Dr. David John to develop a practical, hands-on quality course aimed at anyone working in ED Quality, including new physicians and nurses. The course covered how to conduct a case reviews, data collection and analysis, putting in place systems to improve outcomes, and an expert panel discussion with the audience. The course featured the following faculty:
David P. John, MD, FACEP
James J. Augustine MD, FACEP
Christopher B. Beach MD, FACEP
Ann E. (Annie) Gerhart RN MSN FNP CEN
Azita G. Hamedani MD, MPH
Kevin M. Klauer DO, FACEP
Helmut W. Meisl MD, FACEP
Shari J. Welch, MD, FACEP

The course was successfully presented at the ACEP Spring Congress on April 25, 2007; future presentations are hoped for.

  1. Preliminary planning for the development of a National QI/PS Curriculum, and seeking a section grant to fund this effort.

Section Objectives for 2007-2008

  1. Continued Involvement with the Quality and Performance Committee regarding development and recommendation of performance measures that improve outcomes and are appropriate for Emergency Medicine.
  2. Continued planning for the development of a National QI/PS Curriculum and completion of a grant application to fund the effort.
  3. Pursue further avenues to increase membership, including academic centers and residency physicians.
  4. Increased mutual co-operation on QI issues with SAEM.
  5. Continuation of QIPS leader’s calls and communications to advance the Section’s goals.
  6. Continuation of production of four full Newsletters and updating/improvement of the Section Website.

Submitted by John J. Kelly, DO, FACEP
November 1, 2007





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QIPS Annual Meeting Minutes

Quality Improvement & Patient Safety Annual Meeting

Monday, October 8, 2007 · 1:30 pm - 3:30 pm
Washington State Convention and Trade Center · Room 401
Seattle, Washington



Present for all or part of the meeting were: John J. Kelly, DO, FACEP, Chair; and 30 additional members and guests.

Others participating for all or part of the meeting included Dickson S. Cheung, MD, Chair-Elect; Helmut W. Meisl, MD, FACEP, Immediate Past Chair; Robert I. Broida, Secretary/Newsletter Editor; Dennis M. Beck, MD, FACEP, Chair; Quality and Performance Committee, and Angela Franklin, JD, Staff Liaison.


  • Introductions and Welcome
  • Section Activities, 2006-2007
  • Section Activities, 2007-2008
  • QI/PS National Curriculum
  • Councillor's Report
  • Election
  • Speakers

Major Points Discussed

Dr. John J. Kelly, DO, FACEP, Chair, welcomed everyone to the section meeting and discussed the Section activities that had taken place in 2006-07. Dr. Kelly reported that the Section was the recipient of the Outstanding Web Page Award, Outstanding Section Newsletter Award, and the 2007 Promoting Section Membership Award. The Section also increased membership from approximately 220 to about 235, and produced a total of four newsletters. Dr. Kelly called for volunteers for co-editors to support the Newsletter Editor position. He also reported that QIPS won a Section Grant to develop an ED Quality Course. The work on the Course was led by Dr. David John, and was successfully presented at the ACEP Spring Congress in April, 2007.

With regard to future work of the Section, Dr. Kelly noted that the goal is to build on the success of the ED Quality Course by developing a National Quality Improvement and Patient Safety Curriculum for the ED. Dr. Kelly said the Section plans to apply for a grant to cover the creation of the Curriculum, and invited interested members to contact him about the project.

Dr. Helmut W. Meisl, MD, FACEP, gave the Councillor’s Report and noted that Resolution 28(07), sponsored by the Pennsylvania Chapter and QIPS was adopted at the Council meeting. The Resolution was entitled "Hospital Leadership Actions to Ameliorate Crowding", and resolved that ACEP support strategies by Hospital Leadership that would ameliorate hospital crowding and overcapacity and develop a position paper explaining these concepts, which would be distributed to hospital leaders (CEOs, COOs and others) nationwide.

Dr. Meisl then presided over the election. First on the agenda was a proposed change to the QIPS Operational Guidelines to clarify the selection and progression of Councillor and Alternate Councillor. Dr. Meisl explained that the proposal was needed to create more certainty in the appointment of Councillors and ensure adequate coverage at Council: The proposed amendments were highlighted as follows:

6. Councillor

6.1 The Immediate Past Chairman of the Section, at the time of the Council meeting, shall represent the Section to the Council of the College ("the Council"). The Chair-Elect of the Section at the time of the Council meeting shall serve as the Alternate Councillor. If the Immediate past Chairman cannot serve as Councillor, there shall be a progression, with the Chair-Elect serving the role of first Alternate Councillor, and the Chair-Elect Secretary serving as the second Alternate Councillor, and the Secretary as the third Alternate Councillor. If these alternates are unable to serve at the time of the Council meeting, the Chair shall appoint an alternate Councillor with approval by majority vote of the executive committee.

The proposed change was approved by a majority of QIPS members present.

Dr. Meisl next turned to the election of new officers. The nominees were: Chair: Dickson S. Cheung, MD; Chair-Elect: Robert I. Broida, MD, FACEP, and Secretary/Newsletter Editor: Elaine A. Thallner, MD, FACEP. Pursuant to the vote, the nominees were elected to office by a majority of QIPS members present. Dr. Meisl announced the 2007-2008 QIPS Officers:

Chair/Alternate Councillor: Dickson S. Cheung, MD
Immediate Past Chair/Councillor: John J. Kelly, DO, FACEP
Chair-Elect: Robert I. Broida, MD, FACEP
Secretary/Newsletter Editor: Elaine A. Thallner, MD, FACEP

Dr. Dickson S. Cheung MD, Chair, introduced the guest speakers for the meeting: Dr. Shari L. Welch, MD, FACEP, Quality Improvement Director, Intermountain LDS Hospital in Salt Lake City, UT, and Dr. Dennis Beck, MD, FACEP, Chair of the Quality and Performance Committee (QPC). Dr. Welch presented the group with innovations in improving the flow of patients in the ED: "Five New ideas on Flow", engaging the group in discussion of the various options. Dr. Dennis Beck discussed the new QPC objectives for 2007-08 and his vision of how the QPC and QIPS would work together in the coming year. Objectives include development of ACEP brand measures. After discussion with the group it was agreed that QIPS’ work on the "Chief Complaint Based Quality Indicators" (CCBQI) would prove a valuable starting point in this effort.

