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Best practices in avoiding retained surgical sponges

Despite established practices for counting, cotton sponges are the most common item to be left behind in a patient after intraabdominal surgery.  Several years ago, the Mayo Clinic (Rochester, MN) implemented a data-matrix-coded (fka bar coded) sponge counting system.  In 18 months of continuous use, there have been just under 2 million sponges used in the Mayo Clinic Rochester operating rooms and zero retained-sponge events.  There is a short learning curve to learn to use the new system (about 4 cases), and no increase in overall operative time was found.  There was an average cost increase of just under$12 per case to implement this new system.

Source: Cima, R.R., and others.  Using a data-matrix-coded sponge counting system across a surgical practice: impact after 18 monthsThe Joint Commission Journal on Quality and Patient Safety;37(2):51-58, Feb. 2011.  Posted by the AHA Resource Center, (312) 422-2050, rc@aha.org

Quality improvement: what is the best of current thinking?

The editors of the policy journal Health Affairs take on important themes and provide a forum that attracts top-notch contributors.  The April 2011 issue is devoted to the theme, “Still Crossing the Quality Chasm,” and provides 27 meaty, scholarly, data-rich articles, including several case study-like reports.  Here are some of the highlights:  (Classen, et al.) suggest that the number of adverse events is seriously underreported in U.S. hospitals just by the nature of the reporting mechanisms.  (Goodman, Villarreal, and Jones) calculated that adverse medical events resulted in a social cost of $393-$958 billion in 2006.  (Van Den Bos, et al.) calculated that measurable medical errors resulted in an annual cost of $17.1 billion nationally in 2008.  (Pryor, et al.) describes the success achieved by the large system Ascension Health in reducing the rate of avoidable deaths by at least 1,500 annually.  (Gabow and Mehler) review the approach taken at Denver Health to improve quality which included establishment of a department of patient safety and care quality.  (Joyce, et al.) describe how Legacy Health has been able to cut infection rates through its Big Aims initiative.  (Pronovost, Marsteller, and Goeschel) report on the progress nationally in cutting central line-associated bloodstream infections (CLABSI). 

Sources:  The following are all from Health Affairs;30(4), April 2011.

Classen, D.C., and others.  ‘Global trigger tool’ shows that adverse events in hospitals may be ten times greater than previously measured, pp 581-589.

Goodman, J.C., Villarreal, P., and Jones, B.  The social cost of adverse medical events, and what we can do about it, pp 590-595.

Van Den Bos, J., and others.  The $17.1 billion problem: the annual cost of measurable medical errors, pp 596-603.

Pryor, D., and others.  The quality journey at Ascension health: how we’ve prevented at least 1,500 avoidable deaths a year, and aim to do even better, pp 604-611.

Gabow, P.A., and Mehler, P.S.  A broad and structured approach to improving patient safety and quality: lessons from Denver Health, pp 612-618.

Joyce, J.S., and others.  Legacy Health’s ‘Big Aims” initiative to improve patient safety reduced rates of infection and mortality among patients, pp 619-627.

Pronovost, P.J., Marsteller, J.A., and Goeschel, C.A.  Preventing bloodstream infections: a measurable success story in quality improvement, pp 628-634.

Best practices for decreasing incidence of pressure ulcers

 Allina Hospitals & Clinics (MN) involved all 10 system hospitals in a pressure ulcer initiative beginning in 2008.  Components of the initiative, as described (Sendelbach, et al., 2011) include standardized surveillance and reporting, standardized education, point-of-care resources, nutritional intervention, EHR documentation, and a provider awareness campaign.  The article includes Allina’s Pressure Ulcer Prevention Algorithm.  This initiative was successful in reducing pressure ulcers — with a potential cost savings systemwide of as much as $430,000.   Another case study, featuring Buena Vista Regional Medical Center (Storm Lake, IA), has been published by the Health Research & Educational Trust (2010).  After implementing the pressure ulcer prevention bundle from the Institute for Health Improvement (2008), Buena Vista was able to cut the pressure ulcer incidence rate. 


Health Research & Educational Trust.  Decreasing pressure ulcers through skin care.  Chicago: Health Research & Educational Trust, 2010. 

Institute for Healthcare Improvement.  Getting Started Kit: Preventing Pressure Ulcers, How-To GuideCambridge, MA: IHI, 2008. 

Sendelbach, S., Zink, M., and Peterson, J.  Decreasing pressure ulcers across a healthcare systemJONA. The Journal of Nursing Administration;41(2):84-89, Feb. 2011.

Speeding up discharges: red light green light approach

Several Canadian hospitals have had success in cutting length of stay and improving patient throughput by standardizing the discharge process using lean principles.  A technique, described in these articles, is the “red light green light” visual alerting system that allows all staff to know, at a glance, how close each patient is to discharge and helps to trigger the appropriate tasks.  Color coding on a white board in the patient room shows whether the patient is: red light (3 or more days from discharge), yellow light (2 to 3 days), green light (next 24 hours), or blue (waiting for appropriate discharge destination. 

