Join Section

Quality Improvement & Patient Safety Section Newsletter - June 2008, Vol 9, #3

Quality Improvement & Patient Safety Section

circle_arrow The Chair’s Letter
circle_arrow Fumbled Handoffs at Shift Change: A Common Liability Source for Emergency Physicians - Don't rush to leave the department, take "ownership" of new patients
circle_arrow Historical Figure In Quality:  Ernest Amory Codman, MD
circle_arrow Article review of "The Checklist" by Atul Gawande
circle_arrow Boarding Solutions Report Released
circle_arrow New CMS Demo:  Acute Care Episodes
circle_arrow New PQRI Provisions
circle_arrow FY 2009 Medicare IPPS Proposed Rule (Measures)
circle_arrow GAO on Healthcare Acquired Infections
circle_arrow National Quality Forum Update
circle_arrow New Members and Networking Section
circle_arrow Quality and Safety Articles

Newsletter Index

Quality Improvement & Patient Safety Section


The Chair’s Letter

Dickson Cheung, MD, MBA, MPH

Dr. Dickson CheungFirst of all, congratulations to all that put on the ED Quality Course on April 2nd in San Francisco. Kudos to David John for again putting on a quality (no pun intended) affair for the second time. I attended the course for the first time and was extraordinarily impressed. I personally learned a lot and wish we could come up with a way to package it such that more people to take advantage of all the collective wisdom that was a part of the course.

Well, the QIPS section grant on handoffs was submitted on April 25th.  I spoke with the chair of the grant committee and she says that this year is particularly competitive. We were 1 of 8 grants applications (out of 16) to be asked to submit a final version. Although it is far from a sure thing that we will be receiving our third grant in three years, we put together a strong application. Thanks to all who critically reviewed the grant and sent back very helpful feedback. Hopefully, you will all get positive news in the next month or so and we will be able to proceed with our work on improving handoff procedures between shifts.

The QIPS section meeting during the Scientific Assembly this October in Chicago is shaping up nicely. We were able to invite and secure Sue Nedza, who was the former Chief Medical Officer, Region V of the Centers for Medicare and Medicaid Services and is currently the Vice President, Clinical Quality and Patient Safety at the AMA. Also planning to speak is John Vozenilek who is the director of simulation at Northwestern University and recently received an AHRQ grant to reduce communication errors during patient hand-offs in the emergency department by implementing a patient-specific checklist based on an electronic medical record, and by testing the effect of companion simulation-based training.

Finally, I’ve been thinking about how to further the legacy of our section and to increase its lasting impact on emergency medicine. My latest idea is to sponsor QIPS section awards to individual residency programs. As someone formerly heavily involved in resident education, I recall each program having a "year end" dinner with various awards usually for "outstanding resident", "outstanding research", etc. Residents are now required to participate in some process improvement activity during their residency. How about establishing a "quality award" from QIPS?  The award e.g. plaque, prize would be sponsored by the individual program but be endorsed by us. I think it is important to begin to recognize emergency physicians who are dedicated to quality. And no where better to start influencing the future than with new EM grads. Let me know what you think.

That’s all for now. See you in Chicago!

Back to Top

Fumbled Handoffs at Shift Change: A Common Liability Source for Emergency Physicians - Don't rush to leave the department, take "ownership" of new patients

By Robert A. Bitterman, MD, JD, FACEP, Contributing Editor

Many thanks to Dr. Bitterman and AHC Media LLC and ED Legal Letter for granting us permission to include the following article in the QIPS Newsletter.
Publication Date: 04/11/2008 Source: AHC Newsletters

Patient handoffs, or turning over a patient's care to another physician, are high-risk encounters in emergency medicine due to the potential for breakdowns in communication. Important information may not be provided, the information provided may be misunderstood, or the physician assuming care of the patient may forget the information. Any of these issues can lead to misdiagnoses, adverse outcomes, unhappy patients or families, and litigation for malpractice.

The Institute of Medicine, in its seminal report, Crossing the Quality Chasm, specifically cited patient handoffs as one of the most common sources of error in medicine. 1 Recent studies also confirm that poor communication is the leading cause of sentinel events within hospitals. 2 The malpractice literature corroborates that communication breakdowns occurred in nearly 80% of medical malpractice lawsuits. 3 In response, The Joint Commission identified improvement in patient turnover communications as one of its prime patient safety goals in 2006. 4

In the practice of emergency medicine, handoffs occur in three typical scenarios: first, at change of shift from one emergency physician to another; second, at the time of admission from an emergency physician to the admitting physician; and third, at the time of transfer from an emergency physician at one hospital to an accepting physician at another facility. This article will focus on the change of shift in the ED, though the concepts are equally applicable to the other scenarios as well.