Dr. Cheung then opened the floor for new business, and brief member discussion. Dr. Cheung also noted that a meeting for those interested in assisting with the development of a QI/PS National Curriculum for the ED would immediately follow.

There being no further business, the QIPS Annual Meeting adjourned at 3:35 p.m. PST.



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A Lean Primer

By Dickson Cheung, MD MBA MPH

For a number of years, hospitals have been experimenting with management tools used in industry to help solve some of its problems with increasing patient wait times, increasing workloads and decreasing resources. One management tool that has gained some traction in the healthcare quality movement is Lean Methodology. Why Lean versus dozens of other management methodologies? Well, Lean is ideal for problems where the main outcome metric is lead time or the time it takes to complete a certain task. Examples in the ED include lab turn around time, time to balloon, time to thrombolytics, time to pain medication, time to be seen by the provider, time to admission, time to discharge, etc. You get the idea. Lean also has a straight forward prescribed methodology and relatively quick to implement.

Before I go any further, I should say something about my own background and experience with Lean. I first came across Lean Methodology in business school about five years ago. Most of the examples involved production and assembly lines. At the time, I was at Johns Hopkins and the institution decided to use Lean Sigma (a hybrid of Lean Methodology and Six Sigma) as its main tool of choice for solving its safety and quality problems. I entered a lengthy 4 month Black Belt training course (no, it has nothing to do with martial arts) and during my years at Hopkins, I led and followed a number of Lean Sigma projects. My experience with Lean Methodology and Six Sigma is that it is certainly no cure all. But we did have a few notable successes where the methodology really did seem to work. I do not know how long Lean will continue to be in vogue in the healthcare field (as these methodologies tend to have a limited shelf life) but there are some principles and tools that will probably stand the test of time and so therefore worth learning about.

Lean Manufacturing Methodology, developed at Toyota in Japan, has been used throughout manufacturing and especially, in the automotive industry. The basic strategy is to ruthlessly eliminate waste and to create value at each step in the process. All of this is of course from the viewpoint of the customer a.k.a. the patient. One of the reasons Lean has become so popular is that waste is something that healthcare providers can identify with on a gut level e.g. how many times have you been frustrated by a hemolyzed specimen?

Waste can be categorized into seven groups: inventory, over-production, over-processing, defects, waiting, moving things (transporting patients), motion (moving providers). Examples include performing unnecessary XRs or tests (over-production), duplicating documentation (over-processing), over-staffing (inventory), medication errors (defects) or transporting patient from XR to CT scanner to floor (motion). And of course, the big waste of waiting: for providers, for specimens, for medications, for consultants, for rooms to be cleaned, etc.

In the perfect Lean world, the patient would have just the necessary tests performed to result in a diagnosis and the right amount of treatment to restore health. Of course without any delay or error in the process. In the perfect Lean world, the providers would work at a steady pace and never experience down times nor be overworked during their shift. The supply and demand for resources would be in perfect balance. Utopia. Of course, we in the emergency department do not live in such an orderly world. But Lean attempts to make it more so.

Below is an explanation of common Lean principles and tools. Rarely are all the principles and tools used on any given project.

Lean principles:

  • Just In Time (Flow): provide the right service/item at the right time and in the right amount. Example: a urinalysis is performed immediately on patients with symptoms of a urinary tract infection without waiting for a physician order. The provider would then get the result just as the patient is seen so the diagnosis could be immediately made and treated.

  • Jidoka (Quality): identify local problems and develop corrective measures without continuous management involvement. This tool was originally envisioned as the "autonomic nervous system" of an organization. Every worker serves as their own manager. In the automotive assembly line world, each worker is empowered to identify solutions to a problem before a defective product is produced. In healthcare, this means the nurse, the tech, the ward clerk all are responsible for catching defects as well as the provider.

  • Kanban: a communication system using visual signs to trigger steps in a process and obtain an orderly flow of services. Example: when a lab test is completed and reported out, a visual signal tells the provider to check the result.

  • Production Leveling: balance the workload to avoid resource crunches that will backlog future service. Example: matching the hourly rate of arrival for emergency patients with an appropriate number of nurses and providers. In healthcare, this will likely require a flexible workforce system e.g. an on call system so that the ratio of patients to nurses/providers is as consistent as possible.

  • Standardization: standardize processes across all providers to achieve consistency. Everyone should perform a process the same way according to local standards so that there is no confusion. This is akin to an orchestra playing from the same score of music. Each individual knows exactly what to do at the right time. Process standards are most successful implemented if they are created by the stakeholders.

Lean "tools" include:

  • 5S: sort, straighten, scrub, systemize, standardize. Sort (tag everything that is not needed and throw it out), straighten (give everything a label and a place to reside), scrub (declutter), systemize (regularly maintain an orderly space), standardize (develop processes based on best practices). Low hanging fruit! An orderly place is an efficient place.

  • Spaghetti diagram: a map that geographically depicts how far it takes providers to walk or move patients to accomplish a certain task. The physical environment should be designed in such a way that a process can be completed with the least amount of movement possible. For example, central line or suture carts are efficient because the provider can bring the portable cart directly to the patient and does not need to waste time walking to gather equipment.

  • Value stream map: a flow diagram that visually depicts each step in the process. Aids in identifying where waste and customer value exist in the process.

  • Product family matrix: a table that shows the related steps in various processes. Aids in identifying common steps in processes. For example, the workup of a chest pain patient and a patient who presents with syncope both require an EKG.

