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Army Health Initiative Draws First Lady's Praise
POLICY CORNER: An inside look at the most pressing policy issues
This year, hospitalists will begin to see health reform affect the way they work, and SHM is bringing the best perspective and access to its members.
With the proposed rules anticipated to have been in effect by the end of January, the definition and development of accountable care organizations (ACOs) will answer two long-awaited questions: How will these organizations impact the practice of hospital medicine … and when? Additionally, the Community-Based Care Transitions Program available to hospitals identified as having high readmission rates is scheduled to begin in early 2011.
So how can hospitalists get the information they need to prepare for, and succeed under, all of these new rules? Launched in mid-January, our new Advocacy & Public Policy portal at www.hospitalmedicine.org provides summaries and background material for relevant reform provisions, educational resources, headlines, and coming events—along with an easy way to reach out to elected officials through our Legislative Action Center.
Specifically outlined are SHM’s top priority issues (hospital value-based purchasing [HVBP], bundled payments, and reducing readmissions/improving care transitions), identified by the Public Policy Committee. The summaries also include SHM’s position statement so hospitalists know where SHM stands and what we’re doing to help hospitalists best position themselves to succeed.
In addition to provisions of the Affordable Care Act (ACA) of 2010, we’ve devoted a section to health information technology and updated the Physician Quality Reporting System to reflect ACA changes (including Maintenance of Certification [MOC] and the Physician Compare website).
In January, Patrick Conway, MD, and Patrick Torcson, MD, MMM, FACP, SFHM, chairmen of the Public Policy Committee and Performance & Standards Committee, respectively, presented the “Health Reform: Highlights and Practical Implications for Hospitalists” webinar, which explored ACOs, readmissions, HVBP, and the Centers for Medicare & Medicaid Services’ role in the implementation process. If you missed the presentation, it is available on demand at www.hospitalmedicine.org/webinars.
HM11, which is May 10-13 in Grapevine, Texas, will feature a session on the latest reform news: “The Biggest Changes in Healthcare Reform: What We Know Now.” Though the final presentation likely will change in the days leading up to the meeting, the panel plans to review how other ACA provisions will set hospitalists up to succeed under the new ACO model.
Now is the time for hospitalists to get up to speed. TH
Find all this and more by visiting www.hospitalmedicine.org/advocacy and let us know what you think by e-mailing advocacy@hospitalmedicine.org.
This year, hospitalists will begin to see health reform affect the way they work, and SHM is bringing the best perspective and access to its members.
With the proposed rules anticipated to have been in effect by the end of January, the definition and development of accountable care organizations (ACOs) will answer two long-awaited questions: How will these organizations impact the practice of hospital medicine … and when? Additionally, the Community-Based Care Transitions Program available to hospitals identified as having high readmission rates is scheduled to begin in early 2011.
So how can hospitalists get the information they need to prepare for, and succeed under, all of these new rules? Launched in mid-January, our new Advocacy & Public Policy portal at www.hospitalmedicine.org provides summaries and background material for relevant reform provisions, educational resources, headlines, and coming events—along with an easy way to reach out to elected officials through our Legislative Action Center.
Specifically outlined are SHM’s top priority issues (hospital value-based purchasing [HVBP], bundled payments, and reducing readmissions/improving care transitions), identified by the Public Policy Committee. The summaries also include SHM’s position statement so hospitalists know where SHM stands and what we’re doing to help hospitalists best position themselves to succeed.
In addition to provisions of the Affordable Care Act (ACA) of 2010, we’ve devoted a section to health information technology and updated the Physician Quality Reporting System to reflect ACA changes (including Maintenance of Certification [MOC] and the Physician Compare website).
In January, Patrick Conway, MD, and Patrick Torcson, MD, MMM, FACP, SFHM, chairmen of the Public Policy Committee and Performance & Standards Committee, respectively, presented the “Health Reform: Highlights and Practical Implications for Hospitalists” webinar, which explored ACOs, readmissions, HVBP, and the Centers for Medicare & Medicaid Services’ role in the implementation process. If you missed the presentation, it is available on demand at www.hospitalmedicine.org/webinars.
HM11, which is May 10-13 in Grapevine, Texas, will feature a session on the latest reform news: “The Biggest Changes in Healthcare Reform: What We Know Now.” Though the final presentation likely will change in the days leading up to the meeting, the panel plans to review how other ACA provisions will set hospitalists up to succeed under the new ACO model.
Now is the time for hospitalists to get up to speed. TH
Find all this and more by visiting www.hospitalmedicine.org/advocacy and let us know what you think by e-mailing advocacy@hospitalmedicine.org.
This year, hospitalists will begin to see health reform affect the way they work, and SHM is bringing the best perspective and access to its members.
With the proposed rules anticipated to have been in effect by the end of January, the definition and development of accountable care organizations (ACOs) will answer two long-awaited questions: How will these organizations impact the practice of hospital medicine … and when? Additionally, the Community-Based Care Transitions Program available to hospitals identified as having high readmission rates is scheduled to begin in early 2011.
So how can hospitalists get the information they need to prepare for, and succeed under, all of these new rules? Launched in mid-January, our new Advocacy & Public Policy portal at www.hospitalmedicine.org provides summaries and background material for relevant reform provisions, educational resources, headlines, and coming events—along with an easy way to reach out to elected officials through our Legislative Action Center.
Specifically outlined are SHM’s top priority issues (hospital value-based purchasing [HVBP], bundled payments, and reducing readmissions/improving care transitions), identified by the Public Policy Committee. The summaries also include SHM’s position statement so hospitalists know where SHM stands and what we’re doing to help hospitalists best position themselves to succeed.
