Quality Corner

Look to OMA Quality Corner for Tips on Patient Safety and Quality

OMA staff is constantly learning about new practices, measures, projects and research that can help in your everyday practice of medicine. Quality Corner shares the information we glean in tips that you can try in your daily practice. If there is a topic you would like to see in Quality Corner, please contact Danielle Sobel, OMA Health Policy Specialist, at danielle@theOMA.org. Click on the titles below to read more.


Safe Care Campaign: Patient Safety Education Program
Hi-Tech Patient Education Available On-Demand

At a recent Partnership for Patients meeting, Victoria Nahum, executive director of the Safe Care Campaign, shared the personal impact hospital acquired infections has had on her, as a patient and then as a parent. In the wake of her son’s death due to a hospital acquired infection, she and her husband set out to create an organization dedicated to educating patients about how they may help prevent infection while receiving medical care that didn’t overburden medical staff or require additional training.

The result?

A patient safety education poster that provides instant access to medical error prevention information using QR codes and the patients’ own cellphone at NO COST to the hospital or clinic.

The “Learn How to Be Safe While Receiving Medical Care” poster is FREE, provided as a PDF, available in English and Spanish and includes 9 QR codes that patients can scan and watch linked videos. If the patient can’t scan the codes, they can send a text message and receive a link to access the full library of patient safety videos.

The poster is a collaboration of the Centers for Disease Control and Prevention (CDC), The Joint Commission Speak UPTM Campaign, Kimberly-Clark, The Patient Channel and the Safe Care Campaign.

For more information on the Safe Care Campaign and to download the poster, please click here. 

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AHRQ: Effective Health Care Program 
Evidence-based materials for clinicians, consumers and policymakers

The Agency for Healthcare Research and Quality (AHRQ) recently met with the OMA to discuss their Effective Health Care Program. In support of health services research, AHRQ funds projects that improve the quality of health care and promote evidence-based decision making. Of the three products produced by this research, this article will focus on how your clinic can utilize the Research Summaries in your daily practice, at both the provider and patient level.

Research Summaries are short summaries, written in plain language, that are tailored to clinicians, consumers and policymakers. These summaries cover a wide variety of health conditions and the associated materials are specifically designed for the provider, patient or policymaker. Each material is provided in English, Spanish and audio formats. For providers, many of the topics include a CME module.

Health conditions are grouped into the following categories:

Breathing Conditions

Heart and Blood Vessel Conditions

Cancer

Infectious Diseases and HIV/AIDS

Developmental Delays, ADHD, Autism

Mental Health

Diabetes

Bone and Joint Conditions

Digestive System Conditions

Pediatrics

Genitourinary Conditions

Pregnancy/Childbirth

Gynecology

 

Complete list of summaries are available here.
CME available at: www.effectivehealthcare.ahrq.gov/tools-and-resources/cmece-activities

How can these materials be used in my clinic?

With materials available in each topic for the provider and the consumer, materials for patients could be placed in your waiting area, in examination rooms, discharge paperwork, billing statements, etc. For providers, the one page fact sheets could be placed in break rooms, on bulletin boards, sent electronically over e-mail or shared at team meetings.

Example summary from Heart and Blood Vessel Conditions

For the patient:

Measuring Your Blood Pressure at Home: A Review of the Research for Adults

For the provider/clinician:

Effectiveness of Self-Measured Blood Pressure Monitoring in Adults with Hypertension

Can I get these materials for my clinic?

All materials are FREE and can be downloaded and printed, or print copies can be ordered. To order one or more full-color copies, call the AHRQ Publications Clearinghouse at (800) 358-9295, or order online at the AHRQ Publication Clearinghouse Web site. Refer to the AHRQ publication number when placing your order. 

