P3 Are your nurses happy? Healthcare P4 Leadership P6 Reviewpromos.hcpro.com/pdf/HealthcareLeadershipReview_Complimentary… · that nurses are happier than ever with their career

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A 2% chlorhexidine solution more effective thAn soAp And wAterCleaning patients with washcloths impreg-nated with 2% chlorhexidine solution every day fights hospital-acquired infections in the ICU better than washcloths soaked with simple soap and water.

unsAfe workloAds for 4 in 10 hospitAlists Four in 10 hospitalists responding to a survey from Johns Hopkins University say their workloads exceeded safe lev-els at least once a month; 36% reported excessive workload assignments exceeding safe levels at least once per week.

three cost cutting skills of smart hospitalsHealthLeaders Mediaby Jim Molpus

All hospitals with hopes of a future have a number they use to project the amount of cost they must squeeze out of their organizations in the next few years. The lucky few may have a number that is in single digits, but most healthcare organizations are looking at double-digit cost reduction to match shrinking reimbursement levels.

We asked the members of our HealthLeaders Media CFO Exchange for their organizations’ estimated percentage reduction of operating costs for the next 3–5 years. The average was set at 11%. In HealthLeaders Media’s 2013 Industry Survey: Strategic Imperatives for an Evolving Industry, cost re-duction was rated as the third-highest priority by the 823 respondents, close behind patient experience and clinical quality.

What strikes me as one of the more telling responses to our survey was that 92% rated reduced reimbursements as the top threat facing their orga-nizations, while only 4% rated reduced reimbursements as an opportunity. That paints a picture of an industry scared of a future of forced efficiency and competition on value.

Granted, no one in a regulated industry that has only the most tenuous ties to a retail economy likes looking at a future in which income streams are chopped by a combination of market pressures and government cutbacks. Still, it’s often the case that the best time—or the only time—for corporations to make a significant leap in their market position is when

Are your nurses happy?Keep young nurses from leaving by helping them advance their educations.

why you should add clinicians to the medical staff departmentThere are lots of benefits to integrating individuals with a clinical background.

following up with patients is good for hospitals and patientsWhy it pays for hospitals to get in touch with patients after they head home.

turning a spotlight on the patient experienceLights, camera, action helped one hospital; can it help yours, too?

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the underlying dynamics of an industry shift. That’s when there are opportunities for innovative play-ers to make a stake. Whether it’s Walmart or Target reinven ting discount retail or Southwest creating a new category of airline, industries are reshaped by a disruptor that focuses on the “turn” in “downturn”—not the “down.”

It takes a special vision to compete without a net in a healthcare market where service, quality, and efficiency all have to hum at the same time. I would wager that the same 4% of health systems who view reduced reimbursement as an opportunity also understand that their view of cost containment has to evolve. The axiom that you can’t cut your way to growth has never been truer.

To face a future where cost is an opportunity, healthcare systems must blend three values or skills:1. Hardwired thriftiness. In an industry where

even a midsized health system can have an annu-al budget approaching eight figures, it’s tempting to chase only items with the largest opportunities for cost savings. That leaves too much money in the margins, as it were. Curt Kretzinger, COO at St. Joseph, Mo.–based Heartland Health, says his health system set a goal a while back to find $10 million or more in savings annually, which means it has to look harder each year. “To get the sav-ings, we’ve had to find it in multiple smaller areas,” Kretzinger says. “We have one team that’s looking at $2 million on a redesign of a technology. So we will still probably have one or two of that size, but the vast majority is smaller savings of $100,000 here, $80,000 there, and $300,000 here. When we start adding them all up, it becomes real mon-ey. It’s a lot of small efforts that become a big win for the organization.”

2. Data, analysts, and accountability. If you don’t have the data to understand where you are really losing money, the analytics in your IT system to poke it out, and the analysts who can translate those opportunities into a plan for transformation, your opportunities for cost sav-ing are invisible. Heartland Health uses what it calls PASTE teams—problem, analysis, solution, transition, and evaluation—to identify ground- level opportunities for reducing waste and

from the field

In HealthLeaders Media’s 2013 Industry Survey: Strategic Imperatives for an Evolving Industry, cost reduction was rated as the third-highest priority by the 823 respondents, close behind patient experience and clinical quality.

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Contact Managing Editor Alexandra Wilson Pecci at [email protected] or 603-974-1191.

Healthcare Leadership Review (ISSN: 1082-6718 [print]; 1937-7762 [online]) is published monthly by HealthLeaders Media, 75 Sylvan St., Suite A-101, Danvers, MA 01923. Subscrip-tion rate: $249/year or $448/two years; back issues are available at $25 each. • Healthcare Leadership Review, P.O. Box 3049, Peabody, MA 01961-3049. • Copyright © 2013 HCPro, Inc. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HealthLeaders Media or the Copyright Clearance Center at 978-750-8400. Please notify us immediately if you have received an unauthorized copy. • For editorial comments or questions, call 781-639-1872 or fax 781-639-7857. For renewal or subscription information, call customer service at 800-650-6787, fax 800-639-8511, or email [email protected]. • Visit our website at www.hcpro.com or www.healthleadersmedia.com. • Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. • Opinions expressed are not necessarily those of HLR. Mention of products and services does not consti-tute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions.

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shaving cost. When there is a need for more re-sources, including Six Sigma black belts, those re-quests are submitted to an oversight team where initiatives are prioritized and results tracked with an organizational scorecard.

3. A line to the patient. Cutting just for the sake of cutting poses risks. But the typical healthcare encounter has so much process waste that some cuts can also improve the patient experience. Sav-ings have to pass the “voice of the customer” test at Heartland Health, says Dottie Bray, process leader for performance management. For exam-ple, in a typical primary-to-specialty referral, the patient may be the one who calls to schedule the appointment. When Heartland was redesigning its scheduling portal, it created a module so rep-resentatives in any office could see and schedule appointments in other offices within the Heart-land network. It’s better for the patient, Bray says, while also cutting down on the call volume (which equals time, which equals money) in both primary and specialty care.

To be fair, I’m fairly certain a broad swath of health-care systems have the vision to understand there is opportunity in the value side of delivery. I’m just not so sure there are many like Heartland—a 2009 Malcolm Baldrige National Quality Award winner—that have built the hard-won capability to contain costs, enabling them to compete in a high-quality, high-value care market.