In addition to provisions of the Affordable Care Act (ACA) of 2010, we’ve devoted a section to health information technology and updated the Physician Quality Reporting System to reflect ACA changes (including Maintenance of Certification [MOC] and the Physician Compare website).
In January, Patrick Conway, MD, and Patrick Torcson, MD, MMM, FACP, SFHM, chairmen of the Public Policy Committee and Performance & Standards Committee, respectively, presented the “Health Reform: Highlights and Practical Implications for Hospitalists” webinar, which explored ACOs, readmissions, HVBP, and the Centers for Medicare & Medicaid Services’ role in the implementation process. If you missed the presentation, it is available on demand at www.hospitalmedicine.org/webinars.
HM11, which is May 10-13 in Grapevine, Texas, will feature a session on the latest reform news: “The Biggest Changes in Healthcare Reform: What We Know Now.” Though the final presentation likely will change in the days leading up to the meeting, the panel plans to review how other ACA provisions will set hospitalists up to succeed under the new ACO model.
Now is the time for hospitalists to get up to speed. TH
Find all this and more by visiting www.hospitalmedicine.org/advocacy and let us know what you think by e-mailing advocacy@hospitalmedicine.org.
Resident Restrictions Fuel HM Program Growth
I heard that there are new resident work-hour rules that preclude interns from spending the night in the hospital. Tell me this isn’t true! I am an old-timer.
Thad Horton, MD
St. Louis
Dr. Hospitalist responds: On Sept. 26, 2010, the Accreditation Council for Graduate Medical Education (ACGME) approved new resident duty-hours and supervision standards; the new rules go into effect July 1. ACGME accredits more than 8,800 medical residency programs in the U.S. in more than 130 specialties and subspecialties. More than 111,000 residents and fellows train in these programs annually. ACGME first instituted duty-hour regulations in 2003; those led to a dramatic decrease in resident work-hours.
Basically, the highlights of the new rules are:
- Residents are limited to 80 hours weekly, averaged over a four-week period, and inclusive of all in-house call activities and moonlighting;
- Residents must be allowed one day free of duty every week (at-home call cannot be assigned on these free days);
- PGY-1 residents cannot work more than 16 hours daily, and residents beyond their PGY-1 year cannot work more than 24 hours daily;
- Residents must have at least eight hours off between shifts, and residents who work a 24-hour shift must have a minimum of 14 hours off before starting another shift;
- Residents cannot work more than six consecutive nights as night float; and
- Residents cannot be scheduled for in-house call more frequently than every third night.
I have not seen any specific prohibition on interns working overnight in the hospital. However, the new rules restrict interns to working no more than 16 hours daily, so that will mean interns who stay overnight in the hospital, until 7 or 8 a.m., cannot begin that overnight shift until 3 or 4 p.m. the day before. That means programs planning to keep their interns in-house overnight will have to be creative in their scheduling.
The demand for innovative scheduling won’t be the only implication of these new regulations. A number of forces have driven the rapid expansion of HM over the past decade. We have seen the development of sizable hospitalist programs at a number of teaching hospitals across the country. Hospitalists at teaching hospitals are not only supervising the care provided by residents, but they are also caring for patients without resident involvement. Since the original ACGME duty-hours cutback in 2002, we have seen the development and expansion of hospitalist-staffed, non-resident-covered medical services at most teaching hospitals across the country. Any further restriction in resident work-hours likely will result in the need to hire additional hospitalists to care for patients.
Virtually all HM programs require financial support to make ends meet. The most recent SHM/MGMA compensation and productivity survey found that the average hospitalist full-time equivalent (FTE) requires a little more than $100,000 of support annually. Regardless of the employer, much of that support comes from the hospital. So it appears that hospitals with teaching programs will end up footing the bill for the new resident regulations. I expect HM programs at teaching hospitals will face pushback from hospital administrators, but hiring additional hospitalists is a cost-effective proposition—and not complying with the ACGME rules is not an option, unless your program wants to risk losing its accreditation.
If you are a hospitalist program leader at a teaching hospital, I encourage you to plan accordingly and discuss the impact of these revisions in duty-hours with your teaching program director and your hospital administration.
Communication, Comfort Zone Key to Managing Hypertensive Emergencies
I just saw a patient in our urgent-care clinic sent from an ophthalmologist’s office with newly diagnosed retinal hemorrhages in both eyes and repeated BPs of 170/115. She had no history of hypertension (HTN) and no other symptoms. Does this qualify as an emergency? I couldn’t find any literature in this regard. My sense was it was an emergency, as her vision seemed to be at risk, so I sent her to the ED for IV meds in a controlled environment. Did I overreact?
Dennis Swanson, MD
Grand Rapids, Mich.
Dr. Hospitalist responds: Thank you for your question. There are numerous potential causes of retinal hemorrhages. Aside from trauma, we most commonly see retinal hemorrhages in patients with diabetic retinopathy and/or HTN. As you know, the retina is the only part of the vasculature that we can visualize noninvasively. This is a good example of why it is always important for providers to perform a fundoscopy on every patient with newly discovered HTN.
Retinal hemorrhage is one of several ocular diseases directly related to HTN. Based on your description, it sounds as if the ophthalmologist discovered the retinal hemorrhages and sent the patient to you, given the concern that uncontrolled HTN was the cause of the hemorrhages. You stated that you sent the patient to the ED because you were concerned the patient’s vision “seemed to be at risk.” Most retinal hemorrhages are asymptomatic unless the macular is affected, in which case the patient experiences a change in their visual acuity. Progressive microvascular changes in the retina can cause a loss of visual acuity. Aside from addressing the underlying problem causing the hemorrhages, laser surgery is the typical treatment of retinal hemorrhages. The laser seals off the abnormally bleeding vessels in the retina.
