The HIM professional can have a direct impact on the quality or compliance of specific operations or employees within a healthcare institution. Healthcare institutions, such as hospitals, can be huge institutions made up of hundreds or even thousands of treatment or operation specific areas operation. This can include anything from the surgeon who performs coronary artery bypass to the neonatal intensive care nurse who directly cares for struggling newborns to the physical plant worker who makes sure all the lights in the building stay on and the operating room is maintained at a certain temperature.
As an overall institution the thought of identifying risk and liability within the organization can be quite overwhelming and daunting. The best way to approach this is to break things down into specific issues or areas and focus on one thing at a time, with the overall goal to be improving quality and reducing risk to the institution. This paper will focus on three specific scenarios that represent an area of risk and liability for the institution.
These three scenarios will include the safety of blood transfusions within a hospital, dealing with power failure risks within a hospital and using operational checklists to improve employee efficiency, consistency and reducing the human factor of making mistakes. Scenario one is to be specific to a scenario involving patient care and safety. The specific discussion here will be the use of blood transfusions within the hospital setting. This is a procedure that has been done for dozens of years even as medical science has made tremendous progress.
The reality is that science just hasn’t found a synthetic way to carry oxygen through the blood stream and blood infusions still remain today the best way to do just that. While the best procedure out there for this, blood infusions don’t come without their risks and financial impacts. A study by the University Healthcare Consortium analyzed over 29,000 blood transfusions over a 7 year period from 2003-2009 (Williams, 2011). These transfusions ranged anywhere from scheduled routine outpatient surgeries to unexpected traumatic injuries brought in through the emergency room.
The analysis identified many risks associated with blood transfusions, including poorly trained staff, lack of trained staff, minor hemolytic allergic reactions all the way up to severe anaphylactic reactions. The study was even able to identify that the time of day that the transfusion was performed could positively or negatively affect the patient outcome. So, while this can be a lifesaving procedure a blood transfusion should not be taken lightly.
Another study published in the April, 2012 issue of the professional journal Anesthesiology was conducted by Johns Hopkins Hospital analyzing the outcomes of over 3000 patients who received blood transfusions. This study reveals that measuring the hemoglobin level in patients can be an accurate indicator of when a patient should receive a blood transfusion. This is a significant study because it could have a positive effect on both patient outcome and the financial costs involved in giving a blood transfusion.
The Johns Hopkins study revealed that patients were being given blood transfusions when they really didn’t need it. A normal hemoglobin level ranges between 12-14 and the study reveals that a level as low as 7 or 8 is safe. Prior to this study the leading specialty societies, including the FOCUS research group (Functional Outcomes in Cardivascular patients Undergoing Surgury), set parameters that transfusions were definitely needed if the hemoglobin was below 7 and probably did not need a transfusion if the hemoglobin was 10 or above.
But nobody ever set any parameters on what to do if the hemoglobin ranged between 7 and 10. This left the physician to decide when to start a blood transfusion. The Johns Hopkins study revealed that because of this most physicians always erred in the side of “safety” by ordering a transfusion any time the hemoglobin was at or below 10. But the Hopkins study has now determined that a hemoglobin of 7 or 8 can be considered safe. Giving blood to patients who have a hemoglobin above 7 shows no real benefit and truth is that the risk due to side effects may actually be increased.
Remember that this procedure has been in place for decades and this new research was a game changer. The benefits to a hospital from the Hopkins study are tremendous. The study revealed that the costs to the hospital for one unit (300ml) of blood can cost as much as $1,100. While the donor gives the blood for free it must be analyzed for toxic diseases including Hepatitis and HIV (IMVS 2012). The blood is then separated into red blood cells, platelets and plasma, to be distributed specifically where needed.
Include the storage and transportation costs and you can start to understand why blood is so expensive. Only giving blood when truly indicated has been shown to reduce the use of blood by up to 66% per institution with no change in outcomes to the patient including “length of stay, heart attack, stroke, death, and even the ability to walk” (Clark, 2012). This is where the HIM professional can come into play. The HIM can take research articles like this or even acquire their own research and then do training to educate the hospital staff.