Patient Handoffs between ED Physicians at Shift Change
At shift change, the emergency physician going off-shift may be tired or in a rush to leave the department. The oncoming physician may never examine the patients transferred to their care or really develop a sense of "ownership" for them during their stay. It's often expedient to simply accept the patient's data, without critically questioning the prior physician or obtaining a complete picture of the patient's situation, to be able to begin seeing the new patients who may be crowding into the ED. Failure to allocate enough time to handoffs is a common reason for mistakes. Add high volume, high acuity, a noisy chaotic environment, and a compounding effect when both the nursing staff and physicians change shift simultaneously, and it's easy to see the propensity for error. 5

Role of the emergency physician turning over patients to an oncoming emergency physician. The principal role of the physician leaving the ED is to adequately communicate the existing and foreseeable needs of the patients, the plan of care, and any potential complications to the oncoming emergency physician. The physician ending his/her shift should document the transfer of responsibility to the oncoming physician and the exact time that the transfer of responsibility took place in the ED records. He or she should inform the patient and family of the change in physicians, and build in additional redundancy by telling the patient's nurse that a transfer of care had taken place and who will be responsible for the patient henceforth. Physicians definitely want to avoid the embarrassing and dangerous scenario of a patient "nose-diving" shortly after shift change and no one in the department knowing which physician is responsible for the patient.

Handoff of the complex patient. There are essentially two types of patients turned over at change of shift. First, is the complex work-up type patient who requires considerable attention from the managing physician. In this case, the leaving physician should bring the oncoming physician to the patient's bedside to introduce the physician to the patient and point out key findings or concerns to ensure a seamless transfer of care.

Handoff of the patient with less complicated complaints. The second type includes the "simple action" cases, for which only 1-2 straightforward actions need to be taken that are usually based on a lab test or x-ray result. For example, x-ray may be delayed and the patient needs a simple ankle x-ray that the physician expects to be negative. The emergency physician who originally saw the patient should explain the situation to the patient (and family if present), provide the appropriate care and discharge instructions relative to a negative result, and prepare the necessary discharge materials and prescriptions. Then, if indeed the x-ray is negative the oncoming physician can so inform the patient and ask the nursing staff to discharge the patient.

The question that always comes up in these types of cases is whether the on-coming physician should write a note and sign the medical record? If only a simple straightforward action is necessary, such as checking an x-ray or lab result, then the on-coming physician can perform the task requested for the physician leaving the ED and not sign the chart. Usually, the leaving physician retains sole liability for the patient's care and outcome. If the oncoming emergency physician, rather than a radiologist, reads the x-ray, then the emergency physician should reexamine the patient, write a note on the chart, and sign the chart indicating the actions taken and responsibility assumed.

Certainly, whenever a lab test is abnormal or an x-ray is positive in any way, the oncoming emergency physician should speak to the patient, explain the finding, and arrange the appropriate care or follow-up needed. The physician also should write a note documenting the findings and communications with the patient and sign the ED record.

Remember to slow down during turnover times. Finally, don't be in a rush to leave the emergency department; accept it as part of your life and just plan on being there awhile. Doing so will eliminate a great deal of your own anxiety and markedly improve the quality of care for your patients. Similarly, don't schedule meetings for at least an hour to an hour and a half after your shift ends (depending on the patient volume and acuity of your ED). If you must rush out, ask the oncoming physician to come in early and repay the time to him or her later on.

Many ED groups schedule overlapping shifts, or during double-covered times have physicians who are near the end of a shift only pick up lower acuity patients to mitigate turnover issues. Consider innovative systems to minimize the number of turnovers and accordingly minimize the risk!

Role of the oncoming emergency physician. The oncoming physician should not merely "receive report," but instead actively elicit information, ask clarifying questions, and highlight contradictions or inconsistencies. Ask "if-then" questions to understand the patient's expected course in the ED. Try to quickly see the more complex patients while the off-duty physician is still in the ED in case you identify additional questions or concerns.

Accept "real" responsibility for the patient; introduce yourself to the patient and family, inform them of your role for the remainder of their visit, and assure them that you've fully discussed the patient's case with the initial physician. Then, take care of the patient as if no one else had been involved in their care except you.

Don't always assume the initial diagnosis or x-ray interpretations were correct. If needed, reassess the patient sufficiently to the point that you are satisfied you understand and have a handle on the patient's medical conditions. Be especially leery if you are assuming care of a complex or intoxicated patient from the night physician; disrupted circadian sleep patterns may lead to aberrant medical decision making. The passage of time and a fresh, full evaluation of the patient may reveal additional concerns.

As a general rule, all patients assumed at change of shift should be reevaluated prior to discharge. The "simple-action" type turnover patients may sometimes be an exception, as was noted previously in this article. Certainly, any patients who are in the department a long time, even the straightforward patients, also should be reassessed at the time of discharge. The oncoming physician always should write a note documenting the reassessment, any change in the patient's condition, and the final diagnosis and discharge instructions.

Policy Perspectives on ED Shift Change
If your ED physician group works in a fee-for-service or RVU (relative value unit) model, it is highly recommended that the group assign payment for the patient encounter to the physician who last signs the chart and is responsible for discharging the patient. This physician is the one who accepts ultimate responsibility and liability for the patient's care and disposition. Such a policy truly encourages "real ownership" of the patients who are turned over at change of shift and also diminishes the number of patients ultimately signed out to the oncoming physician.

The shift change process itself should be standardized and include an opportunity to ask and respond to questions. "Sticky note" instructions left on a chart are unacceptable. Face-to-face discussion of the patients' issues using departmental standardized procedures such as checklists, sign-out cards, or computerized grease boards improves the transition of care and minimizes miscommunications and errors. Patients always should be discussed in a standard order, such as starting and ending at the same bed location in the department, to avoid omitting anyone.