Source: Jim Molpus, HealthLeaders Media, Janu-ary 28, 2013, online (www.healthleadersmedia.com).

how to stop unhappy nurses from leavingHealthLeaders Mediaby Alexandra Wilson Pecci

The results of a survey of RNs present something of a paradox for nurse leaders. The survey showed that nurses are happier than ever with their career choices. Yet about 30% of them aren’t happy with their current jobs.

Marcia Faller, PhD, RN, chief nursing officer at AMN Healthcare, which conducted the survey of nearly 3,000 nurses, says it’s a finding that should make nurse leaders stop and listen. The fact that many nurses want to find a new job is a clear sign that a lack of a nursing shortage is no excuse for leaders to start slacking off on their recruitment and retention.

“Nurse leaders really need to pay attention,” she says. “You really do need to continue on those efforts.”

How can nurses be both satisfied with their careers but unhappy with their jobs? Faller has a theory. She believes that nursing’s importance has been thrust into the limelight over the past few years, thanks in part to the findings of the IOM’s landmark Future of Nursing report, for example.

Yet in many instances, that societal shift hasn’t trickled down to nurses’ day-to-day working lives. “I’m not sure that the workplace changes have taken place as fast,” Faller says. “People don’t leave their jobs; they leave their manager and their leaders.”

The survey also reveals that nurses are eager to con-tinue their nursing education in the near term (over the next one to three years). It found that 40% of nurses wanted to pursue an advanced degree.

Broken down by age, the numbers were impressive. Almost 70% of 19- to 39-year-old respondents planned to pursue more advanced degrees, with 37% of this age group saying that they planned to purse a master’s degree in nursing.

In addition, the survey found that 28% of re-spondents are considering getting specialty cer-tification in the next one to three years; 35% say they’re already certified through their professional organization.

In other words, nurses are motivated; they yearn to learn. Harvard Business School professor and author Clayton Christensen describes motivation like this: “[It] means that you’ve got an engine inside of you that drives you to keep working in order to feel successful and to help the organization be success-ful. It causes you to keep at it through thick and thin. Motivators are things like, ‘I have the opportunity to achieve important things, ‘I learn ways to be better,’ and ‘I’m an important part of a team.’ If you have those kinds of experiences every day, you’re motivat-ed, and you’ll be satisfied.”


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The findings of the AMN Healthcare survey are intriguing all by themselves, but smart nurse leaders can also use them to their advantage by harnessing their employees’ career enthusiasm while also impro-ving recruitment and retention.

If most nurses want to advance their educations but are unhappy at work, it makes sense for nurse leaders to do everything in their power to help their current employees achieve their educational goals.

That might mean implementing on-site educational courses and programs, working with nurses on flexible scheduling options so they can better balance work and school, teaching nurses about avenues to certification, and offering tuition reimbursement.

By helping nurses advance their educations, hos-pitals will likely make nurses feel more valued and supported at work. And if nurses have a choice between working at a hospital that incentivizes educational ad-vancement or one that doesn’t, which one do you think they’d choose?

Surveys like these can sometimes feel like simply a snapshot of what nurses are thinking at a given time. It might be hard to glean any real takeaways from pages filled with numbers and percentages. But nurse leaders who are willing to dig deeper, connect the dots, and make changes will be the ones whose nurses are happy and productive—and stick around for a while.

Source: Alexandra Wilson Pecci, HealthLeaders Media, January 8, 2012, online (www.healthleadersmedia.com).

Adding clinicians to the medical staff department can improve the privileging process and streamline responsibilitiesMedical Staff Briefingby Elizabeth Jones

Medical staff services isn’t what it used to be, and no medical services professional (MSP) would argue with that. What was once an administrative job has become

a highly technical career, and it’s getting more special-ized by the day.

According to Wendy Crimp, BSN, MBA, CPHQ, consulting practice director for The Crimp Resource Group, one emerging trend is the separation of privile-ging and credentialing duties. She explained that years ago, the MSP’s role was to ensure that the list of privi-leges was accurate, but as more emphasis was placed on criteria, the job got more complex. Now, privileging entails determining whether physicians need to acquire specific training and certificates and perform a certain number of procedures to be deemed competent. Thus, MSPs have had to tap into a physician’s knowledge and experience to get the job done.

“It has become harder for non-clinicians to adminis-ter privileging programs,” says Crimp.

Focused professional practice evaluation (FPPE) has added another wrinkle. For facilities that are Joint Commission–accredited, confirmation of clinical com-petence via either case review or concurrent proctor-ing is part of the privileging process, and creating a thorough FPPE form for any given specialty requires a clinician’s touch.

“We have more and more clinical activities moving into this previously administrative realm,” says Crimp. “It is hard because although the MSPs have been trained in medical terminology, they frequently have not been trained in clinical nomenclature. A clinical procedure can be named five different ways.”

Given the complexity of the privileging and peer review processes, Crimp recommends that the medi-cal staff office integrate individuals with a clinical background, such as a nurse or respiratory therapist, into the department—or, failing that, at least into the process.

Do what you do bestHiring an individual with a clinical background into

the medical staff department has several advantages. First, if a nurse looks at a cardiac surgery privilege form, he or she will be better able to identify areas that overlap or items that are missing. Second, when that nurse sits down with a physician to review the privi-leging form, he or she will have the clinical expertise to ask the right questions. Third, when it comes time to develop FPPE forms for physicians to use during a


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review, an MSP with a clinical background will be able to create specific questions.

“If you leave the forms generic, you will get generic responses. If you use good clinical background and understand standard of care for that type of patient, you will be able to put together a meaningful form,” says Cynthia Smeenge, manager of the credentialing depart-ment at Spectrum Health in Grand Rapids, Mich.

An alternative to hiring a nurse or other clinician into the medical staff office is to hire a certified medical coder. “Frequently we are hiring people who have never done credentialing and privileging before and training them from scratch. If we are going to train someone from scratch, let’s try to get someone with a secondary skill set. Then when physicians turn in their case logs and there are questions, there is someone besides a physician to answer them,” says Crimp.

If hiring a clinician or medical coder isn’t an option, MSPs can also boost their performance by going back to school. A medical staff coordinator in Smeenge’s department, for example, is returning to school to get her RN. “She isn’t going into clinical practice as much as she wants the clinical background to support her in her role,” says Smeenge. “You can’t help them develop threshold numbers if you don’t understand what the jargon and different procedures are.”