It would be useful to know about any communication that occurred between you and the ophthalmologist. I imagine the ophthalmologist was going to perform laser surgery but sent the patient to the hospital to address the HTN. If you did not feel comfortable managing the patient’s HTN in the urgent-care clinic, you did the right thing by sending the patient to the ED. It also is important to note that patients with hypertensive retinopathy often have other microvascular diseases, including in the kidneys. This patient should be evaluated for any evidence of proteinuria, which can suggest progressive microvascular renal disease, also as a result of uncontrolled HTN. TH
I heard that there are new resident work-hour rules that preclude interns from spending the night in the hospital. Tell me this isn’t true! I am an old-timer.
Thad Horton, MD
St. Louis
Dr. Hospitalist responds: On Sept. 26, 2010, the Accreditation Council for Graduate Medical Education (ACGME) approved new resident duty-hours and supervision standards; the new rules go into effect July 1. ACGME accredits more than 8,800 medical residency programs in the U.S. in more than 130 specialties and subspecialties. More than 111,000 residents and fellows train in these programs annually. ACGME first instituted duty-hour regulations in 2003; those led to a dramatic decrease in resident work-hours.
Basically, the highlights of the new rules are:
- Residents are limited to 80 hours weekly, averaged over a four-week period, and inclusive of all in-house call activities and moonlighting;
- Residents must be allowed one day free of duty every week (at-home call cannot be assigned on these free days);
- PGY-1 residents cannot work more than 16 hours daily, and residents beyond their PGY-1 year cannot work more than 24 hours daily;
- Residents must have at least eight hours off between shifts, and residents who work a 24-hour shift must have a minimum of 14 hours off before starting another shift;
- Residents cannot work more than six consecutive nights as night float; and
- Residents cannot be scheduled for in-house call more frequently than every third night.
I have not seen any specific prohibition on interns working overnight in the hospital. However, the new rules restrict interns to working no more than 16 hours daily, so that will mean interns who stay overnight in the hospital, until 7 or 8 a.m., cannot begin that overnight shift until 3 or 4 p.m. the day before. That means programs planning to keep their interns in-house overnight will have to be creative in their scheduling.
The demand for innovative scheduling won’t be the only implication of these new regulations. A number of forces have driven the rapid expansion of HM over the past decade. We have seen the development of sizable hospitalist programs at a number of teaching hospitals across the country. Hospitalists at teaching hospitals are not only supervising the care provided by residents, but they are also caring for patients without resident involvement. Since the original ACGME duty-hours cutback in 2002, we have seen the development and expansion of hospitalist-staffed, non-resident-covered medical services at most teaching hospitals across the country. Any further restriction in resident work-hours likely will result in the need to hire additional hospitalists to care for patients.
Virtually all HM programs require financial support to make ends meet. The most recent SHM/MGMA compensation and productivity survey found that the average hospitalist full-time equivalent (FTE) requires a little more than $100,000 of support annually. Regardless of the employer, much of that support comes from the hospital. So it appears that hospitals with teaching programs will end up footing the bill for the new resident regulations. I expect HM programs at teaching hospitals will face pushback from hospital administrators, but hiring additional hospitalists is a cost-effective proposition—and not complying with the ACGME rules is not an option, unless your program wants to risk losing its accreditation.
If you are a hospitalist program leader at a teaching hospital, I encourage you to plan accordingly and discuss the impact of these revisions in duty-hours with your teaching program director and your hospital administration.
Communication, Comfort Zone Key to Managing Hypertensive Emergencies
I just saw a patient in our urgent-care clinic sent from an ophthalmologist’s office with newly diagnosed retinal hemorrhages in both eyes and repeated BPs of 170/115. She had no history of hypertension (HTN) and no other symptoms. Does this qualify as an emergency? I couldn’t find any literature in this regard. My sense was it was an emergency, as her vision seemed to be at risk, so I sent her to the ED for IV meds in a controlled environment. Did I overreact?
Dennis Swanson, MD
Grand Rapids, Mich.
Dr. Hospitalist responds: Thank you for your question. There are numerous potential causes of retinal hemorrhages. Aside from trauma, we most commonly see retinal hemorrhages in patients with diabetic retinopathy and/or HTN. As you know, the retina is the only part of the vasculature that we can visualize noninvasively. This is a good example of why it is always important for providers to perform a fundoscopy on every patient with newly discovered HTN.
Retinal hemorrhage is one of several ocular diseases directly related to HTN. Based on your description, it sounds as if the ophthalmologist discovered the retinal hemorrhages and sent the patient to you, given the concern that uncontrolled HTN was the cause of the hemorrhages. You stated that you sent the patient to the ED because you were concerned the patient’s vision “seemed to be at risk.” Most retinal hemorrhages are asymptomatic unless the macular is affected, in which case the patient experiences a change in their visual acuity. Progressive microvascular changes in the retina can cause a loss of visual acuity. Aside from addressing the underlying problem causing the hemorrhages, laser surgery is the typical treatment of retinal hemorrhages. The laser seals off the abnormally bleeding vessels in the retina.
