EMPSF 2nd Annual Patient Safety Summit

September / October 2012

EMPSF 2nd Annual Patient Safety Summit

On March 22 and 23, 2012, the Emergency Medicine Patient Safety Foundation (EMPSF) held its 2nd Annual Patient Safety Summit: From Insights to Outcomes: Getting Results! The meeting brought together key stakeholders and thought leaders from across the emergency care continuum. Among the distinguished panel of speakers were the presidents of the American College of Emergency Physicians, Emergency Nurses Association, National Patient Safety Foundation, and the American Society for Healthcare Risk Management. The meeting represented a cross-section of the emergency medicine community with representatives and patient safety experts from more than 21 states and Canada participating.


EMPSF is a national, non-profit organization dedicated to advancing patient safety in emergency care through education, research, collaboration, and training. Since its founding in 2003, EMPSF has provided a grant and fellowship program to fund patient safety fellows to conduct research in emergency medicine. In 2012 EMPSF launched a webinar series, which continues through October, November, and December with a number of programs offering information from nationally recognized experts on significant patient safety issues in emergency care (see below). As a membership-based organization, we invite you to visit our website: www.empsf.org. For more information, please call 916-357-6723.

October 29
Improving Patient Safety in Pediatric Medicine

November 2
Grievances and Complaints: Understanding the CMS and Joint Commission Standards

November 12
CMS Conditions of Participation: Important Standards for the ED Visitation, Verbal Orders, Protocols, Consent, and More!

December 7
Advanced Directives for the Emergency Department

December 17
Hospital Liability Related to ED Triage, Crowding, and Boarding

The purpose of the Summit was to convene a forum for those who practice in or manage emergency departments to discuss the opportunities and challenges related to improving patient safety in emergency care. The Summit was successful in engaging the emergency medicine community in a focused dialog on many of the key patient safety issues as well as providing several solution-oriented presentations. Some of the topics presented included: standardization, patient safety and medical error; ED performance measures; safety & satisfaction; use of interpreters and low literacy; results of the MCIC & Johns Hopkins Patient Safety Collaborative; teaching human factors in medical education; building high-functioning teams via TeamSTEPPS; call-back systems; the impact of EDIS, EMRs, and patient safety; violence in the ED; prescription drug abuse; medication errors and the role of the pharmacist in the ED; and more. See following pages for brief summaries of some of these presentations.

Upon the conclusion of the Summit, participants had made valuable new contacts, renewed relationships with peers and mentors, and had learned from experts in the field of emergency care patient safety. Armed with new information, contacts and a re-energized commitment to being a change agent for patient safety, participants of the 2nd Annual Patient Safety Summit are now sharing this experience with their colleagues. EMPSF is currently developing new education and collaboration tools to continue to stimulate the dissemination of new insights.

The Summit has been designed as an annual event and a cornerstone of EMPSF’s year-long calendar of education, research, collaboration, and training programs. Be sure to save the date and join us for the 3rd Annual Summit, April 30 – May 2, 2013, at The Cosmopolitan Las Vegas. Come join your peers and make an impact for patient safety!

Dianne Vass is the executive director of the Emergency Medicine Patient Safety Foundation. She may be contacted at dvass@empsf.org.

Call-Back Systems: Extending the Patient Safety Net


EMPSF 3rd Annual Patient Safety Summit
April 30–May 2, 2013
The Cosmopolitan
Las Vegas, Nevada

One of the greatest challenges that we face as providers is the “black hole” that patients enter when they are discharged from the emergency department. Recent studies have shown poor compliance—50% at best—with discharge instructions (Engel et al., 2009; McCarthy, 2012). The truth is that high-risk patients continue to fall through the cracks, resulting in fragmented care, medication errors, complications, unnecessary return visits, and readmissions. There is a growing body of literature and case studies that have shown that the implementation of a call-back system is a useful tool to improve patient safety, decrease risk, and improve both provider and patient satisfaction (Baker, 2010; Agency for Healthcare Research & Quality, 2011).