Sherry Mehler, CPMSM, manager of privileging systems at Cedars-Sinai Medical Center in Los Angeles, took advantage of a medical terminology course her organization offered in 2009, just before diving into a two-year effort with all medical staff departments and divisions to ensure that the privileging forms in each of the 57 specialties met prevailing standards, reflected contemporary practice, and were compatible with online credentialing. The course helped Mehler transition into her new management role, which focuses solely on privileging.

Privileging professionals with a deep understanding of the various procedures can create streamlined privileging forms. For example, on the surface, it might make sense to lump the insertion, management, and pulling of central lines onto one privileging form, but the reality is that inserting a central line is far more complex than pulling it.

“By putting them together, you are requiring people to request the higher-level procedure for a lower-level

procedure,” says Smeenge. Instead, by grouping together the pulling of all of the various central lines into one privileging form and the insertion and man-agement of central lines into another, the medical staff services department can streamline the process and ensure that the appropriate clinicians are performing the appropriate procedure.

“It is that kind of understanding of the complexity of different procedures, treatments, or protocols that helps you develop privileges that make sense in the real world,” says Smeenge.

How to make it happenIn the past, medical staffs have tried partnering with

the quality department, but that doesn’t often work well, says Crimp. Both the quality and the medical staff departments are often so overwhelmed with their own initiatives that they struggle to help each other out. “If you just expect them to help when you call, they will be busy doing other things. If you go with the partne-ring option, it has to be a structured approach where you have once-a-week meetings to discuss business with them or they own a piece of your process—maybe they are going to the physician review meetings with the department chairs and doing interpretations of case logs,” says Crimp.

Ideally, in a partnering situation, the quality and medical staff departments report to the same person who sets the priorities and agendas for both.

“If it isn’t super structured, it won’t happen, and you need to go to plan B, which is to bring the expertise into your department,” says Crimp.

According to Crimp, most of her clients convert an existing position rather than adding staff. One mistake that medical staff departments make when adding an individual with a clinical background to the mix is that they keep the work flows separate. Yes, it makes sense for the nonclinical folks to focus on application management and primary source verifica-tion while the individual with a clinical background focuses on the technical aspects of privileging, but that doesn’t mean that the folks with a clinical back-ground can’t do credentialing work, too, says Crimp. Perhaps the individual with a clinical background facilitates review with the department chair and cre-dentials committee.


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If an organization is financially strapped, Crimp suggests waiting until the department has a vacancy. “It is easier to upgrade a position than create a whole new one,” she says.

According to Smeenge, recruiting for the position may be a challenge because so few people understand medical staff services or, quite frankly, know that the department exists. “I find that if I want to hire clinical people, I’m going to have to really recruit and mentor someone because it is not a well-known area of health-care administration,” she says.

Crimp admits that MSPs haven’t always been open to the idea of inviting clinicians into the medical staff department, but given how overwhelming their jobs have become, many would appreciate the assistance and the ability to focus their efforts and talents in the credentia ling arena, while leaving the technical stuff to the experts.

Source: Elizabeth Jones, Medical Staff Briefing, February 1, 2013, online (www.hcpro.com).

easing pain and improving quality, care, and culture through follow-up contactPatient Safety Monitorby Jacqueline Fellows

All day and all night, healthcare providers try to help people heal and feel better. They take care of sick patients, both the chronic and acutely ill. Much of the care—and the outcomes that follow—is routine for providers.

But many times, care and outcomes are not rou-tine for the patient or family. Even when nothing goes wrong in terms of care, outcomes can be nega-tive, resulting in sadness and confusion for patients or families. They leave the hospital, not immediately comprehending what has happened. They may be in shock, wanting to ask questions but not know-ing how to formulate those questions until weeks or months later. They might fill in the blanks when they don’t have the information they need regarding what happened.

Some might see following up with the patient

or family after care has been given as outside the hospital’s scope. After all, if providers did everything they could and the outcome was still sickness or death, there’s really not anything anyone can do. But after Michael Mikhail, MD, regional director of emergency medicine at St. Joseph Mercy Health System in Ann Arbor, Mich., and chairman of the board of Emergency Physicians Medical Group, received a letter one day about six years ago, he realized that while the hospital might not be required to follow up, healthcare systems are in a unique position to alleviate a different type of pain: emotional pain. Healthcare provi ders are the ones who can answer questions about what happened during a patient’s care. And by reaching out to patients or family members about negative outcomes, Mikhail discovered that the hospital benefited.

Next Step’s creationThe letter Mikhail received was from a widow whose

husband had died unexpectedly about eight months earlier. In the letter, which was also addressed to hos-pital counsel, she expressed concern about the events that led to her husband’s sudden death, and the letter revealed that she still had many questions. Mikhail, troubled by how long the issue had been bothering the woman, asked to meet with her. The meeting turned into the catalyst for a program that is now beginning to spread beyond the ED to the entire hospital, has won a national award, and is beginning to serve as an example to other hospitals. The Next Step program, which is now in its sixth year, identifies unexpected or serious outcomes that begin in the ED and reaches out to the patient or family members to let them know that, if they choose, they can meet with a hospital team to ask questions.

In the meeting with Mikhail, the widow expressed confusion about how her husband got so sick so fast, and wondered whether someone along the way—in-cluding herself—may have missed something. In the specific case of her husband’s care, it was determined that everything that could have been done was done, and that what happened could not have been fore-seen. Still, Mikhail was appalled at the idea that the woman had agonized for so long about the circum-stances surrounding her husband’s death before ap-proaching anyone to ask about it. He speculated that


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perhaps people who suffer from a negative outcome in a hospital, particularly a sudden or unexpected one, may not be able to ask the questions that would help them grasp the reason for their outcome or that of their loved one. They don’t always have the cour-age to ask their questions, and at the time of the event, they are often too distracted or too much in shock. Later on, after the fact, they may be too timid to approach the hospital. Instead, they need to be approached.

“[The meeting] helped her tremendously,” says Mikhail. “She had lots of misunderstandings that were unnecessary yet went on for so long.”

The meeting was attended by hospital legal and risk management counsel, who also saw the benefit of reaching out to patients. When Mikhail broached the idea of having similar meetings in the future, they were immediately on board and spoke to executives about the idea, winning leadership buy-in.

Other staff members eventually showed inter-est in being involved in patient and family meet-ings. The program leaders began training those who wanted to participate, then let them observe some meetings before leading a few under supervision. Everyone involved in an upcoming patient or family meeting rehearses for the meeting shortly before-hand. Mikhail notes that while certainly useful, the rehearsals cannot possibly address every question a participant might have. He also warns hospitals that while the program is beneficial as a whole, these meetings are often emotional and can be stressful and anxiety-provoking, so proper training and men-toring is essential.