It would be useful to know about any communication that occurred between you and the ophthalmologist. I imagine the ophthalmologist was going to perform laser surgery but sent the patient to the hospital to address the HTN. If you did not feel comfortable managing the patient’s HTN in the urgent-care clinic, you did the right thing by sending the patient to the ED. It also is important to note that patients with hypertensive retinopathy often have other microvascular diseases, including in the kidneys. This patient should be evaluated for any evidence of proteinuria, which can suggest progressive microvascular renal disease, also as a result of uncontrolled HTN. TH
I heard that there are new resident work-hour rules that preclude interns from spending the night in the hospital. Tell me this isn’t true! I am an old-timer.
Thad Horton, MD
St. Louis
Dr. Hospitalist responds: On Sept. 26, 2010, the Accreditation Council for Graduate Medical Education (ACGME) approved new resident duty-hours and supervision standards; the new rules go into effect July 1. ACGME accredits more than 8,800 medical residency programs in the U.S. in more than 130 specialties and subspecialties. More than 111,000 residents and fellows train in these programs annually. ACGME first instituted duty-hour regulations in 2003; those led to a dramatic decrease in resident work-hours.
Basically, the highlights of the new rules are:
- Residents are limited to 80 hours weekly, averaged over a four-week period, and inclusive of all in-house call activities and moonlighting;
- Residents must be allowed one day free of duty every week (at-home call cannot be assigned on these free days);
- PGY-1 residents cannot work more than 16 hours daily, and residents beyond their PGY-1 year cannot work more than 24 hours daily;
- Residents must have at least eight hours off between shifts, and residents who work a 24-hour shift must have a minimum of 14 hours off before starting another shift;
- Residents cannot work more than six consecutive nights as night float; and
- Residents cannot be scheduled for in-house call more frequently than every third night.
I have not seen any specific prohibition on interns working overnight in the hospital. However, the new rules restrict interns to working no more than 16 hours daily, so that will mean interns who stay overnight in the hospital, until 7 or 8 a.m., cannot begin that overnight shift until 3 or 4 p.m. the day before. That means programs planning to keep their interns in-house overnight will have to be creative in their scheduling.
The demand for innovative scheduling won’t be the only implication of these new regulations. A number of forces have driven the rapid expansion of HM over the past decade. We have seen the development of sizable hospitalist programs at a number of teaching hospitals across the country. Hospitalists at teaching hospitals are not only supervising the care provided by residents, but they are also caring for patients without resident involvement. Since the original ACGME duty-hours cutback in 2002, we have seen the development and expansion of hospitalist-staffed, non-resident-covered medical services at most teaching hospitals across the country. Any further restriction in resident work-hours likely will result in the need to hire additional hospitalists to care for patients.
Virtually all HM programs require financial support to make ends meet. The most recent SHM/MGMA compensation and productivity survey found that the average hospitalist full-time equivalent (FTE) requires a little more than $100,000 of support annually. Regardless of the employer, much of that support comes from the hospital. So it appears that hospitals with teaching programs will end up footing the bill for the new resident regulations. I expect HM programs at teaching hospitals will face pushback from hospital administrators, but hiring additional hospitalists is a cost-effective proposition—and not complying with the ACGME rules is not an option, unless your program wants to risk losing its accreditation.
If you are a hospitalist program leader at a teaching hospital, I encourage you to plan accordingly and discuss the impact of these revisions in duty-hours with your teaching program director and your hospital administration.
Communication, Comfort Zone Key to Managing Hypertensive Emergencies
I just saw a patient in our urgent-care clinic sent from an ophthalmologist’s office with newly diagnosed retinal hemorrhages in both eyes and repeated BPs of 170/115. She had no history of hypertension (HTN) and no other symptoms. Does this qualify as an emergency? I couldn’t find any literature in this regard. My sense was it was an emergency, as her vision seemed to be at risk, so I sent her to the ED for IV meds in a controlled environment. Did I overreact?
Dennis Swanson, MD
Grand Rapids, Mich.
Dr. Hospitalist responds: Thank you for your question. There are numerous potential causes of retinal hemorrhages. Aside from trauma, we most commonly see retinal hemorrhages in patients with diabetic retinopathy and/or HTN. As you know, the retina is the only part of the vasculature that we can visualize noninvasively. This is a good example of why it is always important for providers to perform a fundoscopy on every patient with newly discovered HTN.
Retinal hemorrhage is one of several ocular diseases directly related to HTN. Based on your description, it sounds as if the ophthalmologist discovered the retinal hemorrhages and sent the patient to you, given the concern that uncontrolled HTN was the cause of the hemorrhages. You stated that you sent the patient to the ED because you were concerned the patient’s vision “seemed to be at risk.” Most retinal hemorrhages are asymptomatic unless the macular is affected, in which case the patient experiences a change in their visual acuity. Progressive microvascular changes in the retina can cause a loss of visual acuity. Aside from addressing the underlying problem causing the hemorrhages, laser surgery is the typical treatment of retinal hemorrhages. The laser seals off the abnormally bleeding vessels in the retina.
It would be useful to know about any communication that occurred between you and the ophthalmologist. I imagine the ophthalmologist was going to perform laser surgery but sent the patient to the hospital to address the HTN. If you did not feel comfortable managing the patient’s HTN in the urgent-care clinic, you did the right thing by sending the patient to the ED. It also is important to note that patients with hypertensive retinopathy often have other microvascular diseases, including in the kidneys. This patient should be evaluated for any evidence of proteinuria, which can suggest progressive microvascular renal disease, also as a result of uncontrolled HTN. TH
Streamlining Method Yields OR Savings
CHICAGO - Applying the Lean streamlining methodology across the entire surgical process significantly improved several operating room performance measures such as on-time starts and turnover time. At the same time, the operating margin in some ORs was increased by more than $45,000 per day, as demonstrated at the Mayo Clinic in Rochester, Minn.