  • Sequence of events: a table that lists the tasks in a process in the order that it needs to be performed and the time it takes to performed each individual task. Aids in assigning tasks to an individual and in predicting how many individuals are needed to perform a particular step in the process. For example, if it takes twice as long to perform a CT scan as it does to draw blood (assuming that there is the same demand for both services), then two workers need to be assigned to the CT scanner for every one phlebotomist. If the capital equipment is the bottle neck, then perhaps more CT scanners are needed. This is the same idea behind the recent changes to airport check-in where now kiosks have replaced traditional stewards because this is where the bottle neck occurs.

  • Operational method sheets: a visual instructional map that clearly depicts how a particular process is to be performed. This is very similar to instruction manuals or road maps that we download from the computer e.g. that clearly outline in no uncertain terms driving directions. Operational method sheets are critical to successfully implementing a standardized process. They are often placed in very conspicuous places where the process is being performed e.g. ACLS algorithms in the resuscitation bay. For a real life example, next time you go into McDonald’s look at one of the side walls and see if you can spot their operational method sheet that reminds workers exactly how many packets of sugar, cream and napkins to put into your bag.

Well, that’s all for now. Lean Methodology in a nutshell. If you are interested in an example, let me know and I include a real life example in the next newsletter.




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Interesting Challenge

California Medical Association’s resolution to AMA regarding P4P
Helmut Meisl, MD, FACEP
(permission obtained to include in newsletter from Dr. Prolo)

Author: Donald J. Prolo, MD
Introduced by: Donald J. Prolo, MD
Endorsed by:  

WHEREAS, Medicare and Third Party Payers seek to impose pre-determined medical care on patients through Pay-for-Performance and Public Reporting Programs (HHS "Health Care Transparency Initiative") that report compliance with process, structural and outcome measures which are being implemented through a multidisciplinary consensus-building organization, the Ambulatory Care Quality Alliance (AQA); and

WHEREAS, AMA President, Dr. William Plested III, wrote in an opinion piece in the AMEDNEWS of Feb 19, 2007 that the Pay-for-Performance and Public Reporting are about cost control, not quality, and that participation in a PFP program may be unethical; and

WHEREAS, such programs have been hastily constructed to satisfy arbitrarily created deadlines of Third Parties, large corporations and the government, leading to adoption of measures without accurate supporting science or proper vetting through medical specialty societies; and

WHEREAS, the valid, peer review studies published in the medical literature have demonstrated that:

  • Pay-For-Performance programs have not aided in improving medical care and have simply re-directed valuable health care dollars to groups already in compliance with government and third party standards;
  • Compliance with such process measures have not improved patient outcomes in areas such as acute myocardial infarction and congestive heart failure;
  • Physicians "game" the system to demonstrate improved compliance numbers in public reporting programs without necessarily improving patient care;
  • Physicians avoid high risk patients to allow their reported numbers used in PFP and Public Reporting Programs to appear favorable;
  • Valid risk adjustment methods have yet to be fully developed for public reporting programs;
  • Minority populations appear at risk to be adversely affected by such programs due to increased incidence of high risk conditions and socioeconomic challenges impairing access to medical care; and

WHEREAS, third Parties have been abusing the use of quality and efficiency measures to demonize publicly and to disadvantage economically physicians for the benefit of the third party payers and large corporations; and

WHEREAS, the AMA and CMA have established principles and guidelines on Pay-For-Performance that have been largely ignored by the government and third party payers; and

WHEREAS, the AMA and CMA have worked hard to assist third parties and government authorities to create valid and fair public reporting and Pay-For-Performance Programs, but the development of such Programs has largely been controlled by large corporations and Third Party Payers; therefore be it

RESOLVED, that our CMA finds that Pay-For-Performance and Public Reporting Programs pose more risks to patients than benefits and calls for an immediate cessation of such programs by private and public Third Party Payers; and be it further

RESOLVED, that our CMA Chair and Board of Trustees advise the Secretary of Health and Human Services and the Ambulatory Care Quality Alliance (AQA) that the CMA will no longer participate in the creation, development or implementation of the Secretary's "Transparency Initiative" or other Pay-For-Performance Programs.




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AMA 2007 Annual Meeting in Chicago

Helmut Meisl MD FACEP

The recent AMA meeting had an extensive discussion on pay for performance.
For your information, I will include the conclusions (as written in the Santa Clara County Bulletin October 2007

  1. collaborate with interested parties to develop quality initiatives that exclusively benefit patients, protect patient access, do not contain requirements that permit third party interference in the patient-physician relationship and are consistent with the AMA’s Principles and Guidelines for Pay-for Performance and Principles for Physician Profiling (H-450.947): (a) ensure quality of care; (b) foster the patient/physician relationship; (c) offer voluntary physician participation; (d) use accurate data and fair reporting; (e) provide fair and equitable program incentives: and actively oppose any pay-for –performance program that does not meet all principles set forth in Policy H-450.947;

  2. strongly oppose the use of tiered and narrow physician networks that deny patient access to or steer patients toward certain physicians primarily based on cost of care factors (new HOD Policy);

  3. pledge an unshakable and uncompromising commitment to the welfare of our patients, the health of the nation, and the primacy of the patient-physician relationship free from intrusion from third parties;

  4. because our AMA finds PFP and public reporting programs may pose more risks to patients than benefits, the AMA must use every lawful means to advocate for an immediate cessation of such programs by private and public third party payers until such time as they have proven their exclusive benefit to patients in pilot projects that comply with AMA Policy H-450.947 (Directive to Take Action);

  5. work with medical and specialty associations to develop effective means of maintaining high quality medical care, which may include physician accountability to robust, effective, fair peer review programs, and use of specialty-based clinical data registries;

  6. provide CMS with data on special populations with higher health risk levels and develop variable incentives in achieving quality; continue to work with CMS to encourage and support pilot projects, such as the Physician Quality Reporting Initiative (PQRI) by state and specialty medical societies that are developed collaboratively to demonstrate effective incentives for improving quality, cost-effectiveness, and appropriateness of care;

  7. advocate that physicians be allowed to review and correct inaccuracies in their patient-specific data well in advance of any public release, decreased payments, or forfeiture of opportunity for additional compensation.




