Category Archives: Clinical Quality

Cleveland Clinic’s Low Cost Health Care Model

With the health care debate looming on the horizon on Capitol Hill, there are some compelling arguments on what should and should not be included in the health care bill. One thing that everyone agrees on however is the cost of care. The current rate of increase in cost of care in America is unsustainable. And, a low cost health care model is the need of the hour.

Some of the key features of their model are that they are highly integrated according to their CEO Dr. Toby Cosgrove. The doctors and hospitals are all part of one organization. Here are some highlights of their model.

1. The Clinic’s doctors are all on salary

2. There is no concept of fee for service -whether a cardiac surgeon performs one surgery or ten they get paid the same.

3. EMR (Electronic medical records) have been available since May 2008

4. An emphasis on preventive care that goes beyond health and wellness bulletins – A heart healthy cafeteria and a fully functional gym.

Now, we should also point out that they are yet to realize a return on investment on the electronic medical records. Also it is now well known that they were also the test site for Google’s health records application roll-out.

While it is clear that the Cleveland Clinic is always ahead on the technology curve it is their unique approach to practice of medicine that has helped them become a leader in low cost health care.

UPMC team talks about smart room project!

We had previously featured an article on this site on the Smart patient room innovation at the Univ. of Pittsburgh Medical Center. Since, then we have talked to David Sharbaugh(DS), the leader of the smart room project and, a senior director at UPMC’s center for quality improvement and innovation and, Lucy Thompson(LT) one of the team members.

Today we bring you this exclusive interview.

What is the vision behind the smart room project ?

DS: We believe this technology will enhance patient safety, allow clinicians to spend more time at the bedside, simplify the jobs of health care workers and improve overall patient satisfaction

Who are the people behind the smart room?

DS: The core development team consisted of 5 people. Working anywhere from part time to full time to complete most of the development. In addition, over the past six months a team of clinicians and medical technologists have worked on this.

Where does the ultrasound technology for Smart Rooms come from ?

DS: the system uses ultrasound tracking devices to identify the numerous caregivers whom a patient might encounter on any given day. UPMC used Sonitor technologies, as the vendor for buying the ultrasound tracking devices.

How much did it cost to build the smart room system?

DS/LT: Since it was internally developed, it mainly cost UPMC man-hours (or FTEs in health care parlance). But, the total cost to the system would be approximately $2 per patient/day.

What clincal metrics does smart room system impact?

DS/LT: We are currently still compiling the metrics and observing the impact, but it is estimated that this system has reduced the time spent searching for allergies, demographics, since there is a visual cue provided to the care giver on the items that need to be completed. Medication safety is expected to impacted and patient safety, and, fall rate are some other metrics that are expected to improve. Currently, smart rooms are in the medical surgical floor.

How long did it take to train staff on this system?

LT/DS: There was minimal training for this, since the screen interfaces that staff and, physicians need to use are very intuitive.

Future enhancements to the Smart patient rooms system.

The Smart Room went live in early October and is being tested in six patient rooms at the UPMC Shadyside campus .They, told us that they are currently working on releasing the second version. The new version would include code information that will automatically display to the relevant care giver when a code is called.

In addition patient will be able schedule tests, get test results, and other information. Another possible enhancement is informative emails to patients!

We think this is innovative and will keep bringing you more information on future enhancements. So keep watching this space.

Redesigned ER with reduced wait times can save lives

Emergency Room incident at King’s County hospital

The King’s county hospital in Brooklyn, N.Y. has several claims to fame; It was the site of the first open-heart surgery performed in New York State; Kings County physicians invented the world’s first hemodialysis machine, conducted the first studies of HIV infection in women and produced the first human images using magnetic resonance imaging (MRI). In addition, Kings County was named the first Level 1 Trauma Center in the U.S.