Standard policy and procedure should define a bright-line transfer of responsibility from emergency physician to emergency physician by requiring the leaving physician to document and note the time of the transfer of care to the oncoming physician in the ED medical record. Policy and procedure should require the oncoming physician to reassess all patients who are assumed, write a final note on the record, and sign the chart. (Again, the "simple-action" type cases maybe an exception to this rule.)

Policy also should require that the patient, the family, and the patient's nurse be promptly informed of the change in the responsible emergency physician so that everyone knows who is in charge of the patient's care at all times.

The key to a successful risk management program is to commit energy and resources to areas of known risk. Patient handoffs at change of shift in the ED are definitely high-risk encounters and prone to communication errors. Awareness of the particular risks of each scenario, implementing formal transition policies and procedures, and improved communication processes will minimize the medical and legal problems related to the handoff.


  1. Committee on the Quality of Health Care in America, Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: The National Academies Press; 2001.
  2. WHO Collaborating Centre for Patient Safety Solutions. Communication during patient hand-overs. Patient Safety Solutions. May 2007, Volume 1, Solution 3. [Identified poor communication as the leading root cause of sentinel events in hospitals.]
  3. Levinson W. Physician-patient communication. A key to malpractice prevention. JAMA 1994;272:1619-1620. [Communication breakdowns evident in 80% of malpractice lawsuits.]
  4. The Joint Commission. 2006 National Patient Safety Goals. Goal 2E: Implement a standardized approach to "hand off" communications, including an opportunity to ask and respond to questions. Joint Commission Perspectives July 2005.
  5. Gandhi TK. Fumbled handoffs: one dropped ball after another. Ann Intern Med 2005;142:352-358; Meisel ZF, Pollack C. Patient safety in emergency care transitions. (Case study). Emergency Medicine Specialty Reports. June 2006.

Additional Resources

  1. Joint Commission International Center for Patient Safety. Strategies to improve hand-off communication: implementing a process to resolve questions. Joint Commission Perspectives on Patient Safety July 2005, Volume 5, Issue 7. Available at Accessed on 2/6/08.
  2. Behara R, Wears R, Perry SJ, et al. A conceptual framework for studying the safety of transitions in emergency care. Advances in Patient Safety, vol 2. Accessed on 2/6/08.
  3. Wears RL, Perry SJ, Shapiro M, et al. Shift changes among emergency physicians: best of times, worst of times. In: Proceedings of the Human Factors and Ergonomics Society 47th Annual Meeting. Denver, CO: Human Factors and Ergonomics Society; 2003:1420-1423.
  4. Burrell M. Shift report: Improving a complex process to enhance patient safety. ASHRM J 2006;26:9-13.
  5. Vidyarthi AR, Arora V, Schnipper JL, et al. Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out. J Hosp Med 2006;1:257-266.
  6. Arora V, Johnson J, Lovinger D, et al. Communications failures in patient sign-out and suggestions for improvement: a critical incident technique. Qual Saf Health Care 2005;14:401-407.
  7. Patterson E.S., et al.: Handoff strategies in settings with high consequences for failure: lessons for health care operations. Int J Qual Health Care 2004;16:125-132.
  8. Cook RI, Render M, Woods DD. Gaps in the continuity of care and progress on patient safety. BMJ 2000;320:791-794.
  9. Wachter RM, Shojania KG. Internal bleeding: the truth behind America's terrifying epidemic of medical mistakes. New York, NY: Rugged Land Press; 2004. SOURCE-ED Legal Letter

Back to Top

Historical Figure In Quality:  Ernest Amory Codman, MD

Elaine Thallner, MD, MSOD

thallnerErnest Codman (1869-1940) was outspoken, courageous, and persistent as a physician leader in quality improvement. He was a meticulous ‘measurer’ even in his personal life (as a hunter, he kept a log of the ratio of birds shot to shells expended and compared his results from one year to the next). He encouraged doctors, hospital trustees, administrators and others to learn, to continually strive to do better through recording data and studying the results.

As a Harvard medical student in1884 and 1885, it was his duty to administer anesthesia (ether) to surgical patients at Massachusetts General Hospital. Patient deaths during surgery were not uncommon at that time. Harvey Cushing, a classmate, and Codman challenged each other to see who could get the best outcomes for their patients. They recorded their results and ultimately developed the first anesthesia charts, which subsequently became standard practice.

As a young surgeon at MGH, he tracked down surgical patients one year after their hospital discharge and recorded their so called ‘end-results,’ linking for the first time cause and effect (treatment and result). He wrote "Great hospitals like Massachusetts General Hospital have a duty to perform to medical and surgical science… By grouping cases into series large enough to favor comparative study and by observing definite previously determined points, a rational clinical science can be established. By putting the results on record, the patient will not only be protected but each operation will have the strongest incentive to excel in all the details of diagnosis and technique which count toward successful result. This method will put an end to the old experimental surgery where each operator took a try at each new operation and reported only the good results. It will also discourage hasty diagnosis and thoughtless operating by busy men with great reputations.1

He resigned from MGH and founded his own small hospital in Boston. Each patient had an ‘end result card’ which included their symptoms, initial diagnosis, treatment, complications, discharge diagnosis, and a one year follow-up. He developed a system to classify errors (Table 1), publicly reported the results of his hospital (including openly admitting his own errors), and challenged hospitals to do the same2:  "If I can thus analyze my errors and deficiencies, a charitable hospital can. Before trustees vote more funds for new buildings and equipment, let them appoint efficiency committees to make analyses of the results they are getting now. They can then decide whether to spend their money for improvement in quality or in quantity – for products or waste products."3 His hospital was always considered an ‘outlaw institution.’4 His End Result Hospital closed in 1919 after he was unable to raise money and other surgeons refused to join his staff (probably fearing that their end-results would be compared and published). Feeling rejected by MGH, upon his death he bequeathed a copy of his outcomes book to each surgeon at MGH.