“This was all during a period of increased growth and volume of cases," Dr. Robert Cima said at the annual meeting of the Western Surgical Association.
“What's even more important was that during this time when we had increased volume of cases, we actually had a decreased need for personnel because we were reducing the need for overtime staffing as well as the just the plain need for extra bodies," added Dr. Cima.
That translated into 37 fewer full-time surgical services employees, 50% fewer late shifts among certified registered nurse anesthetists, and an 18%-56% decrease in health care security services overtime.
The Lean and Six Sigma methodologies, popularized decades ago by companies like automobile maker Toyota as a way to eliminate wasteful steps and improve productivity, have typically been applied to a limited number of ORs or to specific operations.
The Mayo Clinic credits its success to applying the methodology across the entire surgical process and in all 88 of its main ORs performing both in- and outpatient procedures.
“Multiple areas of redundant or non-value-added steps were identified across the entire process flow that would not have been identified with a focus on specific steps," said Dr. Cima, a colorectal surgeon at the Mayo Clinic.
First, a multidisciplinary leadership team developed a map of the surgical process from the decision for surgery to leaving the OR. The team analyzed each step for personnel required, information process, and time expended. In all, 28 systems and 14 points of delay were identified, he said.
Next, multidisciplinary teams were formed and given 6 months to redesign systems around five essential work streams: minimizing unplanned surgical volume variation, streamlining the preoperative process, reducing nonoperative time, reducing redundant information collection, and engaging employees.
“Specific goals were set for each specialty," he said. “It was not 'one size fits all.'“
Each work stream was tweaked to standardize procedure descriptions, implement dedicated staggered surgery start times, and develop a first-case scheduling checklist to eliminate barriers to on-time OR starts.
When streamlining the preoperative process, Dr. Cima said, the most important thing is to start on time.
The hospital tried to get buy-in from employees by implementing OR briefings with the OR team, creating a communication council to effectively disseminate information through all levels of staff, and conducting a survey to identify major drivers of employee participation - many of which were not financial, Dr. Cima noted.
Some of the drivers included promotion of shared goals, encouragement of continuous professional growth, frequent recognition of individual employee contributions, and executive demonstration of values and commitment to the project.
Data collected before the intervention and 18 months afterward from the first three specialties tested showed that on-time starts increased from 50% to 80% for thoracic surgery, from 64% to 92% for gynecologic surgery, and from 60% to 92% for general/colorectal surgery.
The differences were all significant (P less than .05), he said.
The percentage of operations performed past 5 p.m. stayed relatively constant before and after intervention among thoracic surgeons at 34% vs. 36%, respectively. However, it decreased significantly for gynecologic surgeons (from 42% to 36%) and general/colorectal surgeons (from 37% to 31%) (P less than .05 for both).
The average nonoperative or turnover time was reduced by 10-15 minutes among the three specialties, or 25% for thoracic surgery, 43% for gynecologic surgery, and 32% for general/colorectal surgery, Dr. Cima said.
Staff overtime was reduced by an average of 17 minutes per month for thoracic surgery (16%), 19 minutes for gynecologic surgery (18%), and 46 minutes for general/colorectal surgery (53%).
The financial impact of these improvements was at times quite dramatic, he said.
For example, the financial margin increased 22% or $21,340 per OR/day for thoracic surgery, 16% or $24,570 per OR/day for gynecologic surgery, and 55% and $47,700 per OR/day for general/colorectal surgery.
“Some people say this is a Hawthorne effect . . . but this is sustainable and in some cases actually increases as the teams become more efficient," he said, noting that positive improvements have now been reported in nine separate specialties.
Invited discussant Dr. R. Stephen Smith called the project a “monumental effort," but questioned whether the methodology is applicable to the average worker in the average hospital.
“Surgeons and others who toil in the operating room are not analogous to Toyota assembly line workers in Japan," according to Dr. Smith, interim chair, department of surgery, Virginia Tech Carilion School of Medicine in Roanoke.
He also questioned how less affluent institutions could marshal the hospitalwide resources necessary to institute Lean/Six Sigma projects.
Dr. Cima responded that the project required very few resources, and that smaller institutions actually may be in a better position to implement Lean/Six Sigma because they are less constrained by bureaucracy.
Dr. Cima acknowledged that the hospital population may be unique in its commitment to the success of the overall institution, as opposed to individual productivity, but added that there are advantages for the employees to come together in smaller settings such as in ambulatory, outpatient surgical practices.
For example, surgeons may be able to return to the clinic earlier and see more cases if the surgical suite is run more efficiently.
“One of the efforts that has to be brought out to bring people together is to make sure everyone knows what they want out of it and what they are willing to give up," Dr. Cima said. “It is a collaborative effort."
During the discussion, Dr. Tyler Hughes, from Memorial Hospital in McPherson, Kan., asked whether institutions can survive if they don't push through these kinds of process improvements.
“I would submit that any institution that doesn't look at their processes - and not just a step, but the whole process - will not be able to survive the next 10-15 years," Dr. Cima responded.
“The government is clearly sending a signal that efficiency, value, and safety are the three main ways you're going to survive."
The study was supported by the Mayo Clinic, department of surgery. Dr. Cima and Dr. Smith reported no conflicts of interest.
CHICAGO - Applying the Lean streamlining methodology across the entire surgical process significantly improved several operating room performance measures such as on-time starts and turnover time. At the same time, the operating margin in some ORs was increased by more than $45,000 per day, as demonstrated at the Mayo Clinic in Rochester, Minn.