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Universal Precautions Continued: Spoken Communication
Applying Universal Precautions to Health Communication

In the last issue of Quality Corner, the concept of applying universal precautions was discussed as it relates to health communication and connecting with patients at all levels of health literacy (see article below). This week’s edition expands on this concept by exploring two models of communication that physicians, physician assistants and medical practice team members can apply every time they encounter a patient.

6 Best Practices to Improve Spoken Communication
Adapted from presentations at the Making it CLEAR conference

Best Practice

Description

1) Assess Patients’ Needs

  • Ask about preferences for learning: “What is the best way for you to learn?”
  • Assess baseline understanding: “Tell me what you already know about high blood pressure”

2) Focus on 1-3 Key “Need-to-Know” Issues from the encounter

  • Patients typically retain <50% of information
  • Focus on what they need to do, not on facts
  • Summarize the most important aspects of the encounter at the end

3) Learn to use “plain language”

 

  • Eliminate jargon whenever possible; if you can’t avoid, make sure you define or explain the term, phrase or concept
  • Plain language is NOT dumbing it down and rather uses clear, meaningful messages that “land well” 

Instead of:

Try this:

Abdomen

Stomach, belly, tummy

Hypertension

High blood pressure

For more on plain language, check out a toolkit from PRISM (Program for Readability In Science and Medicine) here.

4) Visual Aids Helps All Patients

        Graphic courtesy of Mike Wolf and Stacey Bailey

5) Invite Questions          

  • Remember to phrase as “What questions do you have for me?” (see Quality Corner article titled “Patient-Centered Communication: Ensuring your patient understood” for more detail)

6) Assess Understanding

  • Rather than asking “do you understand?” to assess comprehension, use tools such as the “teach back” or “show me” techniques 
Patient Touch Time: Maximizing your time with your patient

Patient “touch time” is defined at the actual time spent with the patient. To maximize the time spent with the patient by the physician as well as other members of the practice team, TransforMED (www.transformed.com) has developed a series of working papers to improve the interaction between the patient and the practice team to ensure that the highest level of communication and engagement is achieved.

The full working paper can be found here; below is a sampling of the recommended strategies, many of which align with the best practices above.

  • Listen to your patients and do not interrupt! Studies have shown that patients are interrupted by their provider in 18-23 seconds of their explanation of why they need to be seen. If patients are allowed to continue they will share 90%of what they need to share in 3-4 minutes.
  • Empower patients to become more actively involved in their care by encouraging them to have a list of concerns and questions ready when you walk in the room. What symptoms are they experiencing? How long have they been experiencing the symptoms? What have they tried to alleviate the symptoms? What questions do they have? Suggest that they limit their concerns to three or four for the visit. This will allow them to prioritize the concerns they want addressed.
  • Get down to their level…eye level, that is! This lets the patient know you are sincerely interested in them.
  • Work to build a partnership with your patients by engaging patients in decision making related to their care. Anxiety may prevent a patient from accurately hearing instructions or understanding the course of treatment planned. Discuss and validate a patient’s understanding of treatment plans by having them “teach back” the instructions which have been given to them.
  • If additional care is needed, create a guide for follow-up activities that the patient can take with them.
CNA Risk Management Update and Patient Communication

At a recent OMA Practice Roundtable, the risk management update by CNA supported many of the above recommendations. To reduce risk and increase communication with your patient, CNA recommends that:

  1. The physician or team member sit rather than stand when seeing the patient
  2. Make/maintain eye contact with the patient
  3. Do not hurry (or appear to be in a hurry) during the appointment
  4. Let the patient talk first

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Universal Precautions: Not Just for Bloodborne Diseases Anymore
Applying Universal Precautions to Health Communication

Universal precautions refers to taking specific actions that minimize risk for everyone when it is unclear which patients may be affected. What would happen if you applied this concept to health communications?

Providers don’t always know which patients have limited health literacy; health literacy is not education dependent, limited to cultural or ethnic background and is context-specific. Experts recommend that health care providers assume that everyone may have difficulty understanding and that every encounter is at risk for miscommunication.  Applying universal precautions in health communication ensures that practices are in place to minimize the risk that the patient did not understand and allows all patients to make informed decisions about their health care.