Next Step won the 2011 Medically Induced Trauma Support Services (MITSS) HOPE award. The award was established in 2008 to recognize people—patients, families, healthcare providers, hospitals (or teams or departments therein), academic institutions, commu-nity health centers, grassroots organizations, employee assistance programs, etc.—who exemplify the mission of MITSS: supporting healing and restoring hope to patients, families, and clinicians impacted by adverse medical events.

With the program’s success, Mikhail says efforts are being made at St. Joseph to expand Next Step to the ICU, operating room, and labor and delivery. Program

leaders are considering expanding the program out-side the hospital into other parts of the health system. (St. Joseph Mercy Health System operates seven hos-pitals, five outpatient centers, five urgent care facilities, and more than 25 specialty centers. St. Joseph Mercy Hospital is a 537-bed teaching hospital.)

Leaders are also considering a similar program for providers involved in medical errors. These providers, often known as second victims, are frequently trauma-tized by the events as well, which often leads to feel-ings of guilt and shame that can affect their ability to provide safe, quality care.

Benefits of Next StepAccording to a Service Delivery Innovations Profile

by the Agency for Healthcare Research and Quality (AHRQ), the Next Step program has not increased St. Joseph Mercy Hospital’s legal risk. There might be many reasons for this, although the current think-ing on strategies to avoid lawsuits has generally been quite different. According to the AHRQ profile, many working in healthcare are often advised by legal counsel to avoid family members in the case of an unexpected death or clinical event. Culturally, many providers feel that a frank discussion of the event might somehow be interpreted as admitting guilt of an error, even when none occurred and standards of care were upheld. Yet grieving family members without hospital communication and support often feel unheard and look to place blame, even when there was no error. Facilitating communication, rather than purposely avoiding it, might stop need-less finger-pointing.

How Next Step worksThe program was implemented in 2006. Each month

eight to 10 patients (from the roughly 7,500 ED patients treated) and families who might benefit from Next Step come to the attention of the program administrator in one of two ways.

The first way the hospital identifies potential partici-pants is simple: Any hospital-based clinician or staff member can refer a patient or family by contacting the administrative point person for Next Step. Pro-viders have the option of simply calling up program administrators, or they can submit their concern


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anonymously. The latter is the preferred method, as providers who cared for now-upset patients or family members are often worried that they will somehow get in trouble if they bring up the issue.

The second way is through a monthly proactive medical record search. In-hospital mortality reports help identify patients who came through the ED and subsequently died in the hospital. Family members of patients whose deaths are deemed unexpected are considered as participants of the program.

Program leaders review each of these cases to deter-mine whether the patient or family member would like-ly benefit from the program. A task force then selects about four or five candidates a month to be contacted. The task force is made up of a multidisciplinary team of representatives from:• ED (physician and nurse)• Social work• Patient relations• Behavioral health • Pastoral care• Risk management/quality improvement

The program administrator usually contacts the candi-date by phone three weeks after the event, although the approach and timing differ by case. Possibly an indica-tion of the need for such a program, about 40 out of 50–70 people are reached annually, of which two-thirds wish for an in-person meeting, while the other third are satisfied with the phone conversation on initial contact. Clinicians involved in the care episode are not present, although they are notified of what is discussed at the meetings. If candidates express a wish to have them present, and it is deemed appropriate, the clinicians are involved in the meeting, but Mikhail says it’s unusual.

Participants typically express gratitude for the meet-ing, which is often emotional for both parties. If an error comes to light that the health system is respon-sible for, compensation is offered. Not every participant offered compensation takes it, and no participant thus far has filed a lawsuit as a result of a meeting.

Next Step affects patient safety and cultureThe program has been well received by patients and

families, says Mikhail, noting that healthcare providers and the organization as a whole benefit immensely

from the program. He says the woman who sent the letter that began the program and others like her help healthcare providers maintain a sense of what it’s like to be a patient. “Unexpected events occur,” says Mikhail. “We in medical care understand this—we see through our own lens—but [patients] don’t expect it at all.”

The benefit to the organization goes well beyond a better grasp of the patient’s viewpoint. Mikhail says meeting with patients helps improve care and systems. Although Next Step focuses on unexpected outcomes, not adverse events, and the vast majority of care that is discussed after a death is found to be done correctly, both the hospital and patients still learn something.

The result, says Mikhail, is a gold mine of informa-tion for quality improvement. One patient’s family members received a presentation on how the organiza-tion would plan to avoid future instances of a care issue that occurred with their loved one. The plan wouldn’t exist without the involvement of the family members, and now the family knows not only exactly what hap-pened, but that the hospital has made efforts to provide better care. One thing that came out of these meetings was the ability for any ED staff member to “stop the line” and request a patient safety huddle if he or she is concerned about a course of action being taken that might not be safe.

Sometimes the question of whether something was missed will be forever unclear. A minor mistake may be made—for example, a medication might not be given exactly the way it needs to be—but whether that action causes death in a patient who is already suffering from a disease might not be apparent. Either way, Mikhail says, the Next Step team is honest with family mem-bers. To do this, however, the organization makes sure the meetings focus on a systems approach and how the organization can prevent mistakes, rather than sham-ing and blaming clinicians.

It’s important to restate that clinicians who worked on the case aren’t generally involved in these meet-ings, in part to avoid exacerbation of a second victim situation—the clinician may already be suffering from feelings of guilt, shame, and doubt at the possibility he or she made a mistake. This also underscores that if a mistake is found, in most cases it is the result of


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a systems error, making it the responsibility of the hospital, not the clinician.

What can your hospital do?Mikhail says the Next Step program works within a

just culture. Any sudden or unexpected outcome is sim-ply studied further, with the addition of reaching out to the patient, who can often provide useful information for quality improvement.

He advises hospitals to get over the fear of talking openly and transparently with patients. “The concerns are usually around risk management and reputation,” Mikhail says. “But it’s about improved communica-tion. There’s no reason [not to] other than just they are fearful.”

If leadership provides the right kind of support, he says, a hospital and its providers can conquer that fear and create an environment in which the hospi-tal learns from patients and patients learn from the hospital.

Mikhail notes that the Next Step program was created with current staffing and did not require additional hiring or resources.