“This was all during a period of increased growth and volume of cases," Dr. Robert Cima said at the annual meeting of the Western Surgical Association.
“What's even more important was that during this time when we had increased volume of cases, we actually had a decreased need for personnel because we were reducing the need for overtime staffing as well as the just the plain need for extra bodies," added Dr. Cima.
That translated into 37 fewer full-time surgical services employees, 50% fewer late shifts among certified registered nurse anesthetists, and an 18%-56% decrease in health care security services overtime.
The Lean and Six Sigma methodologies, popularized decades ago by companies like automobile maker Toyota as a way to eliminate wasteful steps and improve productivity, have typically been applied to a limited number of ORs or to specific operations.
The Mayo Clinic credits its success to applying the methodology across the entire surgical process and in all 88 of its main ORs performing both in- and outpatient procedures.
“Multiple areas of redundant or non-value-added steps were identified across the entire process flow that would not have been identified with a focus on specific steps," said Dr. Cima, a colorectal surgeon at the Mayo Clinic.
First, a multidisciplinary leadership team developed a map of the surgical process from the decision for surgery to leaving the OR. The team analyzed each step for personnel required, information process, and time expended. In all, 28 systems and 14 points of delay were identified, he said.
Next, multidisciplinary teams were formed and given 6 months to redesign systems around five essential work streams: minimizing unplanned surgical volume variation, streamlining the preoperative process, reducing nonoperative time, reducing redundant information collection, and engaging employees.
“Specific goals were set for each specialty," he said. “It was not 'one size fits all.'“
Each work stream was tweaked to standardize procedure descriptions, implement dedicated staggered surgery start times, and develop a first-case scheduling checklist to eliminate barriers to on-time OR starts.
When streamlining the preoperative process, Dr. Cima said, the most important thing is to start on time.
The hospital tried to get buy-in from employees by implementing OR briefings with the OR team, creating a communication council to effectively disseminate information through all levels of staff, and conducting a survey to identify major drivers of employee participation - many of which were not financial, Dr. Cima noted.
Some of the drivers included promotion of shared goals, encouragement of continuous professional growth, frequent recognition of individual employee contributions, and executive demonstration of values and commitment to the project.
Data collected before the intervention and 18 months afterward from the first three specialties tested showed that on-time starts increased from 50% to 80% for thoracic surgery, from 64% to 92% for gynecologic surgery, and from 60% to 92% for general/colorectal surgery.
The differences were all significant (P less than .05), he said.
The percentage of operations performed past 5 p.m. stayed relatively constant before and after intervention among thoracic surgeons at 34% vs. 36%, respectively. However, it decreased significantly for gynecologic surgeons (from 42% to 36%) and general/colorectal surgeons (from 37% to 31%) (P less than .05 for both).
The average nonoperative or turnover time was reduced by 10-15 minutes among the three specialties, or 25% for thoracic surgery, 43% for gynecologic surgery, and 32% for general/colorectal surgery, Dr. Cima said.
Staff overtime was reduced by an average of 17 minutes per month for thoracic surgery (16%), 19 minutes for gynecologic surgery (18%), and 46 minutes for general/colorectal surgery (53%).
The financial impact of these improvements was at times quite dramatic, he said.
For example, the financial margin increased 22% or $21,340 per OR/day for thoracic surgery, 16% or $24,570 per OR/day for gynecologic surgery, and 55% and $47,700 per OR/day for general/colorectal surgery.
“Some people say this is a Hawthorne effect . . . but this is sustainable and in some cases actually increases as the teams become more efficient," he said, noting that positive improvements have now been reported in nine separate specialties.
Invited discussant Dr. R. Stephen Smith called the project a “monumental effort," but questioned whether the methodology is applicable to the average worker in the average hospital.
“Surgeons and others who toil in the operating room are not analogous to Toyota assembly line workers in Japan," according to Dr. Smith, interim chair, department of surgery, Virginia Tech Carilion School of Medicine in Roanoke.
He also questioned how less affluent institutions could marshal the hospitalwide resources necessary to institute Lean/Six Sigma projects.
Dr. Cima responded that the project required very few resources, and that smaller institutions actually may be in a better position to implement Lean/Six Sigma because they are less constrained by bureaucracy.
Dr. Cima acknowledged that the hospital population may be unique in its commitment to the success of the overall institution, as opposed to individual productivity, but added that there are advantages for the employees to come together in smaller settings such as in ambulatory, outpatient surgical practices.
For example, surgeons may be able to return to the clinic earlier and see more cases if the surgical suite is run more efficiently.
“One of the efforts that has to be brought out to bring people together is to make sure everyone knows what they want out of it and what they are willing to give up," Dr. Cima said. “It is a collaborative effort."
During the discussion, Dr. Tyler Hughes, from Memorial Hospital in McPherson, Kan., asked whether institutions can survive if they don't push through these kinds of process improvements.
“I would submit that any institution that doesn't look at their processes - and not just a step, but the whole process - will not be able to survive the next 10-15 years," Dr. Cima responded.
“The government is clearly sending a signal that efficiency, value, and safety are the three main ways you're going to survive."
The study was supported by the Mayo Clinic, department of surgery. Dr. Cima and Dr. Smith reported no conflicts of interest.
CHICAGO - Applying the Lean streamlining methodology across the entire surgical process significantly improved several operating room performance measures such as on-time starts and turnover time. At the same time, the operating margin in some ORs was increased by more than $45,000 per day, as demonstrated at the Mayo Clinic in Rochester, Minn.