It is ironic then, that the hospital became the center of all media attention for a negligence death in their waiting area in the Emergency Room. Esmin Green, a 49 yr old psychiatric patient had been waiting in the emergency room for more than 24 hours before she toppled from her chair and fell on ground. Although the waiting room was occupied by other patients, a security guard, and a staff member, no one cared to help Green until more than an hour after her fall (Check out the Associated Press report for further details on this).

Isolated incident or alarming trend?

HealthCare Management decided to do some research of our own and here is what we came up with.

An archived article in New York times talks about Federal regulators reprimanding cook county for serious flaws in how it decides who should receive emergency care and for treatment delay
The king’s county hospital’s emergency room sees about 116,000 patients a year
In 2007, Kings County hospital deployed, MediKiosk software solution, that automates patient registration and helps emergency department staff prioritize treatment based on medical urgency
According to a recent survey conducted by the American College of Emergency Physicians (ACEP), 80% of the 328 emergency departments surveyed board psychiatric patients
30% of ACEP surey respondents said they board patients between 8 and 24 hours

Before, we conclude it is a dead end, let us look at some other facts that might present solutions

85% of the doctors in the ACEP survey said that wait times for all emergency patients would improve if there were better psychiatric services available.
More than 80 % agreed that regional dedicated emergency psychiatric facilities nationwide would work better than the current system for dealing with psychiatric emergency patients.

Maybe, it is time to redesign the Emergency care ? We rest our case, now you decide!

Demystifying Electronic Health Records


Increasingly, healthcare organizations are investing in clinical information systems. According Kalorama Information – the publishing division of, hospitals in the United States would be spending close to $4.8 billion on Electronic health record(EHR) or Electronic medical record systems(EMR). Despite the brouhaha, there is a lack of understanding of what an EHR can do and can not do.In this post, we will attempt to peal the layers.

What is an EHR/EMR? Simply put, the EHR is an electronic record of a patient’s medical history. This electronic record includes important information like test and imaging results, medication history, Emergency department visit summaries, doctors’ notes and general health history – from childhood allergies to surgeries.

All of this exisits currently, (in most hospitals).But, in paper charts and in some cases in databases behind applications that do not talk to each other . For Instance, the Emergency department diagnosis, might reside in EMSTAT(a popular ED application) , while the same patient’s Inpatient treatment notes resides in another application such as Affinity.

An EHR ultimately replaces the paper chart currently used to store the same information. The electronic version of the record can be made available to the patient’s caregivers in different locations, more quickly and efficiently. And when done well, it minimizes data redundancy (the need to enter the same information over and over) . So for instance, information captured during an emergency visit can be retrieved by an inpatient care giver, if the patient goes on to recieve care as an inpatient.

How does EHR help hospitals ?

The EHR can help hospitals and health systems make improvements in three major areas.

1. Improved quality of medical decision making

It provides doctors with immediate access to a patient’s health information.Whether it is an Emergency Physicain, or a nurse that needs to phone an on-call physician in the middle of the night, the patient’s chart can be accessed to support important treatment decisions. In addition, in most cases the EHR is connected to a robust library of medical information that can help physicians in making diagnoses and treatment plans based on the latest research.In some cases, it can generate automatic reminders by mail or e-mail to notify test result availbility, critical values and other useful medical information.

2. Improved Patient Safety

Because doctors’ orders and prescriptions are entered into a computer rather than in handwritten orders, pharmacists and other caregivers have no trouble interpreting the information. This greatly reduces the possibility of transcription errors and other medical mistakes. Thereby reducing adverse drug events and increasing patient safety.

3. Improved efficiency

Caregivers will no longer need to search or wait for your patient chart. In addition, lab results and X-rays can be sent electronically to your doctors as soon as they are completed, for immediate analysis, diagnosis and treatment.

In addition to the major areas listed above, there are other advantages including cost savings from an EHR implementation. In a recent article that Houston Neal, (Director, Business Development, shared with us, they talk about how EMR can help reduce medical malpractice insurance premiums, reduced downcoding and even revenue gains by participating in pay for performance time programs (Medicare Care Management Performance (MCMP) ).

