Flu Shots Aren’t Just for Patients
Vaccinating Health Care Workers is Key to Providing High Quality Care

The facts are pretty straightforward. With approximately 36,000 deaths and 200,000 hospitalizations attributed to influenza each year, the flu is among the most common causes of death from a vaccine-preventable disease in the U.S. The flu vaccine is safe for a majority of recipients and has been shown to be 70 to 90 percent effective at preventing the flu or reducing its impact.

Despite these statistics, only 42 percent of health care workers nationwide receive the vaccine each year. This number is well behind the 65 percent of people 65 years old or older who received the vaccination in 2006. This majority of un-vaccinated health care workers could actually put their patients at risk because the flu spreads from person to person and it is possible for someone with no symptoms to transmit the virus to others.

While annual campaigns aim to inform “at-risk” populations that include the elderly and those with compromised immune systems of their need to receive a vaccination, there is a growing movement to educate the health care community about the importance of the vaccinations, not just for the care providers themselves, but for their patients as well.

The Federal Centers for Disease Control and Prevention (CDC) recommends all health care workers who have direct contact with patients receive a flu vaccination each year. This recommendation encompasses hospital employees, from the physicians and nurses to food services and laundry workers, all employees at long-term care facilities, home health providers and private practice physicians and their staff.

Put simply, any staff member who comes into contact with patients should receive an annual flu vaccination. It might seem obvious that one simple way for health care workers to prevent the spread of infectious disease is to make sure they stay free of those diseases themselves, but barriers to vaccinating health care workers are similar to those that keep many high-risk patients from receiving the important vaccinations.

According to the CDC, these barriers include the mistaken belief that the vaccine can actually cause the flu, insufficient time or access to the vaccine, perceived ineffectiveness of the vaccination and perceived low likelihood of contracting influenza. These barriers can be significant, but a solid facility-wide program can help increase the rate of vaccination among employees in any health care setting.

Providing these vaccinations can be just as important for a provider’s bottom line as it is for their patient’s health. The CDC reports that vaccinating staff can reduce both direct medical costs and indirect costs associated with employees missing time due to the flu.

Earlier this year, the CDC published a report outlining recommendations on health care worker vaccinations that described a number of strategies that have been successful in increasing these vaccination rates. These strategies start with educating the staff about both influenza and the vaccine. The more information available to staff, the less likely they will be to buy into the misconception about the flu shot actually giving you the flu.

Once an education program is underway, it is important to provide access to the vaccine for all employees who have direct contact with patients. The barriers of access and cost can be easily eliminated by creating a program that provides an annual vaccination at work and at no cost to the individual employee. For large hospitals or nursing home facilities, providing several times and dates for employees to be vaccinated can also help increase the rate of vaccination among health care workers. Vaccinating chief medical staff and other leadership positions is another simple way to encourage other staff to receive their shots.

Tracking the rate of vaccinations among the staff and regularly reporting this information can help encourage others to receive the vaccination and should be incorporated into a patient safety program.

Increasing the rate of influenza vaccinations among health care workers should be an important goal for all providers. The simple steps required to make these shots accessible can go a long way toward reducing costs, improving care and most importantly, increasing patient safety.

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Nursing Homes Continue Work on Reducing Restraint Use

Nursing homes often place residents in physical restraints in an effort to protect that resident from the effects of an accidental fall, but the evidence from Centers for Disease Control and Prevention (CDC) and other sources actually shows restraints can exacerbate the harm from a fall, even when used as recommended by the manufacturer. Because of this misconception, the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services, and its network of Quality Improvement Organizations (QIOs), including the Illinois Foundation for Quality Health Care (IFQHC) are working to reduce the use of physical restraints in Illinois nursing homes.

It is estimated that of the 1.6 million U.S. residents in nursing homes, half fall annually and about one out of three of these residents will fall more than twice in a year. According to the CDC, “Routine use of restraints does not lower the risk of falls or fall injuries. They should not be used as a fall prevention strategy. …Restraints can actually add to the risk of fall-related injuries and deaths.” Studies show approximately 200 deaths occur annually in nursing homes as a result of strangulation or suffocation from restraints.

While some patients’ medical conditions present a legitimate need for use of a physical restraint, IFQHC’s efforts are aimed at making sure nursing homes understand when this is the case and when a restraint is being applied on a resident who’s health does not warrant the use of such a device.