Wondering how many of your patients have limited health literacy?  Calculate your practice’s estimate using the Pfizer Prevalence Calculator.

Health Literacy Universal Precautions Toolkit

The Agency for Healthcare Research and Quality has a comprehensive Universal Precautions Toolkit that can be found at www.ahrq.gov/qual/literacy/healthliteracytoolkit.pdf.

This toolkit provides step-by-step guidance and tools for assessing your practice and making changes so you connect with patients of all literacy levels. The toolkit is set up to be implemented in manageable chunks that can be implemented over time; it includes over 20 tools in the areas of spoken communication, written communication, self-management and empowerment and supportive systems. Practice managers and staff can use the toolkit action plans, practice assessments, learning modules and easy-to-read forms to jumpstart implementation of universal precaution in health communication.

Highlights from the toolkit:

Easy-to-read materials: includes a variety of forms/materials that clinics can download and customize for their clinic (already written at the 6th grade reading level).

Links to visual aids: includes examples of medication cards, pill charts, children’s books and adult education materials (in multiple languages).

For kids, check out Dusty the Asthma Goldfish and His Asthmas Triggers Fun Book.

HEALTH TiPS (American College of Physicians Foundation): these 4x6 cards address a variety of health conditions, come in both Spanish and English, and can be ordered/downloaded for FREE to help patients better understand their health information.

Internet resources to health literacy: includes links to videos, materials and evidence-based research as referenced in the toolkit.

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Patient Engagement: Just another health care buzz word?

Health care reform, both nationally and in Oregon, are seeking to deliver health care to patients in a new way: by engaging the patient in their own health care. Patient-centered primary care homes depend on an actively engaged and empowered patient population; how do we get patients to understand and increase their role in managing their care?

Researchers, health plans and providers have been developing patient engagement strategies to help increase patient education, knowledge and confidence – all of which have been shown to increase self-managed care.

Patient Activation Measure

One such strategy, known as the Patient Activation Measure (PAM) was developed by one of Oregon’s own – Judith Hibbard, Dr.P.H. at the University of Oregon. This tool measures the individual’s skill and competence in managing their health as well as gauges their beliefs about their role in managing their health. PAM uses a 13-question survey (Figure 1) and can be given by their health care team, health plan or the health care system. PAM places the patient in one of four activation levels; each level addresses a broad array of self-care behaviors that drive health activation.  

PAM

The power of this tool is in its predictive power- it gives health care providers a reliable starting point for designing specific coaching or clinical interventions that address individual needs and vulnerabilities for suboptimal care. PAM scores can also predict health care outcomes including medication adherence, ER utilization and hospitalization.

In Oregon, this tool has already been adopted by Kaiser Permanente, Providence Health Plans, CareOregon, ODS and PeaceHealth.

Interested in implementing this in your practice or learning more?

Insignia Health website: www.insigniahealth.com/solutions/patient-activation-measure 

The Commonwealth Fund, “Patients Gain Information and Skills to Improve Self-Management through Innovative Tools,” Quality Matters. Available at: www.commonwealthfund.org/Newsletters/Quality-Matters/2010/December-January-2010/In-Focus.aspx

Development of the Patient Activation Measure (PAM): Conceptualizing and Measuring Activation in Patients and Consumers: www.ncbi.nlm.nih.gov/pmc/articles/PMC1361049

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Oregon Adverse Event Disclosure Guide
A Resource for Physicians and Health Care Organizations

The Oregon Patient Safety Commission, working in conjunction with nearly 40 organizations including the Oregon Medical Association, developed the Oregon Adverse Event Disclosure Guide to help physicians better understand the purpose of disclosure and provide resources to help develop and improve disclosure programs in Oregon’s health care organizations.