He was a founding member of the American College of Surgeons (1913). They had three original goals: 1) promotion the specialty of surgery and establishment of college fellowship as qualification, 2) eliminate fee splitting between surgeon and referring physician, and 3) standardize hospital care through Codman’s end results idea. A few years later he was asked to resign from the ACS Standardization Committee after a meeting in which he attempted to force Boston hospitals to publicly report their results. [The Joint Commission took over the standardization program in 1951].

Table 1.
Codman's Error Classification

All results of surgical treatment that lack perfection may be explained by one or more of the following causes:
These are partially controllable by organization:
These are partially controllable by public education:
These should be acknowledged to ourselves and to the public, and study directed to their prevention.

Codman served in the army in 1918-1919 and when he returned he turned his attention to studying sarcoma, a fatal rare disease which he felt was often misdiagnosed and imperfectly treated. The ACS established a bone sarcoma registry and after study, Codman pointed out to them that the pathologists were using different nomenclature to describe the same disease (he reviewed histories, xrays, and pathology slides), noted that treatments were vastly different, and he challenged the surgeons to specialize in order to improve patient care.

In summary, Codman aggressively challenged the status quo in support of learning from end results (outcomes). He was ahead of his times, confident in his ideas, and willing to sacrifice to pursue his ideals; however, the lack of acceptance from his colleagues did cause him anguish:  "I have suffered somewhat from a sense of isolation, because I have always been thinking, or saying, one thing or another, with which other doctors did not agree. This, in my early years, made me suspect myself of being peculiar… Even now I have this sense of isolation, although I have become more and more content to wait for acceptance of my views."   His courage and commitment can serve as an example to all of us who strive to do a better job every day and strive to encourage our institutions to do better.


  1. Codman EA:  Observations on a series of ninety-eight consecutive operations for chronic appendicitis. Boston Med Surg J  160:495-502, Oct 1913.
  2. Codman EA: A study in Hospital Efficiency as Demonstrated by the Case Report of the First Five Years of a Private Hospital. Boston: (privately printed). 1917, p 179.
  3. Codman EA: The Shoulder. Boston: (privately printed) 1934, p xv.
  4. Donabedian A: The End Results of Health Care. Ernest Codman’s Contribution to Quality Assessment and Beyond. The Milbank Quarterly 67:2, 1989.


Back to Top

Article review of "The Checklist" by Atul Gawande

David L. Meyers, MD, FACEP

Dr. David MeyersIn the December 10, 2007 issue of my now-favorite medical journal, The New Yorker, Dr. Atul Gawande wrote an essay entitled "The Checklist."  In it, he described the complexities of intensive care and the effect of that care on the recovery of several patients who sustained terrible life-threatening insults and nearly died but survived, including a three year old child, who fell through an icy pond surface and was not found for over a half hour and a middle-aged man with severe liver damage. Dr. Gawande detailed the numerous actions and interventions on these patients in the intensive care units (ICU) where they were treated, which ultimately allowed them to recover from their close calls with death.

He cited an Israeli study that concluded an average ICU patient undergoes 178 specific actions or interventions each day – administration of a medication, suctioning the lungs, placement of an intravenous line, performing dialysis, drawing blood, etc. – each of which posed risks to the patient as well as benefits. The study also noted that errors were made in approximately one to two percent of these actions, a seemingly low level but which meant that one or two were made on each patient every day.  In a particularly insightful comment, Dr. Gawande stated, "Intensive care succeeds only when we hold the odds of doing harm low enough for the odds of doing good to prevail."

Describing the many travails of his middle-aged patient, Dr. Gawande discussed the role of super-specialists, such as intensivists, in managing this and similar patients and then detailed a very serious IV line infection that occurred in spite of the expertise of the treating doctors and nurses, a complication which nearly caused the man’s demise. In acknowledging that even these experts – with their years of training and experience – really practice at the limits of human capability, he went on to discuss the challenge posed when expertise is not enough to achieve the levels of performance needed and expected.

Shifting perspective, he went on to describe early phases in the development by the Boeing Company of the aircraft which was to become the B-17 "Flying Fortress" bomber. The Army Air Corps had commissioned the development of a "next-generation" long-range bomber. In early trials, the prototype – much bigger and more complicated than any aircraft that had come before – had performed satisfactorily. Yet on one of its major tests, the massive airplane gained about 300 feet in altitude and stalled, falling to the ground and killing the pilot and another of the five crew members. The investigation into the cause of the crash revealed no mechanical failures, only pilot error. With all the actions needed to fly this behemoth, he had forgotten to release a rudder control.