The Hopkins tudy indicated that when the HIM spoke directly with the surgeons and showed them the research there was a tendency to accept the new mindset and start delaying blood transfusions until the patient hemoglobin dropped below 7. This resulted in extra blood supply for those patients who truly need it and a significant reduced operating cost to the institution. It’s the HIM’s job to establish or change procedures that reflect changing and beneficial modalities and to get the information out to the hospital physicians and staff so they can help reduce institutional costs and ultimately benefit their own livelihood.
This process can be done for hundreds or even thousands of processes currently in place within a hospital institution. Now we move on from our blood transfusion scenario to one involving the infrastructure of the hospital. The specific example to be used here is the hospital power supply. Hurricane Sandy revealed for many healthcare institutions in the north eastern United States that they were not as prepared as they thought. Some of these hospitals did have emergency generators in place, but they did no good for providing electricity when they were located in the basement of the building submerged in water from the flood.
Sometimes it takes a real catastrophe for us to truly see how prepared we really are and how to improve. It’s crucial that a hospital be able to maintain electricity at all times. Almost every part of the building depends on electricity for staff to function and take care of their patients. Without electricity the lights won’t work, the furnace and air conditioners won’t work, the pumps won’t pump water through the pipes, ventilators will stop working and elevators won’t even be able to transfer sick patients between floors. These are some examples, but surely you can find many more failures if you look hard enough.
For this reason, it is important that a hospital evaluate and have a plan in place to reduce the possibility of losing electricity and also have a plan in place if all safe guards fail. The concerns can truly be specific to a geographic area. For example, a hospital in the Midwest may not have to worry much about being hit by a hurricane, but it could be hit by a tornado. I spoke with hospital administrator Robyn Mazzolini at Advocate Lutheran General Hospital in Park Ridge, Illinois regarding how their hospital has addressed the issue of maintaining electricity to the facility.
Robyn indicated that there were three specific issues of highest concern. They included the loss of power from the local utility company, flooding of the existing generators in the basement of the main hospital and damage from tornados. Robyn indicated that about ten years ago the hospital installed a generator in the basement of the main building that is capable of providing power to the entire ten story hospital, including all lights and HVAC. The problem was that the unit was very large and heavy and, as a result, had to be installed in the basement.
A second generator was installed right next to the first to act as a backup generator should they lose power from the power company. These generators are also designed to operate on both natural gas or stored gasoline in the event the gas lines become compromised. This seemed to solve 90% of the scenarios that could come up. Then the neighboring community experienced a flood that shut down utilities for days and a few weeks in some areas. The hospital was concerned that they would be shut down in the event of a flood in their generator rooms in the basement.
So, they added a third generator inside a remote area on the south perimeter of the hospital. This generator is located inside a concrete structure three floors above ground level. This is a smaller generator that will run specific areas in order for the hospital to stay functional. For example, this generator only supplies certain lights so that there is always enough visibility to operate. It also is designed to operate all electronics in the operating rooms, emergency room and critical care areas so there is no compromise to patient care.
On the remaining medical floors there is one or two red colored electric outlets that operate off this third generator. In addition, this generator is not connected in any way to the basement level so that it can power the upper floors of the hospital even if the ground level is buried under 20 feet of water. The third generator is also enclosed in walls of reinforced concrete with the thought that it could withstand a tornado. It was the HIM and the HIT who were involved in the process to help determine the essential power needs of the hospital.
The HIM evaluated the staff and the various facilities to determine that they could function treating most patients as long as there was one dedicated outlet within each patient room. The HIT also identified that the operating rooms, critical care areas and emergency room pretty much needed full power capabilities no matter what. The HIM and facilities managers both have a critical role in communicating the needs of the patients, staff and hospital to the engineers, administrators and building designers.
And while Lutheran General Hospital was able to spend millions to prepare for a power disruption and pretty much covered every scenario, they still need to be ready to operate should all power to the facility cease. It is the HIM who can evaluate the various areas of the hospital based on resources, staffing and needs to determine the most critical issues to address first in the event of a total power failure. This takes a lot of time and energy and is probably an evolving process as conditions and resources change.