“This was all during a period of increased growth and volume of cases," Dr. Robert Cima said at the annual meeting of the Western Surgical Association.
“What's even more important was that during this time when we had increased volume of cases, we actually had a decreased need for personnel because we were reducing the need for overtime staffing as well as the just the plain need for extra bodies," added Dr. Cima.
That translated into 37 fewer full-time surgical services employees, 50% fewer late shifts among certified registered nurse anesthetists, and an 18%-56% decrease in health care security services overtime.
The Lean and Six Sigma methodologies, popularized decades ago by companies like automobile maker Toyota as a way to eliminate wasteful steps and improve productivity, have typically been applied to a limited number of ORs or to specific operations.
The Mayo Clinic credits its success to applying the methodology across the entire surgical process and in all 88 of its main ORs performing both in- and outpatient procedures.
“Multiple areas of redundant or non-value-added steps were identified across the entire process flow that would not have been identified with a focus on specific steps," said Dr. Cima, a colorectal surgeon at the Mayo Clinic.
First, a multidisciplinary leadership team developed a map of the surgical process from the decision for surgery to leaving the OR. The team analyzed each step for personnel required, information process, and time expended. In all, 28 systems and 14 points of delay were identified, he said.
Next, multidisciplinary teams were formed and given 6 months to redesign systems around five essential work streams: minimizing unplanned surgical volume variation, streamlining the preoperative process, reducing nonoperative time, reducing redundant information collection, and engaging employees.
“Specific goals were set for each specialty," he said. “It was not 'one size fits all.'“
Each work stream was tweaked to standardize procedure descriptions, implement dedicated staggered surgery start times, and develop a first-case scheduling checklist to eliminate barriers to on-time OR starts.
When streamlining the preoperative process, Dr. Cima said, the most important thing is to start on time.
The hospital tried to get buy-in from employees by implementing OR briefings with the OR team, creating a communication council to effectively disseminate information through all levels of staff, and conducting a survey to identify major drivers of employee participation - many of which were not financial, Dr. Cima noted.
Some of the drivers included promotion of shared goals, encouragement of continuous professional growth, frequent recognition of individual employee contributions, and executive demonstration of values and commitment to the project.
Data collected before the intervention and 18 months afterward from the first three specialties tested showed that on-time starts increased from 50% to 80% for thoracic surgery, from 64% to 92% for gynecologic surgery, and from 60% to 92% for general/colorectal surgery.
The differences were all significant (P less than .05), he said.
The percentage of operations performed past 5 p.m. stayed relatively constant before and after intervention among thoracic surgeons at 34% vs. 36%, respectively. However, it decreased significantly for gynecologic surgeons (from 42% to 36%) and general/colorectal surgeons (from 37% to 31%) (P less than .05 for both).
The average nonoperative or turnover time was reduced by 10-15 minutes among the three specialties, or 25% for thoracic surgery, 43% for gynecologic surgery, and 32% for general/colorectal surgery, Dr. Cima said.
Staff overtime was reduced by an average of 17 minutes per month for thoracic surgery (16%), 19 minutes for gynecologic surgery (18%), and 46 minutes for general/colorectal surgery (53%).
The financial impact of these improvements was at times quite dramatic, he said.
For example, the financial margin increased 22% or $21,340 per OR/day for thoracic surgery, 16% or $24,570 per OR/day for gynecologic surgery, and 55% and $47,700 per OR/day for general/colorectal surgery.
“Some people say this is a Hawthorne effect . . . but this is sustainable and in some cases actually increases as the teams become more efficient," he said, noting that positive improvements have now been reported in nine separate specialties.
Invited discussant Dr. R. Stephen Smith called the project a “monumental effort," but questioned whether the methodology is applicable to the average worker in the average hospital.
“Surgeons and others who toil in the operating room are not analogous to Toyota assembly line workers in Japan," according to Dr. Smith, interim chair, department of surgery, Virginia Tech Carilion School of Medicine in Roanoke.
He also questioned how less affluent institutions could marshal the hospitalwide resources necessary to institute Lean/Six Sigma projects.
Dr. Cima responded that the project required very few resources, and that smaller institutions actually may be in a better position to implement Lean/Six Sigma because they are less constrained by bureaucracy.
Dr. Cima acknowledged that the hospital population may be unique in its commitment to the success of the overall institution, as opposed to individual productivity, but added that there are advantages for the employees to come together in smaller settings such as in ambulatory, outpatient surgical practices.
For example, surgeons may be able to return to the clinic earlier and see more cases if the surgical suite is run more efficiently.
“One of the efforts that has to be brought out to bring people together is to make sure everyone knows what they want out of it and what they are willing to give up," Dr. Cima said. “It is a collaborative effort."
During the discussion, Dr. Tyler Hughes, from Memorial Hospital in McPherson, Kan., asked whether institutions can survive if they don't push through these kinds of process improvements.
“I would submit that any institution that doesn't look at their processes - and not just a step, but the whole process - will not be able to survive the next 10-15 years," Dr. Cima responded.
“The government is clearly sending a signal that efficiency, value, and safety are the three main ways you're going to survive."
The study was supported by the Mayo Clinic, department of surgery. Dr. Cima and Dr. Smith reported no conflicts of interest.
Never Say “Never”: Surgical Errors Remain a Concern
The Joint Commission introduced the Universal Protocol to ensure the correct patient, site, and procedure. Although it became effective July 1, 2004, there still exists a lack of data about the true incidence of wrong-patient and wrong-site operations, called “never events,” according to new research.