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Historical Figures in Quality

Elaine Thallner, MD, MS

In order to provide a historical context in the field of quality, I will write about the work of several historical figures over the course of the upcoming year. This is intended to help us learn from the efforts of these individuals, to understand how they approached their work, and to learn about how they were perceived by others.

Florence Nightingale

Significance: statistical data through graphics, influence public policy

Florence Nightingale was born in 1820 into a well-connected, wealthy British family. She had been educated in languages, philosophy, and math. Against her family’s wishes, at a time when it was ‘unladylike’ to be a nurse, she began the study of nursing at age 31 and quickly became a nursing administrator in London. During this time, British and French forces were fighting in Turkey against Russia. Nightingale was recruited in 1854 (age 34) by the British government to become the chief nurse for the soldiers wounded in the Crimean War. The unsanitary conditions in the field hospitals, the lack of any trained British nurses (in comparison to the French), the lack of supplies, and the high mortality rate of the wounded soldiers had already attracted the attention of the British newspapers and the public.

In 1854 she and 38 other nurses sailed to Turkey with the support of the British government and private financial support administered through The Times. They confirmed the dire conditions, recognized that the majority of deaths were from preventable disease (although the germ theory of disease was yet to be introduced), and set to work cleaning despite initial resentment and resistance from the military. The infectious disease death rate at the field hospital plummeted from 60% to 2% within a few months. She collected information and used statistics to lead and influence reforms. Two years later she returned to England. She continued investigating military medical care, using statistical graphics that showed that British soldiers hospitalized in England had a higher death rate than those in British field hospitals in Turkey and higher than civilian males in British non-military hospitals. As a result, several government commissions were established and improvements in water supply, sterilization, ventilation, and sewage were implemented. The military established training programs and a new system for gathering medical statistics was developed. She was now a national hero and founded the Nightingale Training School for Nurses in 1860. She lived to age 90, and despite being mainly confined to bed after her return from the war, she managed to write over 200 books and continued influence public policy.

Cohen B. Florence Nightingale. Scientific American 250(3), 128-137. March.

Ulrich BT. Leadership and Management According to Florence Nightingale. Norwalk: Appleton & Lange, 1992. P 2-6, 10-58.

Next time: Avedis Donabedian



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National Patient Safety Goals

On June 1, 2007, The Joint Commission’s Board of Commissioners approved the 2008 National Patient Safety Goals. The Goals and related requirements are below. New Goals and requirements are indicated in bold and accreditation program applicability is indicated in brackets. Gaps in the numbering indicate a Goal has been "retired," usually because the requirements were integrated into the standards. Program-specific language changes are omitted from this version.

This year’s new requirements (3E and 16A) have a one-year phase-in period that includes defined expectations for planning, development and testing ("milestones") at 3, 6 and 9 months in 2008, with the expectation of full implementation by January 2009. See the Implementation Expectations for milestones.


Goal 1 Improve the accuracy of patient identification
1A Use at least two patient identifiers when providing care, treatment or services. [Ambulatory, Assisted Living, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Lab, Long Term Care, Office-Based Surgery]
1B Prior to the start of any invasive procedure, conduct a final verification process, (such as a "time out,") to confirm the correct patient, procedure and site, using active—not passive—communication techniques. [Assisted Living, Home Care, Lab, Long Term Care
Goal 2 Improve the effectiveness of communication among caregivers
2A For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the information record and "read-back" the complete order or test result. [Ambulatory, Assisted Living, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Lab, Long Term Care, Office-Based Surgery]
2B Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization. [Ambulatory, Assisted Living, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Lab, Long Term Care, Office-Based Surgery]
2C Measure and assess, and if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values. [Ambulatory, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Lab, Long Term Care, Office-Based Surgery]
2E Implement a standardized approach to "hand off" communications, including an opportunity to ask and respond to questions. [Ambulatory, Assisted Living, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Lab, Long Term Care, Office-Based Surgery]

Goal 3 Improve the safety of using medications
3C Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used by the organization, and take action to prevent errors involving the interchange of these drugs. [Ambulatory, Behavioral Health Care, Critical Access Hospital, Home Care, Hospital, Long Term Care, Office-Based Surgery
3D Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field. [Ambulatory, Critical Access Hospital, Hospital, Office-Based Surgery]
3E Reduce the likelihood of patient harm associated with the use of anticoagulation therapy. [Ambulatory, Critical Access Hospital, Home Care, Hospital, Long Term Care, Office-Based Surgery]
Goal 7 Reduce the risk of health care-associated infections
7A Comply with current World Health Organization (WHO) Hand Hygiene Guidelines or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines. [Ambulatory, Assisted Living, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Lab, Long Term Care, Office-Based Surgery]
7B Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection. [Ambulatory, Assisted Living, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Lab, Long Term Care, Office-Based Surgery]
Goal 8 Accurately and completely reconcile medications across the continuum of care
8A There is a process for comparing the patient’s current medications with those ordered for the patient while under the care of the organization. [Ambulatory, Assisted Living, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Long Term Care, Office-Based Surgery]
8B A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization. The complete list of medications is also provided to the patient on discharge from the facility. [Ambulatory, Assisted Living, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Long Term Care, Office-Based Surgery]
Goal 9 Reduce the risk of patient harm resulting from falls
9B Implement a fall reduction program including an evaluation of the effectiveness of the program. [Assisted Living, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Long Term Care]
Goal 10  Reduce the risk of influenza and pneumococcal disease in institutionalized older adults
10A Develop and implement a protocol for administration and documentation of the flu vaccine. [Assisted Living, Disease-Specific Care, Long Term Care]
10B Develop and implement a protocol for administration and documentation of the pneumococcus vaccine. [Assisted Living, Disease-Specific Care, Long Term Care]
10C Develop and implement a protocol to identify new cases of influenza and to manage an outbreak. [Assisted Living, Disease-Specific Care, Long Term Care]
Goal 11 Reduce the risk of surgical fires
11A Educate staff, including operating licensed independent practitioners and anesthesia providers, on how to control heat sources and manage fuels with enough time for patient preparation, and establish guidelines to minimize oxygen concentration under drapes. [Ambulatory, Office-Based Surgery]
Goal 12 Implementation of applicable National Patient Safety Goals and associated requirements by components and practitioner sites
12A Inform and encourage components and practitioner sites to implement the applicable National Patient Safety Goals and associated requirements. [Networks]
Goal 13 Encourage patients’ active involvement in their own care as a patient safety strategy
13A Define and communicate the means for patients and their families to report concerns about safety and encourage them to do so. [Ambulatory, Assisted Living, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Lab, Long Term Care, Office-Based Surgery]
Goal 14 Prevent health care-associated pressure ulcers (decubitus ulcers)
14A Assess and periodically reassess each resident’s risk for developing a pressure ulcer (decubitus ulcer) and take action to address any identified risks. [Long Term Care]