But, in the end, it is the HIM professional who is able to connect all the dots to help bring the best solution for the organization. The third and final scenario presented here is related to staffing and how the HIM can help reduce risk and liability when it comes to the behavior of hospital staff. Hospital employees by their human nature are susceptible to making mistakes or forgetting to do certain things in the course of their patient care. Every health care institution, and any other business for that matter, strives to find ways to provide the best service possible to its customers.
The challenge in improving service and reducing liability is finding a process that actually works. Ohio State University Medical Center found a way to improve the quality and consistency of patient care from its medical professionals. Ohio State did created a system of check lists to be used by hospital staff in their particular department and area of responsibility. So, there were many different checklists, but each employee only had one checklist that they were specifically responsible for.
The University compared the outcome of over 3000 patients both before the check lists were used and then an additional 3000 plus patients after the checklists were used. The results were staggering. The study showed, for example, that the surgical death rate of patients decreased 47% when check lists were used compared to none used. Surgical infection rates were found to have decreased by 45%. These are dramatic results that clearly show a huge improvement in patient care and reduction of risk and liability.
A possible cause for such improvement is that using checklists prevented medical staff from skipping a stop that could have caused a serious complication or infection. The aviation industry has proven that checklists work. When a pilot has a sudden engine failure there is plenty of room for panic and impulsive missed steps. This is why pilots are trained to immediately pull out their check lists, even if they have them memorized, and go systematically down the list to make sure that all steps are completed as indicated.
This following of check lists has proven to significantly improve survivability of the aircraft during an emergency. The use of check lists seems to hold true for the health care industry, too, as the data clearly shows. The HIM plays a critical role in the development and rollout of these check lists to the various departments. The HIM must involve the hospital staff, managers and physicians in the process of developing a check list that easily and safely covers the needs of both the patient and the hospital.
Once developed the HIM must develop and take the time to train the staff so that they understand the intent of the check lists as well as the individual steps and why they are to be completed. This training will ensure that the employees buy into the use of the check lists and choose to use them consistently with every patient. Theoretically, this should provide the same process and the same desired outcomes each time. Besides implementing the checklist program through training the HIM also plays an important role in developing a policy that says how the plan is to be implemented.
Employees appreciate it when everything is clearly spelled out of what is expected of them. The HIM is in a position to deal with both the hospital administrator and the front line nurse who is physically caring for patients. This allows the HIM to obtain feedback and recommendations from all involved in the process and create or modify the plan as it is determined that changes need to take place. The HIM is possibly also in the best position to analyze the data to present the findings of the continued analysis to administrators to determine if the check list process is working or not.
An example of a checklist that Ohio State University Medical Center used was the Pre-Op holding RN checklist that ends with transfer to the operating room RN checklist. Each nurse has specific duties to complete with their patient as they prepare them for their surgical procedure. The Pre-Op nurse can follow the check list to ensure that all required actions have indeed taken place. When transferring care to the operating room nurse the pre-op nurse passes on her check list to verify to the next nurse that everything has been completed properly.
Each nurse is also required to ask the next receiving nurse if they have any questions. As you can see, this process really does maintain a high quality of continuity of care for the patients as they move throughout the various areas in the hospital during their stay. Cutting corners and skipping steps in the patient care process is significantly reduced if not completely eliminated and the HIM or HIT professional is involved all along in helping to create and improve the process within that hospital.
This paper only discussed three scenarios in the process of seeking to maintain quality while reducing financial liability within a hospital environment. These processes can be used and applied towards the thousands of specific areas of responsibility that exist within a large health care facility like a hospital. The HIM professional really does play a crucial role in connecting the various departments and providers within a small or large healthcare institution.
The HIM is in a position to know the pulse of the front line operations as well as the upper office administration’s intended direction going forward. The HIM professional can pull everyone together to compile data and make recommendations or changes that benefit the patient, the physicians and nurses, the facilities operators and even the top level administrators. There are few other individuals who are in such a good position to create such positive change. Quality HIM professionals will be in demand for many years to come.
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Topic: Quality and Risk Scenario
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