CMS defines a physical restraint “as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident’s body that he or she cannot easily remove, which restricts freedom of movement or normal access to one’s body.” Some examples of physical restraints are trunk restraints, lap trays, Merry Walkers®, bed rails, mitts and gloves and Geri-chairs. However, according to the CMS definition, it is the effect the device has on the resident, rather than its name or intended use that determines whether or not the device is classified as a restraint.

According to a June 2007 CMS memorandum, restraints should only be used when there is no other option for treating a medical symptom, and there must be a link between use of the restraint and “how it benefits the resident by addressing the medical symptom.” The memo further states, “Physical restraints as an intervention do not treat the underlying causes of medical symptoms. Therefore, as with other interventions, physical restraints should not be used without also seeking to identify and address the physical or psychological condition causing the medical symptom.”

Because there must be a link between use of a restraint and its impact on the resident’s medical symptom, these symptoms must be documented in the resident’s medical record, ongoing assessments and care plans. CMS further expects all restraint use to be accompanied by a “systematic and gradual process towards reducing restraints.”

There are many alternatives to restraints, including simplifying the resident’s environment and removing clutter, avoiding abrupt changes or rushing the resident, establishing routines, providing daily physical activity and assessing the resident’s hearing and vision.

IFQHC provides education, training and materials at no charge to nursing homes and makes them available online at www.ifqhc.org. Quality improvement advisors also travel the state for individualized consulting and training at nursing homes. These efforts are showing results as the restraint rate for the identified participant group (IPG) is at 3.61 percent, which is below the present statewide rate of 4.11 percent and the national rate of 5.6 percent. Education and communication among nursing home staff have been keys to reducing the rate of restraint use. Since IFQHC began working on this quality measure two-and-a-half years ago, the rate has dropped by 1.04 percent among IPGs, while the statewide rate has only dropped by .62 percent.

“We are extremely pleased that nursing homes have placed the reduction of restraints at a high priority. For those homes struggling with using restraints we strongly recommend investigating the alternatives or contacting us,” explains IFQHC Nursing Home Manager Benneta Sevier, RN.
Some of the benefits to reducing restraints include a significant reduction in serious injuries, an increase in the resident’s ability to attend activities, and often, a greater independence with toileting, feeding and strength. Looking toward the future, IFQHC believes best practice interventions and process changes are the best strategies to make sure Illinois nursing homes eliminate all unnecessary restraints.

For more information on partnering with IFQHC to reduce the use of restraints, contact IFQHC at (800) 386-6431.

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Rural and Critical Access Hospitals Improve Safety Culture

Many existing patient safety standards are based on evidence from studies conducted in urban and teaching hospitals. Due to their unique characteristics and patient volume, hospitals in rural areas differ from their urban counterparts in terms of economics, staff shortages and the kind of care provided.

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Because of these differences, rural and critical access hospitals (CAHs) require their own set of relevant quality of care measures and evidence-based strategies to assess and address their organizational safety culture and promote transformational change.

IFQHC staff work closely with rural hospitals and CAHs to improve the quality of care they deliver to Medicare beneficiaries. Working as part of the national Rural Organizational Safety Culture (ROSC) initiative, IFQHC and a select group of 10 Illinois hospitals are partnering with a focus on assessing and improving the organizational safety climate. The project’s goal, to discover and implement more effective change strategies, is being achieved through a process of evaluating the current culture and testing new processes and approaches to see which practices work best. IFQHC is providing the resources, training, and influence necessary to ensure Illinois’ rural hospitals have the best possible safety cultures.

According to current statistics, nine of the 10 participating hospitals improved on a composite score of three questions related to hospital management support for patient safety. All ten hospitals showed improvement on staff perception of their overall patient safety grade. Transforming organizational culture to empower individuals to make a change is a key component of these efforts. This means creating a person-centered organizational structure, workforce and environment that aims for perfection and empowers leadership and staff to improve their communication and teamwork.

ROSC differs from other Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services, initiatives because it involves a direct partnership with senior leadership that focuses on transformational change in rural hospitals and CAHs. Participants use the Agency for Healthcare Research and Quality’s (AHRQ) Hospital Survey on Patient Safety Culture to determine the hospital’s safety climate at baseline and remeasurement. Since hospitals have different needs and concerns, each hospital identifies a specific safety culture dimension for improvement and then selects, tests and implements change models such as Leadership WalkRounds™, Safety Briefings, Just Culture or Sensemaking Guidelines to improve their organizational safety climate.

Because the partnership with a hospital’s senior leadership is key to the ROSC initiative, a more active role is encouraged in promoting and implementing patient safety measures.