There are different types of call-back programs: homegrown, software, call centers, and web-based systems. The primary goal is to keep the process simple and consistent, with a brief scripted call usually lasting two to three minutes within 72 hours of the patient’s visit. Sample questions include: How are you doing? Were you able to follow up? Is there anything we could have done better? Do you have any questions? These questions allow the provider to gain invaluable information on whether there are complications, worsening symptoms, or concerns about compliance with medications. Call-backs allow providers to deal with complaints and improve patient satisfaction. They also allow providers the opportunity to answer questions and clarify instructions.

Many programs prioritize call-backs on the basis of high-risk categories of patients, such as those that leave “against medical advice” (AMA) or “leave without being seen” (LWBS), or those that are pediatric or geriatric. Call-backs may also be prioritized based on type of complaint or treatment, such as chest pain, abdominal pain, head trauma, headache, fever, or abnormal lab results. Further, there are several common situations that may be excluded from the call-back system: patients who have been assaulted, have sexually-transmitted diseases, or are psychiatric patients (as these patients require specialized follow-up), as well as those that have been admitted or transferred to another facility.

The Advisory Board, Studer Group, Press Ganey, and AHRQ have all commented on the value of effective call-back systems. There are several excellent toolkits available, such as the Project RED Toolkit, which can be found at http://www.bu.edu/fammed/projectred/toolkit.html. Call-back systems have been shown to pay for themselves by decreasing costs, decreasing claims, preventing error, improving outcomes, and improving both patient and provider satisfaction (Filak-Taylor, 2008; Callback program improves unit, 2003). They are also useful in reducing hospital readmissions and return visits to the ED (Jack et al., 2009). Lastly, they serve as an excellent customer satisfaction and public relations tool, which not only provides a competitive advantage but also closes a very important risk loop. In conclusion, effective call-back systems are an affordable way for hospitals and providers to extend the patient safety net, mitigate risk, and improve satisfaction.

Agency for Healthcare Research and Quality. (2011 April-last update). Patient Safety Tools: Improving Safety at the Point of Care. Author: Rockville, MD. http://www.ahrq.gov/qual/pips/

McCarthy, D. M., Engel, K. G., Buckley, B. A., Forth, V. E., Schmidt, M. J., Adams, J. G., & Baker, D. W. (2012). Emergency department discharge instructions: Lessons learned through developing new patient education materials. Emergency Medicine International. 306859. Epub 2012, May 15.

Partners in Patient Safety:
MCIC Emergency Department Patient Safety Collaborative

Michelle Patch, RN, MSN, ACNS-BC
Safety Officer, Emergency Medicine
Johns Hopkins Hospital

Jim Scheulen, PA, MBA
Chief Administrative Officer, Emergency Medicine
Johns Hopkins Hospital

MCIC Vermont, Inc., is a risk retention group that provides medical professional and general liability insurance coverage to its academic medical center shareholders and their various affiliated entities, employees, and physicians. The shareholders of MCIC Vermont are New York-Presbyterian Hospital, Cornell University, Columbia University, The University of Rochester, The Johns Hopkins Hospital and The Johns Hopkins University, and Yale New Haven Hospital and Yale University. MCIC’s goal is to use the shared experience and expertise of the shareholders to develop and implement system changes that have a positive effect on patient care. The MCIC Patient Safety Committee, comprised of clinical leadership from each medical center, develops and implements projects designed to enhance the patient safety efforts at the medical centers and reduce malpractice loss.

Patient Safety Collaborative
The MCIC Emergency Department Patient Safety Collaborative kicked off in January 2009 in response to professional medical liability claims/suits for emergency department (ED) care accounting for 11% of total MCIC incurred costs. Our hypothesis was that partnering of the MCIC insured emergency departments’ leadership to share and implement best practices should assist in decreasing adverse events in the emergency department and prevent medical professional liability-incurred costs. The ED Leadership Committee, which meets three times a year (plus conference calls and webinars), is comprised of ED physician, nurse, and administration leaders from all 13 MCIC insured sites, which provide care to approximately one million patients annually. MCIC-funded ED patient safety nurses in five academic sites act as liaisons between the facilities and MCIC, as well as between ED and other departments. Wearing multiple hats, they serve as patient safety resources and project champions as well as providing education, support, and coordination for a safety and teamwork survey process.