Goal 15 The organization identifies safety risks inherent in its patient population
15A The organization identifies patients at risk for suicide. [Behavioral Health Care, Hospital (applicable to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals)]
15B The organization identifies risks associated with long-term oxygen therapy such as home fires. [Home Care]

Goal 16 Improve recognition and response to changes in a patient’s condition
16A The organization selects a suitable method that enables health care staff members to directly request additional assistance from a specially trained individual(s) when the patient’s condition appears to be worsening. [Critical Access Hospital, Hospital]




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The ED Quality Course

Wednesday, April 2, 2008, 1-5 pm · ICEM · San Francisco Hilton
David P. John, MD, FACEP

Please join us at the 12th International Conference on Emergency Medicine (ICEM) for a free four-hour Pre-Conference course provided by US experts in Emergency Medicine Quality: the ED Quality Course!

Methods to improve quality in the emergency department are difficult to develop but have been shown to be successful. Through an overview of the history of quality improvement and a series of three case-based and practical lectures, members of the ACEP Quality Improvement and Patient Safety Section (QIPS) will share important successes in quality, and provide emergency physicians and nurses the fundamentals for a successful quality program. The final segment of the course will feature an expert panel discussion of key issues in Emergency Medicine quality, including specific case examples of successful quality improvement initiatives, barriers associated with successful implementation of quality improvement initiatives, and the current status and future trends of the quality movement in emergency medicine: opportunities and pitfalls. At the conclusion of this course, attendees should be able to design an emergency department Quality Program or re-tool an already existing plan.

Mark your calendar for Wednesday, April 2, 2008 from 1:00 to 5:00 p.m. and plan to gather with your colleagues from around the globe at the beautiful San Francisco Hilton for the ED Quality Course!



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Washington Update – Quality Measures

Angela Franklin, Esq., Staff Liaison

Reporting of Physician Quality Data for Bonus Payments (PQRI)

PQRI Background

On December 20, 2006 the President signed the Tax Relief and Health Care Act of 2006 Section 101 (TRHCA) into law. Section 101 under Title I authorizes the establishment of a physician quality reporting system by CMS. This statutory program has been named the Physician Quality Reporting Initiative (PQRI).

PQRI eligible professionals who successfully report a designated set of quality measures on claims for dates of service from July 1 to December 31, 2007, may earn a bonus payment of 1.5 percent of total allowed charges for covered Medicare physician fee schedule services—subject to a cap. Providers have until Feb. 29, 2008, to submit 2007 claims. Bonuses for the 2007 program will be distributed in mid-2008, along with confidential feedback on reporting and performance rates. PQRI applies to the traditional Medicare fee-for-service program only.

Additional information on the program is available on the CMS website. To help address some reporting issues that have cropped up over the 2007 reporting period, CMS has published a reporting tips sheet, which is available at

TRHCA also allocated a $1.35 billion for bonuses under the program in 2008, unless changed by congressional action.


The 2008 Medicare Physician Fee Schedule (MPFS) Final Rule, effective for services on or after January 1, 2008, identifies 119 measures CMS has selected for eligible professionals to use to report quality-of-care information under the 2008 Physician Quality Reporting Initiative (PQRI). The current Specifications for the measures have been posted at, along with the Release Notes.

The new measures include the following eleven (11) that emergency physicians can choose to report, which have been modified for 2008 as indicated in the Release Notes. Please note that PQRI Measure #29, "Beta-Blocker at Time of Arrival for Acute Myocardial Infarction (AMI)" has been retired for 2008.

2008 PQRI Measures *Currently Specified for Emergency Medicine


#28. Aspirin at Arrival for Acute Myocardial Infarction (AMI)
#31. Stroke and Stroke Rehabilitation: Deep Vein Thrombosis Prophylaxis (DVT) for Ischemic Stroke or Intracranial Hemorrhage
#34. Stroke and Stroke Rehabilitation: Tissue Plasminogen Activator (t-PA) Considered
#47.  Advance Care Plan
#54. Electrocardiogram Performed for Non-Traumatic Chest Pain
#55. Electrocardiogram Performed for Syncope
#56. Vital Signs for Community-Acquired Bacterial Pneumonia
#57. Assessment of Oxygen Saturation for Community-Acquired Bacterial Pneumonia
#58.  Assessment of Mental Status for Community-Acquired Bacterial Pneumonia
#59. Empiric Antibiotic for Community-Acquired Bacterial Pneumonia
#76. Prevention of Catheter-Related Bloodstream Infections (CRBSI) – Central Venous Catheter Insertion Protocol


*Additional measures may become applicable prior to 12/31/07

ACEP’s Quality and Performance Committee (QPC) is reviewing all the 2008 PQRI measures for potential additional measures that may be appropriate for Emergency Medicine; measure specifications may change prior to December 31st.