Although some experts at the time considered it "too much airplane for one man to fly," and the Army chose to develop another airplane as a result of this accident, a few of the B-17s were purchased for testing. Test pilots were convened to figure out how to overcome its operational problems. They concluded that, rather than more training, a checklist for each step in the operation would help prevent the oversight that took the lives of the two flyers in the early test flight. With this pilot’s checklist, the aircraft went on to full development and hundreds of them were flown millions of miles without accidents.

Returning to the world of the ICU, the lesson of a checklist applied to flying a complex airplane was considered for use in complex patient care by an intensivist at Johns Hopkins Hospital, Dr. Peter Pronovost. Evidence from the medical literature is pretty clear that infections of central IV lines are a common and very serious complication of ICU care. These infections result in added expense and, at best, increased length of stay, at worst, death or devastating outcomes to a significant number of patients.

Proper technique for inserting these lines includes hand-washing before the procedure; putting on mask, hat, gown and gloves; preparing the skin with antiseptic; draping the patient; carefully inserting the line without breaking sterility; applying sterile dressing over the site after completion of the procedure.

Knowing that these steps were not routinely done in every case, Dr. Pronovost decided to test the idea of a checklist to prompt physicians to perform each step, and to record the actions for comparison with subsequent infection rates.

One key element of Pronovost’s effort was to enlist nurses in getting doctors to follow the rules – if the doctor about to perform the procedure did not accomplish each and every step on the checklist, the nurses were authorized and supported by the administration to stop the procedure – a revolutionary step. After a year, the results were dramatic – the line infection rate went from 11 percent to ZERO. Incredulous at these initial results, he observed the processes for another year before accepting them as real. He then expanded the scope of activities subject to similar checklists and found similar major improvements in outcomes like shorter stays in the ICU, fewer deaths, and lower costs of care.

Dr. Pronovost attributed the favorable effect of checklists for completing complex processes to two factors:

  1. They act as prompts and reminders to aid memory.
  2. They specify the minimum expected steps that have been shown to improve outcomes, translating the knowledge in the medical literature to the bedside care of patients.

The success of this work at Johns Hopkins, as measured by fewer deaths, shorter ICU and hospital stays and reduction of costs (by millions of dollars each year), gained wide attention and led to interest all over the world. Several years ago, the Michigan Hospital Association approached Dr. Pronovost to implement a program of using checklists to reduce line infections at the ICUs of its member hospitals.

He began by convincing the hospitals to collect baseline data, which, in 2004, showed a higher average infection rate than in other parts of the country. To prime the ICUs for the interventions, he made certain that chlorhexidine soap and full-size sterile drapes were available and in a convenient form – the manufacturer of the central line kits created a package containing all the necessary items. Nursing leaders monitored use of the checklists and physicians changed their behavior. In 2006, the results were published in a landmark article in the New England Journal of Medicine showing a dramatic reduction in line infections compared to the baseline, and saving over one thousand lives and nearly $200 million. 

From this story, Gawande poses the idea that medicine and physicians are undergoing changes similar to those that aviation and test pilots experienced as knowledge of the factors that caused accidents became clearer and methods to prevent them evolved. Pronovost is somewhat more pessimistic about how rapidly these ideas will be adopted in health care. If history is any guide, payers will drive this and similar initiatives far more than providers.

An interesting coda to this story:  Dr. Gawande wrote an Op-Ed piece on this topic in the New York Times in late December 2007 after it was publicized that the federal Office for Human Research Protection (OHRP) shut down the Michigan program because Dr. Pronovost and his colleagues were deemed to be conducting a study of the effects of the checklist intervention without written informed consent from every patient and provider who participated in it. A firestorm of criticism of the agency ensued and, on February 15, 2008, the OHRP reversed its decision. The agency’s press release explained its original rationale and that of the decision to reverse, and cited references.

The value of using checklists, illustrated by the work of Pronovost and others, can be applied to preventing errors in the ED. Using them at the bedside to assist, prompt and remind practitioners - about risk factors, conditions to consider in the setting of particular symptoms and signs, the work-up of patients who present with those conditions - can supplement clinical judgment, our favorite, yet often unreliable, refuge. Electronic medical records can give physicians ready access to these reminders and checklists at the bedside, thereby facilitating the avoidance of potentially serious or fatal errors. Quality improvement efforts can then easily assess whether and how physicians use the information to provide appropriate care and generate corrective approaches to improve that care. This is true patient-oriented care.

Back to Top

Boarding Solutions Report Released

ACEP’s Boarding Solutions Task Force recently completed a new report, "Emergency Department Crowding: High-Impact Solutions." The beauty of the report’s recommendations is that they are little or no-cost solutions that will have a positive impact on our patients and the amount of time they are boarded in the emergency department.

Please promote this valuable new tool with your colleagues, include it in your chapter newsletters, talk with your hospital medical staff and administrators about it, and promote these solutions in your media advocacy efforts.

Back to Top

New CMS Demo:  Acute Care Episodes

On May 16, 2008, CMS announced an Acute Care Episode (ACE) demonstration for hospitals to test the use of a bundled payment for both hospital and physician services for a select set of episodes of care to improve the quality of care delivered through Medicare fee-for-service.