This question and answer style guide was just released; more information and a printable copy can be found on the Oregon Patient Safety Commission website at http://oregonpatientsafety.org/healthcare-professionals/disclosure-guide.

What is “disclosure” and am I required to report?

In this guide, disclosure is defined as informing the patient of an adverse event through the use of both oral disclosure and written notification.

Required to report: If your organization participates in the Oregon Patient Safety Commission’s Patient Safety Reporting Program, you are required to report an adverse event.

The requirement to report, as a participating health care organization, was passed by the Oregon State Legislature in 2003 and requires the health care organization to  provide written notification in a timely manner to each patient affected by the event. This cannot be used as an admission of liability in a civil action (ORS 442.386(4)).

Oregon Patient Safety Commission recommendations regarding disclosure
  1. Disclosure should be made in the form of oral disclosure followed by written notification by physicians and health care organizations faced with an adverse event.

    Oregon law only requires written notification; the Commission strongly feels that all patients have a right to know about adverse events and that both oral and written disclosure supports and reinforces honest communication with patients.

  2. Physicians and health care organizations should consider disclosing adverse events regardless of harm level or identification of error.

For more information on adverse events and information on patient safety, please visit the Oregon Patient Safety Commission website at http://oregonpatientsafety.org; you can also receive monthly updates through their newsletter at http://oregonpatientsafety.org/news-events/newsletter.

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A Prescription for a Healthier Lifestyle
Resources to help your patients stay fit

The OMA General Membership meeting last weekend (April 20-21st, 2012) featured two sessions focused on helping patients maintain healthy lifestyles by staying physically active.

Leading a Healthier Lifestyle

Patrick House, winner of The Biggest Loser, Season 10, not only shared his experience on The Biggest Loser and his weight-loss journey but talked about how he is helping kids in Mississippi overcome childhood obesity through his program, LEAN on ME (Learn, Educate, Advocate, Nullify, Obesity, Now in My Education system).

His recommended resource?

The AMA’s Weigh What Matters Program

Weigh What Matters is a family obesity prevention program that offers physicians resources to start the conversation about weight-loss for your patients. The website contains multiple resources, including an app!

Weigh What Matters App

 

 App: Weigh What Matters (available on the App Store or the Android Market)

Editorial: I tested the app and found it useful for tracking my weight, food and exercise against my weight goals. It is easy to use and free; compared to other free weight tracking apps, this is an easy and useful tool to keep on one’s phone/tablet!

The website offers a variety of factsheets, including an Office Team Reference Sheet, Patient Action Plan and Brochure as well as a Physician Guide.

Find these resources and more at www.ama-assn.org/resources/weighwhatmatters/physicians.html

Exercise is MedicineTM

Dr. Robert E. Sallis presented on Exercise is MedicineTM, an initiative to improve the health and well-being of all patients through a prescription for regular physical activity. Physical activity has a powerful effect on both the treatment and prevention of virtually every chronic disease, including obesity. His goal is to make physical activity assessment and exercise prescription a standard part of the disease prevention and treatment paradigm for all patients.

When prescribing exercise, Dr. Sallis recommends you “Think FITT”:

F= Frequency (most days of the week; 5 or more days)
I= Intensity (Moderate; 50-70 percent of max heart rate)
T= Type (use large muscle groups; something enjoyable)
T= Time (30 minutes)

More about his initiative, including a Provider’s Action Guide, can be found at http://exerciseismedicine.org/physicians.htm.

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The “Choking Game”
What should you be listening for from adolescent patients?

What is the “choking game”?

According to the CDC, "the choking game" is defined as: "... self-strangulation or strangulation by another person with the hands or a noose to achieve a brief euphoric state caused by cerebral hypoxia. Participants in this activity typically are youths. Serious neurologic injury or death can result if strangulation is prolonged."

Also known as: Knock Out, Space Monkey, Flatlining, The Fainting Game

How does this affect my patients?