“The ROSC project was a unique opportunity for small hospitals to be involved in a leading edge activity, benchmark against their peers nationally and statewide and receive recognition as quality-focused organizations,” says IFQHC Rural Quality Improvement Lead Diane Land.

Through its experience working with rural hospitals and CAHs in the ROSC initiative, IFQHC learned communication and feedback are vital when addressing a hospital’s organizational safety culture.

“It is critical to finish the communication and feedback loop. Once a survey is completed, expectations have been raised that something is going to be done about the topic surveyed. Senior leaders need to not only share the overall vision, but share the strengths and weaknesses and the action items – what is being done as a result to improve patient and staff safety,” comments Land.

As a result of participating in the ROSC initiative with IFQHC, hospital leaders and participants feel they are now better able to relay their organizational safety culture vision to staff, boards, community members and the media. Hospital leaders are also better able to identify areas of strength, opportunities for improvement and track changes over time through improved experience, patient safety, communication and efficiency.

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Evidence Backs Electronic Records as Key to Successful Care Transitions

Accurate and up-to-date patient information is key to successful care in all health care settings, but making sure that information follows a patient during transitions between settings is absolutely critical in order to prevent adverse outcomes and reduce costs. While the technology systems may not be in place today, a growing body of evidence is showing how electronic health records (EHRs) can be a valuable tool in making sure vital information is transferred to the next care setting along with a patient.

Every time a patient is shifted from hospital care to that of a home health agency, a nursing home or discharged altogether, the new caregivers need to be aware of many details about the previous care provided. If this information is incomplete during transfer it often must be re-created by the next setting, possibly leading to medical errors or duplication of tests and other medical services.

This lack of critical information can lead to missed opportunities for treatment, adverse medication reactions and rehospitalization. Not only does this increase the health risks for the patient, but it can increase costs for providers as well. Duplicating tests, prescriptions and even the time and money spent creating, managing and storing separate records for the same patient all add up to more expensive care for everyone involved.

Expecting patients or their caregivers to manage every detail of their care is not an effective way of handling transitions between settings. Not only are they often unfamiliar with the intricacies of medical terminology and significant details such as medication dosing, but during a time of transition the patient and/or caregiver is often unsure of which provider they should turn to with questions.

A February 2007 report from the U.S. Department of Health and Human Services (HHS) examined the ways EHRs can help bridge the gaps between care settings and found the use of electronic records to have a positive impact on patient safety. The report states, “Quantitative evidence increasingly indicates that patient safety is jeopardized during transitional care… Stakeholders in the post-acute care/long-term care settings that received even limited electronic health information from other parts of the health delivery system perceived this type of exchange to be of significant value as a result of the implementation of an EHR by the [system].”

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An EHR system can assist with transitions between care settings by putting all communication about the patient’s condition and care on a single platform. If the patient has one record that all care providers can access, each setting can see the care plans from the previous setting, check on medications prescribed elsewhere to avoid duplication or adverse reactions and, if the system allows two-way communications, send notes or questions to other providers.

The results from a 2004-06 study sponsored by the Agency for Healthcare Research and Quality (AHRQ) backs up the message of the HHS report. The study examined two groups of providers in New York and focused on transfers from hospital to home health settings, with one group communicating via an electronic form and the other handling transfer information through handwritten orders. The study found the odds of a patient returning to the hospital dropped by 62 percent for the patients who had their transfer instructions shared electronically.

In the study, patient records were shared through a secure, password-protected Web application that was available to physicians and nurses involved providing care in both the hospital and home health settings. However, the shape of future EHR-managed transfers could be very different from the one used in the study.

A 2004 Executive Order from President Bush calls for all Americans to have portable EHRs by 2014 with a goal of using these records to improve the overall quality of health care in the United States. The government is pushing for the development of necessary software, technology and standards to accomplish this goal, but keeping these important records private and secure is always paramount in these efforts.

While EHRs and other health information technologies (HITs) are fairly common in hospitals and increasingly common in physician offices, the technology is far from prevalent in home health or nursing home settings. Furthermore, with all of the various HITs designed and marketed by different companies, interoperability between the systems chosen by different providers is not a guarantee. Funding is another obstacle to the widespread adoption of EHRs and HITs as the costs to set up a system can be imposing for smaller providers.

Despite these sizable obstacles, the benefits of implementing new information management technologies throughout the health care environment are too great to be ignored. The potential for electronic communication about patient conditions and care plans to benefit public health and quality of care is enormous and the move to these technologies will continue to gather momentum.