There will be an informational teleconference for this demonstration, the Acute Care Episode (ACE) demonstration, for potential applicants and other interested parties on June 4, 2008 from 3 to 4:30 p.m. EST. The teleconference will be an opportunity to ask questions and for CMS to clarify issues in both the solicitation and the demonstration project itself. The call-in number for the teleconference is 1-888-982-4492 (participant passcode "Acute Care").

For more information about the demonstration, please visit the ACE demonstration webpage at:

Back to Top

New PQRI Provisions

The Centers for Medicare & Medicaid Services (CMS) recentlin announced steps it will provide a variety of new reporting options, and make it easier for eligible professionals to participate and receive feedback on their performance in order to encourage participation in PQRI. These changes are not expected to alter reporting for the Emergency Medicine measures.

For the 2007 program, Emergency Medicine was among three specialties with above average participation rates. Approximately 16% of all eligible providers participated, and approximately 50% of those are expected to receive bonuses. For additional information regarding PQRI, please see:

Back to Top

FY 2009 Medicare IPPS Proposed Rule (Measures)

Angela Franklin, Esq., Staff Liaison

angelafranklinOn April 14th, the Centers for Medicare and Medicaid Services (CMS) released its proposed fiscal year (FY) 2009 Medicare hospital inpatient prospective payment system (IPPS) rule, which among other things, would expand the FY 2008 list of hospital acquired conditions (HACs) or "never events", for which Medicare would not fully reimburse if acquired in the hospital from 8 to 18 conditions (please see QIPS Newsletter, "IPPS Final Rule – Reporting Quality Measures in Inpatient Settings", December 2007, Vol. 9, #1). The proposed rule would also expand to the number of measures hospitals must report in order to receive a full payment update in FY 2010 from 30 to 72 measures. CMS is seeking comments on the proposed rule by June 13th, 2008. ACEP plans to review the proposed rule and submit comments.


Hospital Acquired Conditions (HAC); Present on Admission (POA) reporting

The HAC provisions in Medicare regulations required hospitals to begin reporting on their Medicare claims on October 1, 2007, whether certain specified diagnoses were present when the patient was admitted. The first eight conditions were:

  • Object inadvertently left in after surgery
  • Air embolism
  • Blood incompatibility
  • Catheter associated urinary tract infection
  • Pressure ulcer (decubitus ulcer)
  • Vascular catheter associated infection
  • Surgical site infection- Mediastinitis (infection in the chest) after coronary artery bypass graft surgery
  • Certain types of falls and trauma

CMS is proposing to expand the list of conditions that hospitals must report if present when a patient is first admitted, to the following:

  • Surgical site infections following certain elective procedures
  • Legionnaires’ disease (a type of pneumonia caused by a specific bacterium)
  • Extreme blood sugar derangement
  • Iatrogenic pneumothorax (collapse of the lung)
  • Delirium
  • Ventilator-associated pneumonia
  • Deep vein thrombosis/Pulmonary Embolism (formation/movement of a blood clot)
  • Staphylococcus aureus septicemia (bloodstream infection)
  • Clostridium difficile associated disease (a bacterium that causes severe diarrhea and more serious intestinal conditions such as colitis) 

Beginning October 1, 2008, Medicare will no longer pay the hospital at a higher rate for the original eight conditions or any conditions added to the list in the final rule, if they were acquired during the hospital stay.

Comments sought on MRSA. In addition to the above proposed never events, CMS is requesting comments on Methicillin-Resistant Staphyloccus aureus (MRSA). CMS acknowledges that MRSA is not reasonably preventable even when evidence-based guidelines are followed. Nevertheless, CMS is seeking comments regarding developing payment policy to address MRSA in the hospital setting because of its public health threat.

Updates to the HAC and POA Indicator Reporting Web Pages. CMS has updated all web pages of the Hospital-Acquired Conditions (HAC) & Present on Admission (POA) Indicator Reporting section to reflect considerations in CMS’ Inpatient Prospective Payment System (IPPS) Fiscal Year (FY) 2009 Proposed Rule. The HAC & POA Indicator information is available at on the CMS website.


For the Reporting of Hospital Quality Data for Annual Hospital Payment Update (RHQDAPU), the IPPS proposed rule expands the number of measures hospitals must submit in order to receive a full payment update from 30 measures for FY 2009 to a total of 72 measures for FY 2010. A full list of the measures may be found in the proposed rule.

Updated AMI, Pneumonia measures. For the FY 2010 RHQDAPU program, CMS is also proposing to update the following measures:

  • AMI—Timing of Receipt of Primary Percutaneous Coronary Intervention (PCI); and
  • Pneumonia—Timing of receipt of initial antibiotic following hospital arrival measures.

The technical specifications for these measures will not change, and hospitals will continue to submit the same data that they currently submit. However, beginning with discharges on or after January 1, 2009, CMS will calculate the measures using the updated timing intervals.

The following table lists the increase in the RHQDAPU program measure set since the program’s inception:


IPPS payment year Number of
Topics covered



AMI, HF, PN, SCIP, Mortality, HCAHPS.
AMI, HF, PN, SCIP, Mortality, HCAHPS.
AMI, HF, PN, SCIP, Mortality, HCAHPS,
  Nursing Sensitive, Readmission, VTE,
  Stroke, AHRQ IQI/PSI measures and
composites, Cardiac Surgery.