For the first time in 2008, the Oregon Healthy Teens (OHT) survey included a question on lifetime prevalence and frequency of choking game participation. This was the first systematic assessment at the state level for awareness of and participation in strangulation activities among youth.

The 2009 OHT survey found that approximately 6.1 percent of eighth gradersand 7.5 percent of eleventh-graders have participated in the choking game. Of these, 64 percent have tried it twice and 1 in 5 has done so more than five times.

Generally, males and females participate at the same rate. However, black males and Pacific Islander males and females may be participating at a higher rate than white youth. Associated risk behaviors primarily include substance abuse and sexual activity with poor nutrition, gambling and exposure to violence.

What can I do?
  1. Comprehensive Adolescent Wellness Visits
     Ensure that each of your adolescent patients receives a comprehensive adolescent wellness visit and include an assessment of the youth’s risk for participation in the choking game.
  2. Also Known As
    Observe the patient for physical signs of participation and remember to listen for variations of the name of the game: Knock Out, Space Monkey, Flatlining, The Fainting Game.
  3. It’s not a Game
    Warn young people of the dangers of asphyxia games; emphasize that while the terminology used is “game”; this is not a game and participation can lead to injuries and death.
  4. Oregon Health Authority Fact Sheet on the Choking Game (link below) 
    Print this fact sheet and distribute to patients and/or families of the adolescent patient. This handout can be placed in patient lobbies, on bulletin boards or included in informational packets sent to patients.
Resources:

Oregon Health Authority: “The Choking Game: A fact sheet for parents and teachers” available at http://public.health.oregon.gov/HealthyPeopleFamilies/Youth/Documents/FactSheetCG.pdf

Ramowski, S.K., Nystrom, R.N., Rosenberg, K.D., Gilchrist, J., & Chaumeton, N.R. (2012) Health Risks of Oregon Eighth- Grade Participants in the “Choking Game”: Results From a Population-Based Survey. Pediatrics, 129, (5) p. 1-6. Available online at http://pediatrics.aappublications.org/content/early/2012/04/11/peds.2011-2482

CDC Morbidity and Mortality Weekly Report (January 15, 2010) “Choking Game” Awareness and Participation Among 8th Graders –Oregon 2008. Available at www.cdc.gov/mmwr/preview/mmwrhtml/mm5901a1.htm

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Quality Initiatives in Oregon
Reducing Surgical Site Infections and Adverse Events

This edition of Quality Corner highlights Oregon’s participation in two quality initiatives: Project JOINTS and Partnership for Patients. Both initiatives have multi-partner state support, offer free participation and are currently enrolling interested hospitals; find out if your hospital is participating!

Project JOINTS:The Enhanced Surgical Site Infections Prevention Bundle

Project JOINTS, an IHI initiative is a 10-state pilot aimed at reducing surgical site infections (SSIs) in hip and knee surgeries. Project JOINTS is working to accelerate the adoption of the Enhanced Surgical Bundle, a bundle of three evidence-based practices in conjunction with the two applicable Surgical Care Improvement Project (SCIP) practices:

  • Use of an alcohol-containing antiseptic agent for preoperative skin preparation
  • Preoperative bathing or showering with chlorhexidine gluconate (CHG) soap for at least three days before surgery
  • Staphylococcus aureus screening and use of intranasal mupirocin and CHG bathing or showering to decolonize Staphylococcus aureus carriers
  • Applicable SCIP practices:
    • Appropriate use of prophylactic antibiotics
    • Appropriate hair removal

Can hospitals still join?

Hospital registration is FREE, with no data obligation from the hospital. Once enrolled, the hospital and its surgeons and medical staff will have access to the Project JOINTS webinars, IHI staff assistance, and materials (including posters and media communications). The webinars/calls will have CEU credits available and are recorded and posted on the Project JOINTS website.