Source: Jacqueline Fellows, Patient Safety Moni-tor, February 1, 2013, online (www.hcpro.com).

spotlighting the patient experienceHealthcare Marketing Advisorby Jacqueline Fellows

Props. Scenes. Designers. Spotlights. All of those terms sound more fitting for a Hollywood movie set than for a hospital, right? But they are the exact words Covenant Health employees hear when they are picked for the hospital’s unique internal communication training program called spotlighting. Developed in conjunction with design consultants at IDEO in 2010, spotlighting aims to fulfill the hospital’s strategic goal of fostering sacred encounters with every patient.

“We seek to both manage and improve the way we take care of others, but the root of that is this human encounter,” says Jeff Thies, interim executive vice president of mission integration and vice president of

the Leadership Institute and governance support at St. Joseph Health, which owns Lubbock, Texas–based Covenant.

Making sure every patient encounter is sacred also honors the health system’s Catholic tradition, says Cayce Kaufman, regional patient experience director for Covenant’s four West Texas area hospitals.

“You want to make sure that you’re serving in a certain way and [that] you help people feel a certain way that reflects our values, what we believe in, and what our first heritage was all about: ‘We will serve our dear neighbors without distinction.’ It’s how we make people feel,” says Kaufman. “It’s not just to increase our patient satisfaction. It’s also to say that we believe that every encounter can be sacred, and this [spotlighting] is how you help foster that.”

The hospital’s first step was to define the term sacred. Thies says a text-mining analysis of internal documents related to sacred encounters produced 16 keywords. A team of patients, staff, physicians, and trustees then identified which of the 16 words they would use to define sacred.

“Over 50% of them selected four attributes: dignity, care, connection, compassion,” says Thies.

Those terms are now the cornerstones Kaufman leans on during spotlighting training.

Behind the scenesAt its core, spotlighting is about identifying oppor-

tunities that can become sacred encounters between a patient and a nurse, caregiver, or doctor. These opportunities are called scenes, and they can take place anywhere, but IDEO found three main oppor-tunities that lend themselves to being a scene, or a moment when a sacred encounter can happen: ad-mitting, resting, and discharge. In spotlighting lingo, says Kaufman, it’s warm welcome, sweet dreams, and thoughtful goodbye.

Though the scenes sound standard, they aren’t. Each department, or design team, creates its own scene dur-ing a brainstorming session that Kaufman leads. She first has the design team pick a moment that can be singled out as a potential sacred encounter, then she asks the team to pick a tone or a word that helps define how staff want their patients to feel on their unit.

For example, says Kaufman, one of the day surgery


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units chose a tone of motherly. “Once you get the tone, you can decide, what does that look like? What are the gestures? It’s not scripting. It’s real different than saying, ‘You need to say this, and you need to do this.’ We say, ‘What types of things did your mom do?’ ”

To find out how the team defines its tone, Kaufman has them go through magazines and cut out images that demonstrate the tone they picked. For motherly, the staff clipped pictures of hot chocolate, a fireplace, and a cup of tea. When Kaufman asked why those pictures represented a motherly tone, she says the staff told her it was because those things reminded them of their moms tucking them in at night.

From there, the team is asked: “What can happen at the beginning, in the middle, in the end of a scene that’s very imperceptible to your patient?” Kaufman notes the importance of a seamless, organic com-munication that comes naturally and does not appear rehearsed.

At this point in the scene design process, Kaufman has the team practice certain gestures that convey a motherly tone. She also encourages staff to think of a prop—something tangible a patient can have that’s a reminder of what, hopefully, is a special moment they shared with a Covenant nurse or another staff member.

“I always equate [gestures and props] to, it’s a whole lot like a lollipop in a pediatrician’s office. Was there value in that? Probably not, but how did it make the child feel?” says Kaufman.

For the day surgery unit that picked the motherly tone, the gesture was tucking the patient’s sheets around them. The prop was a pair of fuzzy socks. The final completed scene, says Kaufman, was nurses “tucking [patients] into a bed, saying, ‘This is where your care begins with me today,’ pulling out a pair of warm fuzzy socks, [saying] ‘Just in case you need some socks for your feet—we want you to be warm and comfortable.’ ”

Lights, camera, actionOnce the scene is designed, the team members try it

out with a set of fresh eyes. It could be a patient, or it could be someone from a different unit. There’s lots of feedback and modification of the scene before it’s rolled out to the entire department.

“It takes a long time to do this,” says Kaufman, who

estimates that start to finish, the process of spotlighting a single department can take as long as three months.

Since Covenant began spotlighting 18 months ago, nine departments have gone through complete train-ing. Kaufman picks units with already high satisfaction scores for spotlighting first, which she acknowledges is a departure from the typical strategy of fixing what’s broken.

“We had to start somewhere,” she says. “It’s had a big impact. We recognize a lot of times departments that are doing well don’t always get a lot of attention.”

Kaufman explains that it’s easier to take a service that is already working well to the higher level of creat-ing a sacred encounter. “You really want to work with high-performing teams that don’t have issues,” she says, noting that other departments in need of process improvement are receiving help to fix deficiencies, and will eventually be spotlighted as well.

After settling on a department, Kaufman assigns roles to each team member. There’s the design lead, who is usually the department champion; it could also be the formal or informal leader of the department. Then there are the designers, a mix of clinical and non-clinical staff within the department.

Examples of other scenes at Covenant include a warm welcome during admitting at all four of Covenant’s hospitals. When this scene was developed, it required a member of executive leadership to visit ev-ery patient who had been admitted that day and hand the patient a business card with his or her direct num-ber on it in case the patient needed anything. Kaufman says senior leadership was not convinced initially.

“When I had to train every single leader and say, ‘This is part of your work now,’ I got so much pushback because it was one more thing they had to do,” says Kaufman.

Troy Thibodeaux, COO for Covenant, admits to being one of the doubters.

“I was certainly skeptical because I’ve seen so many types of campaign spins on patient experience initia-tives, and at that time I felt like this was another one,” he says. “It also seems … when you hear all the lingo of scene development, props, and all that, it sounds kind of hokey when you first hear it.”

But Thibodeaux’s mind was quickly changed after his first day of rounding with newly admitted patients.


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compassion in fiscal year 2011 to 93.8% to date.Hospital Consumer Assessment of Healthcare Pro-

viders and Systems (HCAHPS) scores for Covenant’s overall hospital rating in the Texas region have also increased over the same time period from 69.13% to 73.52%, but Kaufman and Thies aren’t ready to make a concrete link to the increase as a result of spotlighting.