The final 2008 measure specifications will be available on the PQRI section of the CMS Web site at by December 31, 2007. Specifications will include instructions for reporting and identify the circumstances in which each measure is applicable. CMS warns that the 2008 PQRI measure specifications for any given measure may be different from the specifications for the same measure used in 2007.

CMS is also urging providers who may have encountered problems reporting to consider reporting broader "structural" measures that are applicable to most practitioners (e.g. measures relating to the use of electronic health records and e-prescribing).

Reporting of Hospital Quality Data for Annual Hospital Payment Update

NQF Approves Hospital-Level ED Transfer Measures
Call for Comprehensive Hospital-Level Measures Expected in December

In November the National Quality Forum (NQF) recently endorsed twelve (12) Emergency Department Transfer Measures put forth by CMS and the University of Minnesota Rural Health Research Center (UMRHRC). This work represents Phase 1 of the NQF’s Emergency Care Project. ACEP members served on the NQF Steering Committee that considered the measures and ACEP provided several comments in the process.

As part of final OPPS rule (discussed below), hospitals are required to report several of the measures, now that they have been endorsed by NQF. The measures are as follows.


NQF Endorsed ED Transfer Measures In OPPS
Final Rule
1. Aspirin at Arrival (CMS) X
2. Median to Fibrinolysis (CMS) X
3. Fibrinolytic Therapy Received Within 30 Minutes of ED Arrival (CMS) X
4. Median to ECG (CMS) X
5. Median Time to Transfer to Another Facility for Acute Coronary Intervention (CMS)


6. Administrative Communication (UMRHRC)  
7. Patient Information (UMRHRC)  
8. Vital Signs (UMRHRC)  
9. Medication Information (UMRHRC)  
10. Physician Information (UMRHRC)  
11. Nursing Information (UMRHRC)  
12. Procedures and Tests (UMRHRC)  

Endorsement is effective as of October 31. Details on the measures may be found on the NQF Website. In Phase 2 of the Emergency Care Project, NQF plans to issue a call for comprehensive ED measures in December.

OPPS Final Rule - Reporting Quality Measures in Outpatient Settings

In the Outpatient Prospective Payment System (OPPS) final rule CMS has selected seven (7) quality measures to initiate the Hospital Outpatient Quality Data Reporting Program (HOP QDRP); five AMI relevant to emergency department transfers, and two surgical care measures will be required, as listed in the table below. The new requirements are intended to be complementary to, and modeled after, the current Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) . Details:

  • Outpatient quality reporting will begin on April 1, 2008 (rather than the proposed January 1, 2008 date)
  • A hospital’s Ambulatory Payment Classification (APC) payments will be affected in 2009 if it fails to participate in quality reporting. If an outpatient facility decides not to participate, its payment conversion factor will be reduced by two percent (2%) in 2009
  • Outpatient quality reporting will include only outpatients and transfers to another hospital, not hospital admissions (quality measures for inpatients will be reported using the inpatient data set)
  • Hospitals must submit a "Notice of Intent to Participate" and register with the Quality NetExchange by January 31, 2008 regardless of whether or not they plan to participate, and
  • CMS is considering additional measures for 2009 and beyond.

Outpatient PPS, HOP QDRP Measures

Emergency Department Transfer Measures (Acute Myocardial Infarction)  
ED-AMI-1 Aspirin at Arrival NQF Endorsed, eff. 10/2007
ED-AMI-2 Median Time to Fibrinolysis NQF Endorsed, eff. 10/2007
ED-AMI-3 Fibrinolytic Therapy Received within 30 minutes of Arrival NQF Endorsed, eff. 10/2007
ED-AMI-4 Median Time to Electrocardiogram (ECG) NQF Endorsed, eff. 10/2007
ED-AMI-5 Median Time to Transfer to Primary PCI NQF Endorsed, eff. 10/2007

Surgical Care  
PQRI #20 Perioperative Care: Timing of Antibiotic Prophylaxis PQRI measure also
PQRI #21 Selection of Prophylactic Antibiotic (p 1130) PQRI measure also

Joint Commission Alignment. The Joint Commission has added this initial set of seven hospital outpatient measures to its current complement of core measure sets that may be used to satisfy ORYX performance measurement requirements. Beginning with January 1, 2008 discharges, Joint Commission accredited hospitals must collect and submit data to the Joint Commission for a minimum of four (4) core measure sets or a combination of applicable core measure sets and non-core measures.

Hospitals selecting the outpatient measure set to meet ORYX requirements will be asked to confirm this selection by January 1, 2008, but will not be required to initiate data collection until April 2008. Additional information about Joint Commission performance measurement requirements and core measures is available at

IPPS Final Rule – Reporting Quality Measures in Inpatient Settings

Under the Deficit Reduction Act of 2005 (DRA), for FY 2007, hospitals must submit quality data on an expanded set of measures, starting with discharges in calendar year (CY) 2006. Hospitals that fail to comply with this requirement for a fiscal year will receive a 2.0 percentage point reduction in their annual update of the Medicare hospital inpatient prospective payment system (IPPS) payment rate. For the FY 2008 update there are 27 quality measures, as listed in the table below.