To sign up, hospitals can go directly to the Project JOINTS website, www.ihi.org/offerings/Initiatives/ProjectJOINTSand submit a short, fillable form.

Partnership for Patients: Hospital Engagement Network

The Partnership for Patients: Better Care, Lower Cost is a public-private partnership that will help improve the quality, safety and affordability of health for all Americans. The Oregon Association of Hospitals and Health Systems(OAHHS) with the American Hospital Association and the Health Research and Educational Trust (HRET) is working to develop learning collaboratives for hospitals and provide a wide array of initiatives and activities to improve patient safety.

Harm Reduction Categories

Each Hospital Engagement Network (HEN) is responsible for identifying a set of improvement activities that are most relevant to the contracted hospital’s needs and relate to the following categories:

  • Adverse drug events (ADE)
  • Birth-related injuries
  • Catheter-acquired urinary tract infections (CAUTI)
  • Central line-associated blood stream infections (CLABSI)
  • Falls
  • Pressure ulcers
  • Avoidable Readmissions
  • Surgical infections and complications (SSI)
  • Venous thrombembolisms (VTE)
  • Ventilator-associated pneumonia (VAP)

For more information or to connect with OAHHS, visit www.oahhs.org/quality/initiatives/partnership-for-patients.

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Low Back Pain: NEW resources to help patients "Get Vertical!"

The Oregon Health Care Quality Corporation recently launched a new campaign to help people with low back pain better understand safe and effective care. Their campaign, "Get Vertical: And Don't Take Low Back Pain Lying Down!" reflects the recommendations for quality patient care in the 2011 State of Oregon Evidence-Based Clinical Guideline for the Evaluation and Management of Low Back Pain.

The Quality Corp website (link below) includes a patient quiz on low back pain as well as information that can help the patient better understand what works best for the common type of low back pain caused by strain on muscles and ligaments.

Quality Corp Low Back PainHow can you use this information in your clinic?

The Quality Corp booklet on Safe and Effective Care for Low Back Pain is available as a free download that can be shared with your patients.  Quality Corp does have a limited supply of printed booklets available if you would like a copy for your waiting room, doctors’ rooms or to distribute to patients. To order a booklet, please contact Quality Corp at info@q-corp.org.

Web Resources:

Quality Corp: Partner for Quality Care “Get Vertical” campaign: www.partnerforqualitycare.org/lowbackpain

Oregon Health Policy and Research, Evidence-Based Guidelines for Low Back Pain: www.oregon.gov/OHA/OHPR/HERC/Evidence-Based-Guidelines.shtml

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Patient-Centered Communication
Ensuring that your patient understood

Adapted from a presentation by Dr. Cliff Coleman (OHSU) on Best Practices for Patient-Centered Communication

Invite the patient to ask questions by asking, "What questions do you have for me?"

Asking a patient if they have any questions at the end of their visit is a commonly used practice that is intended to gauge a patient's understanding of their diagnosis, treatment plan or overall visit. To achieve the best result and ensure higher patient comprehension, phrasing is key:

Instead of

"Do you have any questions?" 
This implies that the patient is expected to "get it" and that everything discussed in the visit was understood.  If they didn't understand, then something must be wrong with them...

Try

"What questions do you have for me?"
This implies that the patient should have questions and is expected to ask any follow up, clarifying or additional questions. This normalizes the feeling that a patient may experience in an office visit of being overwhelmed by the process, diagnosis and/or treatment options. Opening up the floor to the patient allows them to better engage with you and improve their health as an engaged patient.

So you learned 6,000 new words in medical school? Your patient didn't!           

Helping your patient understand medical jargon isn't easy, but it doesn't have to be complicated! Multiple resources on how to use plain language are available at no cost, including this thesaurus from the CDC: 
http://depts.washington.edu/respcare/public/info/Plain_Language_Thesaurus_for_Health_Communications.pdf

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v2 2016