Medication reconciliation form -A Patient safety Net

Medication reconciliation

The goal of medication reconciliation is to provide correct medications to the patient at all transition points within the hospital and at discharge. At every transition point, a nurse must review previous medication orders with new orders to reconcile differences to help eliminate medication errors. Poor communication of a patient’s medical information at transition points results in medication errors and adverse drug events.

JCAHO Requirements

According to the JCAHO National patient safety goals, accurately and completely reconciling medications across the continuum of care is an important patienty safety goal. It is important to recognize that sound system design is intrinsic to the delivery of safe, high quality health care, the goals generally focus on system-wide solutions, wherever possible.

Med Rec Form

Using a standardized medication reconciliation form, the nurse can completely reconcile medications and obtain other information that can improve patient safety. Consequently, the physician will have an organized document with current information at hand to reconcile. The nurse can them compare the list against the physician’s admission, transfer, and/or discharge orders. this form was created to obtain an accurate list of all medications (prescriptions, over-the-counter, supplements, herbals, etc.) taken by the patient at home prior to out-patient or in-patient admission. This includes the drug name, dosage, frequency and route.

Download!! – You can download this form from the clinical toolkit page.

Reduce ICU Length of Stay by goal setting

In my previous article on Critical care or Intensive care(The link betweek efficiency and patient safety), we saw how efficiency can impact patient safety and thereby the outcome. Now let us examine a recent innovation in the area of critical care that has actually accomplished this at the John’s Hopkins Hospital, Baltimore,MD.

The Problem

Poor and inconsistent communication among providers in the intensive care unit (ICU) can lead to a lack of understanding of daily goals and the failure to deliver needed services that accelerate recovery and discharge.
ICU patients tend to have life-threatening problems and complex care needs that require a combination of many treatments and services in order to achieve timely recovery and discharge.
Lack of communication among providers can lead to a lack of understanding about what needs to occur each day in the ICU.
The net result is that patients remain in the ICU longer than necessary, and are at greater risk of harm, including morbidities and mortality.

The Solution

The ICU care team (which includes the attending physician and/or fellow, anesthesia and surgery residents, a nurse practitioner, a nurse, and a pharmacist) visits each ICU patient every day between 20 and 25 minutes and uses the ICU Daily Goals Form to document the This creates a standardized way to communicate with one another and a focussed plan of care.

Expected Benefits

The benefit of this innovation may be greatest with high-intensity patients, such as those in the ICU. It also may be most applicable in academic medical centers and other organizations where ICU care is provided by many different types of practitioners.
Reduced LOS – At Johns Hopkins where this innovation was pioneered, the mean length of stay in the ICU reduced from 2.2 days to 1.1 days

Using Efficiency to improve Quality of care

Treatment of Community Acquired Pneumonia

According to the American Academy of family Physicians, there are 5.6 million cases of Community-acquired pneumonia annually in the US. The cost of treatment and care for CAP is an estimated $8.4 billion. The type of management and treatment of CAP and outcomes can significantly influence the cost of care and outcomes for hospitals.

Streamlining the workflow

University of Kentucky Medical Center(featured in the video) clearly shows how hospitals can save significant amount of time, costs and improve patient care by analyzing workflows.

Streamlining the drug preparation and administration process for CAP

By studying the process(time taken to process one order of an IV antibiotic ad mixture) they have observed that it takes approximately 16:42 minutes to prepare and administer the (Nursing + Pharmacy time). So from an efficiency standpoint it makes sense reduce or completely eliminate steps involved in drug preparation and have fewer administrations.

Efficient method of drug administration

Choosing monotherapy instead of combination therapy reduces the number of steps.Using agents with longer half-lives allows for once-daily administration, which in turn leads to improved compliance and outcomes and decreased costs. In addition, transitioning patients to oral therapy as soon as they are clinically stable can significantly reduce the length of hospitalization-the major contributing factor to health care costs.

University of Kentucky Medical Center applied this and reduced the time to prepare and administer Pre-mix doses of Monotherapy to 3:26 minutes