Heart Attack (Acute Myocardial Infarction)

  1. Aspirin at arrival
  2. Aspirin prescribed at discharge
  3. ACE inhibitor (ACE-I) or Angiotensin Receptor Blocker (ARBs) for left ventricular systolic dysfunction
  4. Beta blocker at arrival
  5. Beta blocker prescribed at discharge
  6. Thrombolytic agent received within 30 minutes of hospital arrival
  7. Percutaneous Coronary Intervention (PCI) received within 120 minutes of hospital arrival
  8. Adult smoking cessation advice/counseling

Heart Failure (HF) 

  1. Left ventricular function assessment
  2. ACE inhibitor (ACE-I) or Angiotensin Receptor Blocker (ARBs) for left ventricular systolic dysfunction
  3. Discharge instructions
  4. Adult smoking cessation advice/counseling

Pneumonia (PNE)

  1. Initial antibiotic received within 4 hours of hospital arrival
  2. Oxygenation assessment
  3. Pneumococcal vaccination status
  4. Blood culture performed before first antibiotic received in hospital
  5. Adult smoking cessation advice/counseling
  6. Appropriate initial antibiotic selection
  7. Influenza vaccination status

Surgical Care Improvement Project (SCIP) – named SIP for discharges prior to July 2006 (3Q06)

  1. Prophylactic antibiotic received within 1 hour prior to surgical incision
  2. Prophylactic antibiotics discontinued within 24 hours after surgery end time
  3. SCIP-VTE 1: Venous thromboembolism (VTE) prophylaxis ordered for surgery patients
  4. SCIP-VTE 2: VTE prophylaxis within 24 hours pre/post surgery
  5. SCIP Infection 2: Prophylactic antibiotic selection for surgical patients

Mortality Measures (Medicare patients)

  1. Acute Myocardial Infarction 30-day mortality Medicare patient
  2. Heart Failure 30-day mortality Medicare patients Patients’ Experience of Care
  3. HCAHPS patient survey

Selection of Hospital-Acquired Conditions for FY 2008. Section 5001(c) of Deficit Reduction Act (DRA) requires Secretary to select at least two conditions by October 1, 2007 that are:

  1. High cost or high volume or both;
  2. Assigned to a higher paying DRG when present as a secondary diagnosis; and
  3. Reasonable preventable through application of evidence based guidelines.

The IPPS final rule lists eight (8) conditions (see table below) that hospitals must report beginning October 1, 2008 (FY 2009). Hospitals began reporting secondary diagnoses present on admission on October 1, 2007. Beginning on October 1, 2008, the conditions will not be assigned to higher paying DRG unless they are present on admission (POA).

In addition, CMS listed another 3 conditions, which will be considered for reporting in the FY 2009 IPPS proposed rule, and another 3 conditions that will be analyzed for future selection.


  1. Serious preventable event: object left in surgery
  2. Serious preventable event: air embolism
  3. Serious preventable event: blood incompatibility
  4. Catheter associated urinary tract infection
  5. Pressure ulcers
  6. Vascular catheter associated infection
  7. Surgical site infection – Mediastinitis after CABG
  8. Falls


Additional Possibilities for 10/1/08 Notes:
1. Ventilator associated pneumonia Work underway to create new code
2. Staphylococcus aureus septicemia Clarification needed regarding when instances are preventable
3. Deep vein thrombosis (DVT) and pulmonary embolism (PE) Clarification needed regarding when instances are preventable, such as after certain elective surgeries

To be Analyzed for Future Selection

  1. Clostridium Difficile-Associated Disease (CDAD)
  2. Methicillin-Resistant Staphyloccocus Aureus (MRSA)
  3. Wrong Surgery



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Welcome New Members!

  • Timothy G Greco, MD, FACEP, Fullerton, CA
  • Norman A Chapin, MD, Purling, NY
  • Waseem Ahmed Khawaja, MD, MPH, Westlake, OH
  • Rustin B Morse, MD, Scottsdale, AZ
  • Laura Rendano, MD, Geneva, NY
  • Annitha Annathurai, MD, Singapore



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Quality and Safety Articles

Helmut Meisl, MD, FACEP

Here is again a list of recent articles that may interest you. These are compiled by AHRQ PSNet at ( ).