“It doesn’t always shake out with HCAHPS because HCAHPS is a frequency measure,” says Kaufman. “It measures the percent[age] of time that you saw me doing certain behaviors, whereas spotlighting is more about I can concur that I felt a certain way.”

Thies adds that attributing the increase in HCAHPS score solely to spotlighting may discount other work the hospital does that contributes to that metric.

“There [are] so many elements that contribute to successful improvement in HCAHPS scores, and we’re very clear that spotlighting is a profound experience in support of [a] sacred encounter. There is deep belief that it is profoundly supportive of the work we seek to advance from a patient experience standpoint, but in terms of the specific metrics that demonstrate impact … that’s something we’re trying to understand more fully ourselves,” says Thies.

Thibodeaux says he believes the link between HCAHPS and spotlighting will become clearer when the program is rolled out in all the system’s hospitals.

“In the long run, that is going to have an impact. In a market like our market, which is Lubbock, a com-munity of about 200,000 people and service area of about a million, there’s really a handful of competi-tors in town and so, in a town this size, it really can become a differentiating factor,” says Thibodeaux. “Lubbock’s a town where you get feedback from the community on a pretty regular basis on how good you’re doing or how bad you’re doing. And I have heard so many people out in the community tell me stories about how they’ve seen the transformation of Covenant over the past two years. They’re very specific stories and they really ring true with everything that we’re doing in spotlighting.”

Source: Jacqueline Fellows, Healthcare Marketing Advisor, January 2013, online (www.healthleadersmedia.com). H

“It was one of those days. I was running crazy, I was in a bad mood, and [Kaufman] said, ‘Troy, just come up and let’s do one patient.’ And, long story short, I did one patient and ended up finishing the entire list of patients that were admitted that day, and it was the best day I’d had in months here just because that’s why we work here. And in administrative roles we lose sight of that sitting behind a desk, behind papers all day long.”

Thibodeaux is now one of spotlighting’s biggest cheerleaders, according to Kaufman.

“It was so energizing to me,” says Thibodeaux. “As senior leaders, we never spend enough time on the floors interacting with patients. This is a very concise way to do it on a regular basis, and it also gives us a way to make sure that patients who are new, coming into the hospital, who are fearful, that they’re going to have contact with a senior leader of the organization right along with their initial arrival.” He says senior leader-ship’s more visible presence has increased employee morale as well.

Thies says the impact on employee morale, patient satisfaction, and staff engagement is systemwide. “From an employee engagement standpoint, we see it profoundly impacted in terms of the reporting experi-ence with spotlighting that staff expresses in the focus groups. What’s been significant is a real reawakening of the call to the healing arts,” he says.

RatingsCovenant’s use of the spotlighting program has also

had a profound impact on Kaufman’s patient feedback reports. The hospital monitors the success of its spot-lighted departments through patient and staff focus groups, which are held quarterly.

“What we’re seeing is surveys will come back and you’ll honestly see patients writing to us, ‘It was so motherly on that unit,’ and … we never told them this is an area that’s been spotlighted. The patient has no knowledge about it, and that’s when you know it’s successful,” says Kaufman.

The patient satisfaction scores bear out what Kaufman is reading as well. For the day surgery unit that chose the tone of motherly, Kaufman says the patient satisfaction scores went from 88.3% of patients reporting “always” being treated with respect and


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discuss the drug with a pharmacist. Then, 21 days after the patients first received their prescription, re-searchers contacted all patients and conducted interviews to learn about their medication use, symptoms, health status, and healthcare visits, and collated that with their EHR and the results of their automated calls. The researchers identified 125 ADEs experienced by 125 patients, 58 of which were caught by the ISTOP-ADE system.

Source: HealthLeaders Media, February 5, 2013, online (www.healthleadersmedia.com).

Gift bans at med schools impact Rxing

When medical schools ban or restrict gifts from drug companies, the doctors who graduate from these schools remember. A study from researchers at Columbia Uni-versity found that a medical school with an active gift restriction policy was associated with reduced pre-scribing of two out of three newly marketed psychotropic drugs that were examined in the study. For example, physicians who attended a medical school with an active conflict of interest policy were less likely to prescribe lisdexamfetamine over older stimulants and paliperi-done over older antipsychotics. Prescribing rates were even lower among students who had a longer exposure to such policies or who were exposed to stricter policies.

Source: National Library of Medicine, January 30, 2013, online (www.ncbi.nlm.nih.gov).

New format for child- specific EHRs

CMS and the Agency for Health-care Research and Quality have announced a new EHR format spe-cifically for children’s healthcare. According to the agencies, many existing EHR systems are not tai-lored to capture or process health information about children. The new EHR format includes recom-mendations for child-specific data elements so developers can un-derstand the types of information that should be included in EHRs for children. Child-specific data elements and functionality recom-mendations are sorted into topic areas that include prenatal and newborn screening tests, immuni-zations, growth data, information for children with special healthcare needs, and child abuse reporting. The format also provides guidance on structures that permit interop-erable exchange of data, including data collected in school-based, pri-mary, and inpatient care settings.

Source: Agency for Healthcare Research and Quality, February 6, 2013, online (www.ahrq.gov).

Patient-centered medical faces hurdles

Getting patients involved in their medical decision-making may have big payoffs, like improved health outcomes and reduced costs, but overworked physicians and untrained providers stand in the way of those efforts really getting off the ground. The findings, from

a new RAND Corporation study, also show that deficient medical information systems are another barrier to effective patient-centered medical care. To make shared decision-making a reality, RAND researchers say doctors and other health workers need more instruc-tion about how to engage patients and better information systems to make sure patients know their options and receive individual-ized care. The study, published in Health Affairs, analyzes the experi-ences of eight primary care sites at the midpoint of a three-year effort to expand shared decision-making.

Source: Health Affairs, February 2013, online (www.healthaffairs.org).

Adverse drug reactions IDed by phone

An automated phone calling system that asks patients about the prescriptions their doctors ordered, with follow-up calls from pharmacists, can mitigate adverse drug events (ADE) and prescrip-tion noncompliance that might otherwise go unnoticed. The result of the experiment with the phone system is published in the current issue of JAMA Internal Medicine. Researchers designed what they call the ISTOP-ADE System, which automatically called patients on the third day, and again on the 17th day after they were given a new prescription. Patients were asked whether they had problems getting or taking their medications, had any new symptoms, or wanted to

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Better outcomes from patient engagement

Patients who are more engaged in their healthcare have better health outcomes, according to studies in the February issue of Health Affairs. These patients make decisions with physicians and other healthcare professionals; understand risks, benefits, and alternatives to care; and actively self-manage chronic conditions. Their care also costs less. In an analysis of more than 30,000 patients, researchers found that patients who were least “acti-vated” (a term that researchers use to describe patients’ willingness to play an active role in their care) had healthcare costs that were higher than those of patients who were ac-tively involved in self-management and decisions about their care. These average costs were 8% higher in these patients’ first year of care and up to 21% higher in their second year of care.