Back to Top

GAO on Healthcare Acquired Infections

The Government Accountability Office (GAO) has recently released a report: "Healthcare Acquired Infections in Hospitals: Leadership Needed from HHS Prioritize Prevention Practices and Improve Data on These Infections." (GAO-08-673T, April 16, 2008)


Back to Top

National Quality Forum Update

The NQF has several projects underway that ACEP is actively participating in:

  • Emergency Care Project. NQF is proceeding with Phase 2, and is considering several facility-level measures related to ED throughput, as well as two ACEP measures regarding abdominal pain and pulmonary embolism. A draft of recommended measures is expected to be released in June for public comment.
  • Outpatient Imaging Efficiency. NQF is forming a panel to review measures related to the appropriateness and efficiency of outpatient imaging at the practitioner and facility level.
  • Hospital Care: Outcomes and Efficiency. NQF is seeking measures related to hospital readmissions, as well as volunteer panelists to review the measures. Measures and nominations are due to NQF June 9th.


For more information, please see:


Back to Top

New Members and Networking Section

Editor’s note:  This section will serve as an area for new members to introduce themselves to the QIPS membership, identify areas of interest and begin networking!

Boris Khodorkovsky MD

After graduating from Albert Einstein College of Medicine in 2001, I completed my emergency medicine residency at SUNY Downstate/Kings County Hospital in 2005. During the last year of my residency, I was elected chief resident. In 2005, I joined a faculty of the Emergency Department at Staten Island University Hospital, an academic institution of one of the boroughs of the New York City. Currently, my administrative activities include peer reviews of documentation and coding guidelines, as well integration of electronic medical records to facilitate safe patient discharges. One of my specific interests in Quality Improvement and Performance Safety is the effect of ED staffing pattern on patient flow in and out of the department and how it might affect patient’s care.

Back to Top

Quality and Safety Articles

Helmut Meisl, MD, FACEPHelmut Meisl, MD, FACEP
Here again is a list of recent articles for your interest. These are compiled by AHRQ PSNet at (

April 2008

Development, testing, and findings of a pediatric-focused trigger tool to identify medication-related harm in US children's hospitals.
Takata GS, Mason W, Taketomo C, Logsdon T, Sharek PJ. Pediatrics. 2008;121:e927-e935.

How willing are patients to question healthcare staff on issues related to the quality and safety of their healthcare? An exploratory study.
Davis RE, Koutantji M, Vincent CA. Qual Saf Health Care. 2008;17:90-96.

The effect of computerized physician order entry with clinical decision support on the rates of adverse drug events: a systematic review. Wolfstadt J, Gurwitz JH, Field TS, et al. J Gen Intern Med. 2008;23:451-458.

Role of registered nurses in error prevention, discovery and correction.
Rogers AE, Dean GE, Hwang WT, Scott LD. Qual Saf Health Care. 2008;17:117-121.

Resident uncertainty in clinical decision making and impact on patient care: a qualitative study.
Farnan JM, Johnson JK, Meltzer DO, Humphrey HJ, Arora VM. Qual Saf Health Care. 2008;17:122-126.

2007 National Healthcare Quality Report.
Rockville, MD: Agency for Healthcare Research and Quality;2008. AHRQ Publication No. 08-

Is the measurement mandate diverting the patient safety revolution?
Wachter RM. National Quality Measures Clearinghouse (NQMC). March 3, 2008.

Limiting nurse overtime, and promoting other good working conditions, influences patient safety.
Collins Sharp BA, Clancy CM. J Nurs Care Qual. 2008;23:97-100.

Safety in anaesthesia: a study of 12,606 reported incidents from the UK National Reporting and Learning System.
Catchpole K, Bell MDD, Johnson S. Anaesthesia. 2008;63:340-346.

Getting boards on board: engaging governing boards in quality and safety.
Conway J. Jt Comm J Qual Patient Saf. 2008;34:214-220.

A fatal case of iatrogenic hypercalcemia after calcium channel blocker overdose.
Sim MT, Stevenson FT. J Med Toxicol. 2008;4:25-29.

Applying modern error theory to the problem of missed injuries in trauma.
Clarke DL, Gouveia J, Thomson SR, Muckart DJJ. World J Surg. 2008 Mar 12.

Incidence, preventability and consequences of adverse events in older people: results of a retrospective case-note review.
Sari AB, Cracknell A, Sheldon TA. Age Ageing. 2008 Mar 10.

The Patient Safety and Quality Improvement Act of 2005: developing an error reporting system to improve patient safety.
Riley W, Liang BA, Rutherford W, Hamman W. J Patient Saf. 2008;4:13-17.

Simulation-based training for patient safety: 10 principles that matter.
Salas E, Wilson KA, Lazzara E, et al. J Patient Saf. 2008;4:3-8.

Work hours regulations for house staff in psychiatry: bad or good for residency training?
Rasminsky S, Lomonaco A, Auchincloss E. Acad Psychiatry. 2008;32:54-60.

The science of improvement.
Berwick DM. JAMA. 2008;299:1182-1184.