Michelle Goldfarb explained the committee structure and methodology for project selection, which uses a standardized taxonomy to analyze the company’s claims experience with known sources of error in ED. The collaboratives’ accomplishments include establishment of triage guidelines, team training, strategies to improve delayed and missed diagnosis, early recognition and management of sepsis, non-stroke neurological emergencies, and a newly formed ED-radiology workgroup focusing on risk reduction strategies to reduce failures to “close the loop” for incidental or discrepant findings.

Michelle Patch presented examples of her areas of responsibility at Johns Hopkins, specifically highlighting the Safety Attitudes Questionnaire process and staff education and training.

Jim Scheulen highlighted changes to front-end operations at three Johns Hopkins ED campuses that have significantly reduced Left Without Being Seen (LWBS), decreased Length of Stay (LOS), and improved patient satisfaction. The MCIC collaboration has provided a platform for direct contact with system developers from Ochsner and Banner Health Systems under an AHRQ/HRET Door-to-Doc grant project.

Benefits of the MCIC collaborative include information sharing, education, identification, and frank discussion of real issues in a collegial environment. Core elements of the program include:

  • Leadership commitment
  • Dedicated safety nurses
  • Standardized clinical guidelines
  • Positive changes to traditional work flow
  • Comprehensive risk analysis platform

Since the beginning of the collaborative, MCIC Vermont has seen an annual decrease in emergency department claims frequency of 33%, with savings of $6 million. Employee survey scores reflecting an improved culture of safety have also been reported across all sites. The long-term goals of the collaborative are:

  • Continued enhanced safety culture as demonstrated by improved SAQ scores.
  • Continued reduction in frequency and severity of ED claims/suits and incurred costs.
  • Consensus on best practices.
  • Industry best practices become standard operating procedures.
  • Continued patient safety education for staff.
  • Continued professional development of patient safety nurses as they emerge as subject matter experts.
  • Improved patient satisfaction scores.

Electronic Medical Records:
Taking the Good with the Bad

With regard to electronic medical records (EMR), the industry has moved at light speed so that practices that are solely using paper records are more the exception than the rule (Jamoom et al., 2012). We all know the problems of paper records that EMRs were intended to address—errors due to poor handwriting, inconsistency in the information charted and how it was charted, and treating providers having difficulty finding information in the record. The most popular EMRs address those issues. However, just as compliance officials and risk managers educated providers about risks, benefits, and good practices for paper record documentation, providers now need to be educated about risks, benefits, and good practices for documenting in an EMR.

For example, EMR functions such as carry over, cut and paste, and auto-populating are touted as saving providers precious time in documenting information already documented by others or re-documenting information from a previous visit. However, CMS and Medicare Administrative Contractors have cautioned providers to be careful in using these features. For example, at least one Medicare Administrative Contractor has warned that the use of an “auto carryover” function could result in a note that documents more information than was actually generated and addressed during that particular visit. If a higher Evaluation & Management code was generated as a result, the submission could be considered fraudulent. Likewise, a CMS surveyor conducting an EMTALA (Emergency Medical Treatment and Active Labor Act) investigation questioned whether an emergency department physician actually performed a medical screening exam when the physician’s note was simply a cut and paste of the RN’s note with no additional information.

The easy accessibility to the EMR by all providers is a benefit that may result in better continuity of care. However, the ability to easily access information in the EMR may also result in fewer direct conversations between the physicians caring for the patient or between the physicians and nursing staff. The resulting decrease in direct communication could potentially result in the loss of an exchange of information not in the EMR that is critical for the patient’s care or could improve the patient’s treatment or care. Many physicians complain that sitting at a computer and inputting information in the EMR may detract from communication with the patient, and the distraction may result in the loss of crucial information relevant to the patient’s health and safety.

The best advice for compliance officers, risk managers, and providers is to (1) know what functions are enabled on the EMR and audit to ensure they are being used appropriately; (2) impress upon EMR users that ease of documentation does not diminish the importance of documentation; and (3) revise education and training to reflect good documentation practices specific to the EMR being used.

Jamoom, E., Beatty, P., Bercovitz, A., Woodwell, D., Palso, K., & Rechtsteiner, E. (2012, July). Physician adoption of electronic health record systems: United States, 2011. NCHS Data Brief, No. 98. U.S. Dept. of Health and Human Services.