Another application of the red-green visual color coding approach has been implemented at University Hospital (San Antonio, TX).  In this simple method, there are two jars at the nurses’ station.  When a patient room needs to be cleaned, a red slip with the room number is dropped in one jar.  When housekeeping has cleaned a room, a green slip with the room number is dropped in the other jar.  This alerts the unit clerk that a bed is available.


Oldfield, P., and others.  Red light-green light: from kids’ game to discharge toolHealthcare Quarterly;14(1):77-80, 2011. 

Puzic, S.  ‘Flo’ chart helps cut patient hospital staysWindsor Star, Feb. 11, 2009.

A no-tech solution for reducing hospital bed turnaround timeRobert Wood Johnson Foundation, June 2008.

Magnet status. Is it worth it?

As of March 2011, slightly fewer than seven percent of registered hospitals in the U. S. have earned the Magnet Recognition Program credential that recognizes organizations for nursing excellence. According to an article in Trustee magazine, the cost of achieving Magnet status can run from $46,000 to $251,000.

Is it worth it?

  • At Atlanticare Regional Medical Center, Atlantic City, NJ, both nurse turnover and vacancy rates dropped after the hospital achieved Magnet status, even as bed size grew by 20 percent.
  • Palomar Pomerado Health in San Diego County, CA, estimates they saved about $1.2 million a year system-wide by reducing the nurse turnover rate through the Magnet journey.
  • An article in the Journal of Nursing Administration calculates the monetary value of improved outcomes experienced by Magnet hospitals, including not only reduced turnover and vacancy rates, but also fewer needlesticks and musculoskeletal injuries and decreased falls and pressure ulcers.

The author of the Trustee article quotes Barbara Wilson, board chair at St. Luke’s Boise-Meridian Medical Center, ID, as identifying five main benefits in investing the time and money in Magnet:

  • Results in better outcomes
  • Provides a tool for recruiting nurses
  • Invests in front-line employees
  • Produces more engaged employees
  • Provides an organizational competitive advantage


Frellick, M. A path to nursing excellence. Trustee. 64(3):15-21, Mar. 2011. http://tinyurl.com/4ak72an

Drenkard, K. The business case for Magnet. Journal of Nursing Administration. 40(6):263-71, June 2010. http://tinyurl.com/4mq73jr

Growth of the program. Designations and redesignations as of March 2011. American Nurses Credentialing Center. Mar. 21, 2011. http://www.nursecredentialing.org/Magnet/ProgramOverview/GrowthoftheProgram.aspx

Failure: best practices at learning from mistakes

The Harvard Business Review is serious about the importance of doing a better job at learning from our failures — so much so that the entire April 2011 issue is devoted to the topic.  Of particular note is Harvard Business School Professor Amy Edmondson’s article, “Strategies for Learning from Failure,” which provides a careful look at different types of failures and how to build a learning culture.  Another interesting piece is by Professors Bazerman and Tenbrunsel, “Ethical Breakdowns,” excerpted from their new book, Blind Spots: Why We Fail to Do What’s Right and What to Do About It, taking a look at the behavior of managers and the way incentives operate.  Conversely, Gino and Pisano, also from the Harvard Business School, wrote about “Why Leaders Don’t Learn from Success,” arguing that there is a proper approach to drawing lessons from successful ventures.   

Source: The failure issueHarvard Business Review;89(4):entire issue, April 2011.

Achieving Exceptional Patient & Family-Focused Care in Hospitals

A new Innovation Series white paper from the Institute for Healthcare Improvement may help hospitals improve their patient-centeredness, a core component of quality health care. The paper identifies 5 key drivers  — leadership, staff hearts and minds, respectful partnership, reliable care, and evidence-based care — for an exceptional patient or family experience in the hospital.

The report also provides an overview of patient- and family-centered care and discusses the primary and additional drivers for an exceptional experience. An exemplar hospital for each key driver is named, and tips for improving patient and family-centered focused care are shared.