Source: Health Affairs, February 2013, online (www.healthaffairs.org).

Physicians unprepared for Sunshine Act

Physicians are actually less informed than they were one year ago about the Sunshine Act, the final rule for which was released in February. The MMIS and Health-care Data Solutions survey found that of the more than 1,000 physi-cian respondents, more than half admitted they didn’t know that the law requires pharmaceutical and

medical device companies to report on expenditures annually, and that such information would be avail-able in a public database. Many respondents (63%) were concerned about the record of these payments in the database. The survey also found that 21% of physicians would sever their relationship with a manufacturer who reported inac-curate information about payments or transfers of value if disclosed to the public, and 43% admitted this would affect their ongoing relation-ship with the industry. According to the survey, 54% of physicians who had industry relationships re-ceived samples, 57% received food or beverages in the workplace, 48% participated in a medical industry–sponsored program, 11% partici-pated in speaker bureau programs, 10% participated in advisory board programs, and 2% are still accept-ing free event tickets or gifts.

Source: MMIS, February 4, 2013, online (www.mmis-inc.com).

CHIME cites burdens to EHR data reporting

In comments submitted to CMS, the College of Healthcare Infor-mation Management Executives (CHIME) voiced concern about hospital readiness to submit accurate and complete quality data via EHR systems. Responding to a CMS re-quest for information about hospital and vendor readiness to submit elec-tronic data as part of the Inpatient Quality Data Reporting program, the organization of healthcare CIOs

warned that current technology and work flow burdens make accurate and complete quality data reporting through the EHR nearly impossible. CHIME also urged CMS to seek ways to broa den the program to more hospitals and use the results ob-tained by pilot participants to further assess hospital and vendor readiness of EHRs to support inpatient quality data reporting.

Source: CHIME, January 28, 2013, online (www.cio-chime.org).

Court: Online doctor review free speech

The Minnesota Supreme Court has ruled that an online post about a doctor is protected free speech. The court dismissed a case from a neurologist that complained an on-line review referred to him as “a real tool,” reports the Minneapolis Star Tribune. “Referring to someone as ‘a real tool’ falls into the category of pure opinion because the term ‘real tool’ cannot be reasonably interpret-ed as stating a fact and it cannot be proven true or false. ... We conclude that it is an opinion amounting to ‘mere vituperation and abuse’ or ‘rhetorical hyperbole’ that cannot be the basis for a defamation action,” the justices said.

Source: Minneapolis Star Tribune, January 30, 2013, online (www.startribune.com).

Adults woefully undervaccinated, CDC says

Substantial increases in vac-cination coverage are needed in


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Cancer screenings often ‘oversold’

Consumer Reports is using its March issue to talk to consumers about “oversold” cancer screenings that have the potential to confuse patients. The report evaluates 11 cancer screenings and says that eight should be avoided for people who are not at high risk and have no signs or symptoms of cancer. Screening tests for cervical, colon, and breast cancer are the most effective tests available, according to Consumer Reports’ first ratings of cancer screening tests. But most people shouldn’t waste their time on screenings for bladder, lung, oral, ovarian, prostate, pan-creatic, skin, and testicular cancer, it says. For example, the screening for ovarian cancer gets the lowest rating for women of all ages because the screening tests are not very effective. Women don’t need to be tested unless they are at high risk. The screening for pancreatic cancer gets the lowest rating for adults of all ages. People don’t need the test un-less they are at high risk, because no test is likely to detect the disease at a curable stage, the report says.

Source: Consumer Reports, January 30, 2013, online (www.consumerreports.org).

Georgia launching telemedicine program

The Georgia Department of Pub-lic Health (DPH) is embarking on a program that aims to transform its statewide telemedicine program into one of the most comprehensive

for negative health outcomes when they used CDSSs. In addition, phy-sicians who are worried that using CDSSs will negatively affect their relationships with patients could incorporate the tools to engage patients and help them understand diagnoses and recommendations.

Source: University of Missouri, January 24, 2013, online (www.munews.missouri.edu).

Most physician websites are too simple

Only one-third of physicians in three American cities offer direct website help to healthcare consumers trying to understand their symptoms, according to a Vanguard Communications analy-sis of 300 doctors with the high-est patient satisfaction ratings in Boston, Denver, and Portland, Ore. It found that although 69% of the physicians have websites, only 33% of those doctors’ sites provided much more than online biographies and general practice information. The portion of physicians using their websites to update patients on research and health trends was even smaller: Only 4% had made at least one blog posting in the last year. “Doctors in these cities are still using their websites primar-ily as electronic brochures about their practices rather than as online health resources,” Ron Harman King, Vanguard’s CEO, said in a statement.

Source: Vanguard Communica-tions, January 30, 2013, online (www.vanguardcommunications.com).

adults, according to the CDC. The agency analyzed data from the 2011 National Health Interview Survey to assess adult vaccination cover-age for certain vaccines, including the pneumococcal vaccine, tetanus toxoid–containing vaccines, hepa-titis A, hepatitis B, herpes zoster (shingles), and human papilloma-virus (HPV) vaccines. It found that compared with 2010, there were modest increases in Tdap vaccina-tion and HPV vaccination among women, but only little improve-ment in coverage for the other vac-cines among adults in the United States. Coverage for tetanus vac-cination during the past 10 years was unchanged. Many adults have not received any recommended vaccines, and vaccination coverage estimates are well below the target levels, the CDC says.

Source: CDC, February 3, 2013, online (www.cdc.gov).

Patients have negative opinion of CDSS

Increased physician use of computerized clinical decision support systems (CDSS) leads to greater patient dissatisfaction and could increase noncompliance with preventive care and treatment recommendations, according to research from the University of Missouri. The research found that patients view physicians who use decision aids as less capable than practitioners who make judgments unaided or consult their colleagues. However, patients were less likely to assign physicians responsibility

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in the nation, it reports. In January, DPH began distributing 13 telemed-icine carts to health districts around the state, each equipped with a stethoscope, endoscope, and a basic exam camera. DPH also says it will finish the videoconferencing infra-structure it has been consolidating, updating, and expanding over the past year. Accor ding to state public health officials, the program will eventually allow people to visit the telemedicine “hubs” in their local health districts to get health and dental evaluations. DPH will also train public health staff to operate telemedicine cart equipment, it says.