Operational Excellence in Emergency Medicine

This presentation to the Emergency Medicine Patient Safety Foundation audience in March 2012 reviewed the performance measures emergency department (ED) leaders need to manage their departments effectively. The Emergency Department Benchmarking Alliance (EDBA; www.edbenchmarking.org) has been developing performance measures and data definitions and analyzing years of data to identify trends in patient presentations and material for future ED planning. The performance measures are compatible with the annual CDC National Hospital Ambulatory Medical Care Survey reports.

The presentation featured a description of initiatives to develop consistent definitions for  performance measures and related them to ED quality and safety. That allows ED leaders to describe the “value stream” of services provided in the community for patients, the hospital, and the medical staff.

The EDBA Data Survey encompasses the data from the first 750 members of the Alliance, which saw 26 million patients in 2011. For 2011, EDs continued to see increasing volumes of patients, continuing a 20-year trend where volume has increased about 2.5% per year. ED volume increased between 3 and 5% in most EDs from 2010 to 2011. More patients were admitted than in prior years, with an admission rate of 18% of patients arriving for service. About 17% of patients arrive by ambulance, and our ambulance patients are admitted at an increasing rate. More inpatients are arriving through the ED, with two-thirds of hospital admissions originating in the ED.

American EDs are improving throughput and the greeting process. With those improvements, ED walk-away rates have decreased and now average less than 2% across all EDs. High-volume EDs still have longer processing times and higher walk-away rates. The EDBA data is stratified by volume of patients served, with volume cohorts of 20,000 patients serving as a reliable predictor of patient processing. Using the 20,000 volume cohorts, there are linear increases in median length of stay, walkaway rates, EMS arrivals, and admission rates.  Processing of admitted patients also takes longer as the volume cohorts increase.

Overall patient acuity is trending higher, and there is continued increase in EKG utilization for ED patients, particularly in high-volume EDs. There has been a plateau in the use of CT imaging and a continued decrease in the number of plain imaging x-ray procedures in the ED. Many more EDs have incorporated computerized provider order entry (CPOE) processes, with 75% now using those systems.

EDs must provide adequate and well-designed space for optimal patient care and the safety of both providers and patients. Bed utilization averages around 1,620 visits per patient care space per year, and space utilization is around 3.2 visits per square foot. Many EDs have incorporated Fast Track units into their operation, and about half have units that are designed for the management of trauma patients or pediatric patients.

The emergency medicine and healthcare operations literature does not recognize that best practices vary according to ED volumes served, the acuity of patients, and the services provided by the hospital. The “value stream” of ED services is the provision of unscheduled care service for the community served. Patients and the hospital rely on rapid processing of all patients, and increasingly the data demonstrate that long boarding times for admitted patients in the ED lead to poor overall processing and high walk away-rates.

The Joint Commission Patient-Centered Communication Standards

The Joint Commission (TJC) has implement five standards that are known as the patient-centered communication standards. The visitation standards went into effect July 1, 2011, while the remaining became effective July 1, 2012. All hospitals and emergency departments should be in compliance now with these standards.

The corresponding hospital requirements by the Center for Medicare and Medicaid Services (CMS) were also discussed. Any hospital that receives Medicare or Medicaid reimbursement must follow these interpretive guidelines, and they must be followed on all patients.

The first issue is low health literacy. Medication sheets and discharge instructions need to be written in a manner that patients can understand. About 20% of the population reads at a fifth-grade level, and another 20% read at an eighth-grade level. Telling a patient they have a corneal abrasion may not as clear as telling them they have a scratch on their eyeball. Staff should ask the patient to read back or teach back information provided. Staff should document that there was teach-back regarding the patient discharge instructions. The National Patient Safety Foundation’s “Ask Me Three” program is an effective tool for keeping communication at an understandable level.

The second issue involves limited English proficiency (LEP). There are more than 50 million patients living in the United States whose primary language is not English. Interpreters need to be provided during critical parts of care. The use of the interpreter should be documented. Staff members who are fluent in the language spoken by the patient are not generally qualified to be interpreters just because they speak the language. One who has taken, for example, a 40-hour class and passed and examination would be qualified to be an interpreter. Optionally, one can take an oral and written exam and become certified in certain languages such as Spanish, Russian, or Mandarin. An exception is made for patients who are hearing impaired, and all deaf interpreters should be certified. Hospitals are required to ensure that all interpreters are qualified to do their job.