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Consider the Users When Implementing New Technologies

New technology can offer all manner of efficiencies, process improvements and even cost savings to an organization as large and complex as a hospital, but implementing a new system involves much more than simply buying the latest machines and plugging them in.

In order to successfully adopt a new system, assessing and preparing for the human needs of the system’s users is equally important as making sure the equipment being purchased can accomplish the required tasks. Navigating these parallel paths is key to a successful implementation that maximizes the use and effectiveness of new technology. A partnership between 27 Illinois hospitals and the Illinois Foundation for Quality Health Care (IFQHC) is uncovering ways to reach this goal.

The Systems Improvement and Organizational Culture Change (SIOC) project has been underway for more than two years with a goal of helping the participating hospitals prepare for the implementation of computerized physician order entry (CPOE), bar code tracking at point of care (BPOC), or telehealth systems. More than 75 percent of the participating hospitals have made demonstrable improvements to their readiness for a technology system. Two participants, St. Bernard’s Hospital in Chicago and St. James Hospital in Olympia Fields and Chicago Heights, successfully transitioned to BPOC systems for medication administration during the course of the project, and St. Bernard’s also implemented CPOE in their Emergency Department. Many other hospitals are in the final planning stages and will be implementing systems soon.

While the SIOC project is still ongoing, the efforts of the participating hospitals are already providing useful lessons for others to follow when they look to make similar system changes. A key is making sure human factors are addressed alongside the fairly straightforward technology details of implementation so both people and machines are ready at the same time.

When it comes to new technology, it is important to make sure the hardware will actually fit in the space available. But beyond such basics, the SIOC hospitals found they often need to update existing computers to make sure networks connect to each other and new equipment is compatible. Other considerations include the use of portable devices, such as PDAs and wireless equipment, that might better serve the needs of the clinicians. While planning for BPOC, many hospitals found extensive changes need to be made in the pharmacy department, both to standardize drug stocks and to ensure every dose of medication is bar coded and available in unit dose form.

Attention to detail is key for assessing technology needs, but the SIOC project is showing how the human changes can be more challenging and often require a greater effort to achieve success. People can be resistant to change, and some are intimidated by new technology, so the human needs of new technology must be addressed with care. After having been in practice for many years, clinicians may view a new system as being forced to learn their job all over again. A successful hospital will have a solid plan in place for managing the extensive changes required of each user, and of the organization as a whole.

In addition to change management, a crucial piece of work to ensure success is process mapping. Each hospital should map their current processes so they can be compared to the processes that will be in place with the new technology. These process maps can serve as tools to educate staff about how the new system will eliminate steps, make their work more efficient and often decrease the likelihood of errors.

However, the value of the system alone is often not enough to win over the entire staff. Because of this, successful hospitals brought together interdisciplinary teams to lead the transitions. It is important to involve all areas and all levels of hospital staff because new systems and technologies will impact everyone working in the building, whether or not they will actually use the systems.

The SIOC program also is showing the importance of committed senior leadership and dedicated staff “champions” to ensure a successful implementation. A hospital needs these system-wide changes to be embraced by the senior leaders because this sends the message that the changes are important. The development of “champions” who believe in the new technology is crucial because they demonstrate its effectiveness to other staff and provide an example for their peers. Hospitals working on CPOE systems have found “physician champions” to be the best ambassadors to bring changes to the rest of the staff.

New technology is an increasing part of the competitive hospital world, and these systems can have a positive impact on patient safety and care quality. To keep up with the times, more and more hospitals are implementing BPOC and CPOE systems. However, the SIOC project is showing that preparing a hospital’s organizational culture to embrace the change is just as crucial as turning on all the new computers.

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Quality Insider is a publication produced by the Illinois Foundation for Quality Health Care for Illinois health care providers, stakeholders, and policy makers who wish to transform the way care is delivered.

Peg Mason – Vice President, Health Care Quality Programs
Nancy Moersch – Senior Director
Scott Fortin – Communications Manager
Noah Levine – Managing Editor

For address changes, subscription requests, and other correspondence, e-mail newsletter@ilqio.sdps.org or mail to:
Illinois Foundation for Quality Health Care
ATTN: Quality Insider
2625 Butterfield Road, Suite 102E
Oak Brook, IL 60523

This material was prepared by the Illinois Foundation for Quality Health Care, the Quality Improvement Organization for Illinois, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. IL-8SOW-QIO-55-12/07

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