Effect of computer order entry on prevention of serious medication errors in hospitalized children.
Walsh KE, Landrigan CP, Adams WG, et al. Pediatrics. 2008;121:e421-e427.

The Accreditation Council for Graduate Medical Education's limits on residents' work hours and patient safety.
Jagsi R, Weinstein DF, Shapiro J, Kitch BT, Dorer D, Weissman JS. Arch Intern Med. 2008;168:493-500.

The attitudes and experiences of trainees regarding disclosing medical errors to patients.
White AA, Gallagher TH, Krauss MJ, et al. Acad Med. 2008;83:250-256.

An effort to improve electronic health record medication list accuracy between visits: patients' and physicians' response.
Staroselsky M, Volk LA, Tsurikova R, et al. Int J Med Inform. 2008;77:153-160.

Developing an adverse event reporting system using administrative data.
Bahl V, Thompson MA, Commisky EL, Anderson S, Campbell DA Jr. J Patient Saf. 2008;4:31-37.

Implementing patient safety interventions in your hospital: what to try and what to avoid.
Ranji SR, Shojania KG. Med Clin North Am. 2008;92:275-293.

SBAR for patients.
Denham CR. J Patient Saf. 2008;4:38-48.

Can we use incident reports to detect hospital adverse events?
Blais R, Bruno D, Bartlett G, Tamblyn R. J Patient Saf. 2008;4:9-12.

National surveillance of emergency department visits for outpatient adverse drug events in children and adolescents.
Cohen AL, Budnitz DS, Weidenbach KN, et al. J Pediatr. 2008;152:416-421.e2.

Prescribing errors in a pediatric emergency department.
Rinke ML, Moon M, Clark JS, Mudd S, Miller MR. Pediatr Emerg Care. 2008;24:1-8.

The occurrence of potential patient safety events among trauma patients: are they random?
Chang DC, Handly N, Abdullah F, Efron DT, et al. Ann Surg. 2008;247:327-334.

Antibiotic timing and errors in diagnosing pneumonia.
Welker JA, Huston M, McCue JD. Arch Intern Med. 2008;168:351-356.

Effect of pharmacists on medication errors in an emergency department.
Brown JN, Barnes CL, Beasley B, Cisneros R, Pound M, Herring C. Am J Health Syst Pharm. 2008;65:330-333.

Organizational factors associated with high performance in quality and safety in academic medical centers.
Keroack MA, Youngberg BJ, Cerese JL, Krsek C, Prellwitz LW, Trevelyan EW. Acad Med. 2007;82:1178-1186.

Effectiveness and efficiency of root cause analysis in medicine.
Wu AW, Lipshutz AKM, Pronovost PJ. JAMA. 2008;299:685-687.

How often are potential patient safety events present on admission?
Houchens RL, Elixhauser A, Romano PS. Jt Comm J Qual Patient Saf. 2008;34:154-163.

Systematic review: the evidence that publishing patient care performance data improves quality of care.
Fung CH, Lim YW, Mattke S, Damberg C, Shekelle PG. Ann Intern Med. 2008;148:111-123.

Survival from in-hospital cardiac arrest during nights and weekends.
Peberdy MA, Ornato JP, Larkin GL, et al; for National Registry of Cardiopulmonary Resuscitation Investigators. JAMA. 2008;299:785-792.

Comparing measures of patient safety for inpatient care provided to veterans within and outside the VA system in New York.
Weeks WB, West AN, Rosen AK, Bagian JP. Qual Saf Health Care. 2008;17:58-64.

Effective interventions and implementation strategies to reduce adverse drug events in the Veterans Affairs (VA) system.
Mills PD, Neily J, Kinney LM, Bagian J, Weeks WB. Qual Saf Health Care. 2008;17:37-46.

Rates of medication errors among depressed and burnt out residents: prospective cohort study.
Fahrenkopf AM, Sectish TC, Barger LK, et al. BMJ. 2008 Feb 7.

Do medical inpatients who report poor service quality experience more adverse events and medical errors?
Taylor BB, Marcantonio ER, Pagovich O, et al. Med Care. 2008;46:224-228.

Why do interns make prescribing errors? A qualitative study.
Coombes ID, Stowasser DA, Coombes JA, Mitchell C. Med J Aust. 2008;188:89-94.

Patient safety and telephone medicine: some lessons from closed claim case review.
Katz HP, Kaltsounis D, Halloran L, Mondor M. J Gen Intern Med. 2008 Jan 29.

Measurable outcomes of quality improvement in the trauma intensive care unit: the impact of a daily quality rounding checklist.
DuBose JJ, Inaba K, Shiflett A, et al. J Trauma. 2008;64:22-29.

Improving patient safety by taking systems seriously.
Shortell SM, Singer SJ. JAMA. 2008;299:445-447.

Characteristics and outcomes of patients receiving a medical emergency team review for acute change in conscious state or arrhythmias.
Downey AW, Quach JL, Haase M, Haase-Fielitz A, Jones D, Bellomo R. Crit Care Med. 2008;36:477-481.

Internal medicine work hours: trends, associations, and implications for the future.
Shiotani LM, Parkerton PH, Wenger NS, Needleman J. Am J Med. 2008;121:80-85.

Safer by design.
Tonks A. BMJ. 2008;336:186-188.

Back to Top

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.

Click here to
send us feedback