  • Adverse drug events in hospitalized cardiac patients.
    Fanikos J, Cina JL, Baroletti S, Fiumara K, Matta L, Goldhaber SZ. Am J Cardiol. 2007;100:1465-1469.
  • A framework for health care organizations to develop and evaluate a safety scorecard.
    Pronovost PJ, Berenholtz SM, Needham DM. JAMA. 2007;298:2063-2065.
  • Effect of a rapid response system for patients in shock on time to treatment and mortality during 5 years.
    Sebat F, Musthafa AA, Johnson D, et al. Crit Care Med. 2007;35:2568-2575.
  • Guilty, afraid, and alone — struggling with medical error.
    Delbanco T, Bell SK. N Engl J Med. 2007;357:1682-1683.
  • Limited health literacy is a barrier to medication reconciliation in ambulatory care.
    Persell SD, Osborn CY, Richard R, Skripkauskas S, Wolf MS. J Gen Intern Med. 2007;22:1523–1526.
  • Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists.
    Kripalani S, Jackson AT, Schnipper JL, Coleman EA. J Hosp Med. 2007;2:314-323.
  • Enhancing pediatric safety: using simulation to assess radiology resident preparedness for anaphylaxis from intravenous contrast media.
    Gaca AM, Frush DP, Hohenhaus SM, et al. Radiology. 2007;245:236-244.
  • Medical errors involving trainees: a study of closed malpractice claims from 5 insurers.
    Singh H, Thomas EJ, Petersen LA, Studdert DM. Arch Intern Med. 2007;167:2030-2036.
  • Drug selection errors in relation to medication labels: a simulation study.
    Garnerin P, Perneger T, Chopard P, et al. Anaesthesia. 2007;62:1090-1094.
  • Medication safety: just a label away.
    Jennings J, Foster J. AORN J. 2007;86:618, 620-625.
  • Medication tracers: a systems approach to medication safety.
    Hendrick EC, Montanya KR, Griffith N. Hosp Pharm. 2007;42:916-920.
  • Communication techniques for patients with low health literacy: a survey of physicians, nurses, and pharmacists.
    Schwartzberg JG, Cowett A, VanGeest J, Wolf MS. Am J Health Behav. 2007;31(suppl):S96-S104.
  • Is hospital patient care becoming safer? A conversation with Lucian Leape.
    Buerhaus PI. Health Affairs. 2007;26:w687-w696.
  • Validation of a diagnostic reminder system in emergency medicine: a multi-centre study.
    Ramnarayan P, Cronje N, Brown R, et al. Emerg Med J. 2007;24:619-624.
  • Communicating in the "gray zone": perceptions about emergency physician-hospitalist handoffs and patient safety.
    Apker J, Mallak LA, Gibson SC. Acad Emerg Med. 2007;14:884-894.
  • Creating a fair and just culture: one institution's path toward organizational change.
    Connor M, Duncombe D, Barclay E, et al. Jt Comm J Qual Patient Saf. 2007;33:617-624.
  • Communication patterns in a UK emergency department.
    Woloshynowych M, Davis R, Brown R, Vincent C. Ann Emerg Med. 2007;50:407-413.
  • Is the availability of hospital IT applications associated with a hospital's risk adjusted incidence rate for patient safety indicators: results from 66 Georgia hospitals.
    Culler SD, Hawley JN, Naylor V, Rask KJ. J Med Syst. 2007;31:319-327.
  • No safety, no quality: synthesis of research on hospital and patient safety (1996-2007).
    Tzeng HM, Yin CY. J Nurs Care Qual. 2007;22:299-306.
  • Systematic review of the incidence and characteristics of preventable adverse drug events in ambulatory care.
    Thomsen LA, Winterstein AG, Søndergaard B, Haugbølle LS, Melander A. Ann Pharmacother. 2007;41:1411-1426.
  • Intensive care unit safety incidents for medical versus surgical patients: a prospective multicenter study.
    Sinopoli DJ, Needham DM, Thompson DA, et al. J Crit Care. 2007;22:177-183.
  • Adverse drug events in pediatric outpatients.
    Kaushal R, Goldmann DA, Keohane CA, et al. Ambul Pediatr. 2007;7:383-389.
  • Patient safety in nursing practice.
    Farquhar M, Collins Sharp BA, Clancy CM. AORN J. 2007;86:455-457.
  • Publicly available hospital comparison web sites: determination of useful, valid, and appropriate information for comparing surgical quality.
    Leonardi MJ, McGory ML, Ko CY. Arch Surg. 2007;142:863-869.
  • Costs of adverse events in intensive care units.
    Kaushal R, Bates DW, Franz C, Soukup JR, Rothschild JM. Crit Care Med. 2007 Sep 5; [Epub ahead of print].
  • Improving sleep hygiene of medical interns: can the sleep, alertness, and fatigue education in residency program help?
    Arora VM, Georgitis E, Woodruff JN, Humphrey HJ, Meltzer D. Arch Intern Med. 2007;167:1738-1744.
  • Discharge rounds in the 80-hour workweek: importance of the trauma nurse practitioner.
    Haan JM, Dutton RP, Willis M, Leone S, Kramer ME, Scalea TM. J Trauma. 2007;63:339-343.
  • Workforce perceptions of hospital safety culture: development and validation of the patient safety climate in healthcare organizations survey.
    Singer S, Meterko M, Baker L, Gaba D, Falwell A, Rosen A. Health Serv Res. 2007;42:1999-2021.
  • Making the Patient Safety and Quality Improvement Act of 2005 work.
    Vemula R, Assaf RR, Al-Assaf AF. J Healthc Qual. 2007;29:6-10.
  • Fatal 1,000-fold overdoses can occur, particularly in neonates, by transposing mcg and mg.
    ISMP Medication Safety Alert! Acute Care Edition. September 6, 2007;12:1-4.
  • Physician scores on a national clinical skills examination as predictors of complaints to medical regulatory authorities.
    Tamblyn R, Abrahamowicz M, Dauphinee D, et al. JAMA. 2007;298:993-1001.
  • The variability and quality of medication container labels.
    Shrank WH, Agnew-Blais J, Choudhry NK, et al. Arch Intern Med. 2007;167:1760-1765.
  • Serious adverse drug events reported to the Food and Drug Administration, 1998-2005.
    Moore TJ, Cohen MR, Furberg CD. Arch Intern Med. 2007;167:1752-1759.
  • Criminalization of medical error: who draws the line?
    Dekker SW. ANZ J Surg. 2007;77:831-837.
  • Getting surgery right.
    Clarke JR, Johnston J, Finley ED. Ann Surg. 2007;246:395-405.
  • Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform.
    Volpp KG, Rosen AK, Rosenbaum PR, et al. JAMA. 2007;298:975-983.
  • Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform.
    Volpp KG, Rosen AK, Rosenbaum PR, et al. JAMA. 2007;298:984-992.
  • Randomized trial to improve prescribing safety in ambulatory elderly patients.
    Raebel MA, Charles J, Dugan J, et al. J Am Geriatr Soc. 2007;55:977-985.
  • Disclosing unanticipated outcomes to patients: the art and practice.
    Gallagher TH, Denham CR, Leape LL, Amori G, Levinson W. J Patient Saf. 2007;3:158-165.
  • Justifying patient risks associated with medical education.
    Chiong W. JAMA. 2007;298:1046-1048.




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This publication is designed to promote communication among emergency physicians of a basic informational nature only. While ACEP provides the support necessary for these newsletters to be produced, the content is provided by volunteers and is in no way an official ACEP communication. ACEP makes no representations as to the content of this newsletter and does not necessarily endorse the specific content or positions contained therein. ACEP does not purport to provide medical, legal, business, or any other professional guidance in this publication. If expert assistance is needed, the services of a competent professional should be sought. ACEP expressly disclaims all liability in respect to the content, positions, or actions taken or not taken based on any or all the contents of this newsletter.

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