Source: Government Health IT, January 28, 2013, online (www.govhealthit.com).

Doctors get help with Rx communication

Physicians aren’t very effective when it comes to communicating with their patients about newly prescribed medicines, but a new training scheme from researchers at UCLA might be able to help. Ac-cording to the research team, when doctors prescribed medicines, the information they provided to pa-tients was usually spotty; they rarely addressed the cost of medications and they didn’t adequately monitor their patients’ medication adher-ence. So researchers designed a training scheme aimed at improv-ing how physicians communicate five basic facts about a prescribed medication: the medication’s name, purpose, directions for use, duration of use, and potential side effects.

The researchers found that physi-cians who completed the training demonstrated a significant improve-ment in how they communicated this crucial information. Compared to a control group that didn’t receive the training, these doctors discussed at least one additional topic out of the five and sometimes went beyond the basics, touching on other per-tinent facts about medications that are important for patients to know.

Source: UCLA, January 14, 2013, online (www.ucla.edu).

Telehealth on 1.8M patient trajectory

Telehealth is projected to reach 1.8 million patients worldwide by 2017, according a new report from InMedica. It finds that in 2012, an estimated 308,000 patients were remotely monitored by their healthcare provider for congestive heart failure, chronic obstruc-tive pulmonary disease, diabetes, hypertension, and mental health conditions worldwide. The major-ity of these were postacute patients who have been hospitalized and discharged. In the United States, an estimated 140,000 postacute pa-tients were monitored by telehealth in 2012, compared to 80,000 am-bulatory patients.

Source: InMedica, January 21, 2013, online (www.in-medica.com).

Three states link health information networks

The Nebraska Health Informa-tion Initiative, Kansas Health

Information Network, and Missouri Health Connection are now con-nected and able to exchange direct secured messages across state lines. The project was launched in March 2010 as part of the Nationwide Health Information Network. With direct messaging, care providers can send and receive authenticated, encrypted healthcare informa-tion such as lab results, clinical notes, and patient care summaries through a secure electronic mail-box system to and from recipients over the Internet. By connecting Missouri, Kansas, and Nebraska, providers can now eliminate faxing multiple pages across state borders and instead use a direct secured email message.

Source: Nebraska Health Information Initiative, January 22, 2013, online (www.nehii.org).

Nearly half of babies are undervaccinated

In a new study published in JAMA Pediatrics, Kaiser Perma-nente researchers found that 49% of children ages 2–24 months did not receive all recommended vac-cinations or did not get vaccinated according to the Advisory Com-mittee on Immunization Practices (ACIP) schedule. Researchers used the Vaccine Safety Datalink, a col-laborative effort among the CDC and nine managed care organiza-tions, to analyze immunization records of 323,247 children born between 2004 and 2008. Data from immunization records helped illuminate the number of days


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evaluated. Healthgrades estimates that if all other U.S. hospitals performed at this high level from 2009 through 2011, 164,414 deaths could have potentially been pre-vented. For hospitals to be eligible for this award, they had to perform better than expected in at least 19 of 27 conditions and procedures measured.

Source: Healthgrades, January 2013, online (www.healthgrades.com).

HHS unveils proposed HIE rules

Federal officials rolled out a 474-page proposed rule designed to clarify and promote consistency around eligibility, benefits, and ap-peals for people enrolling in health insurance exchanges (HIE) in 2014, and to provide more flexibility for states’ Medicaid programs. HHS said the new proposed rule will make it easier for consumers to learn whether they’re eligible for Medicaid or tax credits. The rule in-cludes information on how consum-ers will receive communications on eligibility determinations and how they can appeal eligibility denials. It also gives states flexibility in design-ing benefits and determining cost sharing in the Medicaid program. Under the proposal, state-based ex-changes may choose to rely on HHS for verifying whether an individual has employer-sponsored coverage and conducting some types of ap-peals, HHS said.

Source: HealthLeaders Media, January 15, 2013, online (www.healthleadersmedia.com). H

each child was missing scheduled vaccines for any reason, including parents intentionally choosing not to vaccinate their children accord-ing to ACIP recommendations. Children who did not receive their vaccines on time were considered “undervaccinated.” The study found the number of undervac-cinated children increased sig-nificantly during the study period, and one in eight undervaccinated children’s parents intentionally chose not to adhere to ACIP im-munization guidelines. Study find-ings also indicate undervaccinated children are less likely to visit their doctor’s offices and more likely to be admitted to hospitals, compared to their peers vaccinated under the standard schedule.

Source: JAMA Pediatrics, January 21, 2013, online (www.archpedi.jamanetwork.com).

Final HIPAA rule issuedNew modifications to HIPAA aim

to enhance patient privacy pro-tections, provide individuals new rights to their health information, and strengthen the government’s ability to enforce the law, according to HHS. Until now, HIPAA rules have focused on healthcare provid-ers, health plans, and others that process health insurance claims. The changes expand many of the requirements to business associ-ates of these entities that receive protected health information, such as contractors and subcontractors. Some of the largest breaches reported to HHS have involved

business associates. Penalties are increased for noncompliance based on the level of negligence, with a maximum penalty of $1.5 million per violation. The changes also strengthen the HITECH breach notification requirements by clarifying when breaches of unse-cured health information must be reported to HHS. Individual rights are also expanded. Patients can ask for a copy of their EMR in an electronic form. When individuals pay by cash, they can instruct their provider not to share information about their treatment with their health plan. The final omnibus rule also sets new limits on how information is used and disclosed for marketing and fundraising purposes and prohibits the sale of individuals’ health information without their permission.

Source: HHS, January 17, 2013, online (www.hhs.gov).

Top hospitals have in-hospital mortality

Healthgrades has announced the top 5% of U.S. hospitals for clini-cal outcomes, as determined by an evaluation of data on clinical mea-sures, in its new report, Hospital Quality Clinical Excellence Report 2013. The 262 hospitals, out of more than 4,500 evaluated, have earned Healthgrades’ prestigious Distinguished Hospitals Award for Clinical Excellence™. These hospi-tals have a 30.9% lower risk-adjust-ed in-hospital mortality rate across 18 conditions and procedures as compared to all other U.S. hospitals

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