Source: Balik B, Conway J, Zipperer L, and Watson J. Achieving an exceptional patient and family experience of inpatient hospital care. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2011. http://www.ihi.org/IHI/Results/WhitePapers/AchievingExceptionalPatientFamilyExperienceHospitalCareWhitePaper.htm

Related resources:

Strategies for Leadership: Patient- and family-centered care. Chicago: American Hospital Association, in collaboration with the Institute for Family-Centered Care, 2004. [Multi-media toolkit with video, video discussion guide, resource guide, and hospital self-assessment tool] http://www.aha.org/aha/issues/Quality-and-Patient-Safety/strategies-patientcentered.html 

Frampton S and others. Patient-centered care improvement guide. Derby, CT: Planetree, Inc. and Picker Institute, Inc., Oct. 2008. http://www.planetree.org/Patient-Centered%20Care%20Improvement%20Guide%2010.10.08.pdf

Institute for Patient- and Family-Centered Care http://www.ipfcc.org/

2010 National Healthcare Quality Report. Agency for Healthcare Quality and Research, Feb. 2011. http://www.ahrq.gov/qual/nhqr10/nhqr10.pdf [includes benchmarks and national progress on achieving patient-centeredness]

Hospital Compare web site. Washington, DC: US Department of Health and Human Services, Dec. 2010-ongoing. http://www.hospitalcompare.hhs.gov/ [compare individual hospitals on patient ratings of their hospital experience]

Hospital-acquired infections: ICU CLABSI rates declining

 The US Department of Health and Human Services (DHHS) has set a goal of cutting central line-associated blood-stream infections (CLABSIs) in half by 2013.  Some substantial progress has already been made, as seen in the new CDC Vital Signs article cited below.  In intensive care units, the CLABSI rate has decreased from an estimated 43,000 infections in 2001 to an estimated 18,000 in 2009, or a reduction of 58 percent.  CDC also provides 2009 estimates for CLABSIs in other inpatient units (23,000), and in outpatient hemodialysis clinics (37,000).  The impact of the reduction in CLABSIs in ICUs in 2009 is estimated to from 3,000 to 6,000 lives saved and $414 million in averted extra health care costs.  Providers spotlighted as having best practice initiatives in place for reducing CLABSI include the Pittsburgh Regional Healthcare Initiative and the MHA Keystone Center for Patient Safety & QualityBest practices for reducing CLABSIs can be found in the CDC document: Guidelines for the Prevention of Intravascular Catheter-Related Infections, cited below.

Sources: Vital signs: central line-associated blood stream infections, United States 2001, 2008, and 2009.  MMWR. Morbidity and Mortality Weekly Report;60:1-6, Mar. 2011.  http://www.cdc.gov/mmwr/pdf/wk/mm60e0301.pdf; and, Guidelines for the prevention of intravascular catheter-related infections.  MMWR. Morbidity and Mortality Weekly Report;51(RR10):1-26, Aug. 9, 2002.  http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5110a1.htm

‘Healing without harm’: HROs and islands of excellence

Commercial airlines, nuclear submarines, and nuclear power plants can be characterized as ‘high reliability organizations’ (HROs), in which the defect and error rate is low.  Health care organizations, by and large, have not achieved the same level of reliability.  Basic principles of HROs are described in the Delk et al. white paper.  Five provider organizations that are leaders in patient safety and quality, termed ‘islands of excellence,’ are described in detail, including: Sutter Health, Gundersen Lutheran Health System, SSM Health Care, Sanford Health, and WellStar Health System.  Another health system that has formally committed to the ‘healing without harm’ concept of a high reliability organization is Ascension Health.  A series of articles discussing the Ascension Health approach to eliminating preventable injuries and death is available in free full text here.

Sources: Delk, M.L., and others.  Healing Without Harm: 21st Century Healthcare Through High Reliability.  Center for Health Transformation, [no date, 2010?]  http://www.healthtransformation.net/galleries/wp-hospital/CHTHealingwithoutHarm_v3.pdf; and, Ascension Health.  Activity.

Making business case for the ED observation unit

An estimated one-third of hospital emergency departments have a dedicated observation unit, usually in the range of 4 to 20 beds, with an average length of stay of 10 hours.  About 5 to 10 percent of ED visits may be cared for in the observation unit, and 20 percent of these end up being admitted to the hospital.  The Baugh et al. article is a concise, fact-packed literature review on the topic of making a clinical and business case for offering an observation unit.  The American College of Emergency Physicians (ACEP) is another excellent source of information on observation units, including selected text from a new text on observation medicine.  Chapter 6 in the new Graff text compares the advantages and disadvantages of four different models of observation unit organization.  Chapter 10 covers quality improvement and Chapter 12 discusses considerations in pediatric observation medicine.  ACEP also has a policy statement on observation units.


Baugh, C.W., Venkatesh, A.K., and Bohan, J.S.  Emergency department observation units: a clinical and financial benefit for hospitals.  Health Care Management Review;36(1):28-37, Jan.-Mar. 2011.

Graff, L.G.  Observation Medicine: The Healthcare System’s Tincture of Time, [2010?].  Chapter 6: Hospital based observation unit design.  Chapter 10, Patient quality (continuous quality improvement), safety, and experience for the observation unit.  Chapter 12, Pediatric observation medicine.

American College of Emergency Physicians.  Emergency Department Observation Services, Jan. 2008.