To determine the frequency, root causes, and outcomes of these never events, Dr. Philip F. Stahel of Denver Health Medical Center and the University of Colorado School of Medicine, and colleagues performed a retrospective analysis of the Colorado Physician Insurance Company's (COPIC's) comprehensive database (Arch. Surg. 2010;145:978-84).
Dr. Stahel and his colleagues screened 27,370 physician self-reported adverse occurrences between Jan. 1, 2002, and June 1, 2008. The researchers initially found 119 wrong-site and 29 wrong-patient procedures, but eliminated cases they could not classify as being a factual wrong site or wrong patient. The final analysis consisted of 107 wrong-site and 25 wrong-patient procedures.
Analysis of root causes found errors in:
· Diagnosis, a root cause for 14 (56.0%) wrong-patient and 13 (12.1%)
wrong-site procedures.
· Communication, 25 (100%) wrong-patient and 52 (48.6%) wrong-site
procedures.
· Judgment, 2 (8.0%) wrong-patient and 91 (85.0%) wrong-site procedures.
· Treatment, 22 (88.0%) wrong-patient and 9 (92.5%) wrong-site procedures.
In addition, system issues were a root cause in 21 (84.0%) wrong-patient procedures and 78 (72.9%) wrong-site procedures. This category included time-out not being performed in 77 (72%) wrong-site cases.
Wrong-patient cases often were due to a mix-up of patients' medical records, radiographs, and laboratory or biopsy samples, as well as errors in communication.
Next, the researchers looked at outcomes, namely:
· Death, which occurred in 1 patient (0.9%) secondary to a wrong-site procedure.
· Significant harm, which occurred in 5 (20%) wrong-patient and 38 (35.5%)
wrong-site cases.
· Minimal harm or functional impairment, which occurred in 8 (32%) wrong-
patient and 65 (60.7%) wrong-site cases.
· No-harm event, which occurred in 9 (36%) wrong-patient and 3 (2.8%)
wrong-site cases.
The most frequent specialties involved in wrong-patient procedures were internal medicine (24.0% of cases) as well as family or general practice, pathology, urology, obstetrics-gynecology, and pediatrics (8.0% each). The most frequent specialties involved in wrong-site occurrences were orthopedic surgery (22.4% of cases), general surgery (16.8%), and anesthesiology (12.1%).
Overall, nonsurgical specialties were involved in 14 (48.3%) wrong-patient and 29 (27.1%) wrong-site cases.
“The findings from the present study emphasize a continuing and concerning occurrence of wrong-site and wrong-patient procedures in the current era of the Universal Protocol, leading to frequent patient harm and, rarely, patient death,” the researchers said. “Shockingly, nonsurgical disciplines equally contribute to patient injuries related to wrong-site procedures.”
The researchers believe these findings warrant expansion of the Universal Protocol to nonsurgical specialties.
Limitations of the study include the restricted coverage of the COPIC database to about 6,000 physicians in Colorado; the potential for subjective bias in determining root causes; and the designation of inadequate planning for the procedure, which represents a generic category.
Coauthors on the research analysis reported the following conflicts: Dr. Ted J. Clarke is the chief executive officer of COPIC; Dr. Jeffrey Varnell and Dr. Alan Lembitz are employed by COPIC; and Dr. Michael S. Victoroff and Dr. Dennis J. Boyle are consultants for COPIC.
Although compliance with the Universal Protocol is important, “it is not the magic wand of Merlin.” Consider: The Universal Protocol has been in place since 2004, yet Dr. Philip F. Stahel and colleagues found that preventable errors, or “never events,” exist at alarming rates. Further, the number of wrong-site procedures this study cites more likely reflect the number of errors reported rather than the actual rates of events. So, the number of wrong-site procedures is probably much higher than reflected here.
Perhaps a more accurate measurement comes from the complication rates and safety culture scores under the National Surgical Quality Improvement Program, or NSQIP. Safety culture scores reflect the comfort level of hospital employees about speaking up about safety concerns. To improve public reporting and benchmarking, hospitals should be required to publicly report their NSQIP outcomes and culture scores. Finally, the Universal Protocol, while important, does not relieve hospital systems from emphasizing individual responsibility in preventing surgical errors.
Although compliance with the Universal Protocol is important, “it is not the magic wand of Merlin.” Consider: The Universal Protocol has been in place since 2004, yet Dr. Philip F. Stahel and colleagues found that preventable errors, or “never events,” exist at alarming rates. Further, the number of wrong-site procedures this study cites more likely reflect the number of errors reported rather than the actual rates of events. So, the number of wrong-site procedures is probably much higher than reflected here.
Perhaps a more accurate measurement comes from the complication rates and safety culture scores under the National Surgical Quality Improvement Program, or NSQIP. Safety culture scores reflect the comfort level of hospital employees about speaking up about safety concerns. To improve public reporting and benchmarking, hospitals should be required to publicly report their NSQIP outcomes and culture scores. Finally, the Universal Protocol, while important, does not relieve hospital systems from emphasizing individual responsibility in preventing surgical errors.
Although compliance with the Universal Protocol is important, “it is not the magic wand of Merlin.” Consider: The Universal Protocol has been in place since 2004, yet Dr. Philip F. Stahel and colleagues found that preventable errors, or “never events,” exist at alarming rates. Further, the number of wrong-site procedures this study cites more likely reflect the number of errors reported rather than the actual rates of events. So, the number of wrong-site procedures is probably much higher than reflected here.
Perhaps a more accurate measurement comes from the complication rates and safety culture scores under the National Surgical Quality Improvement Program, or NSQIP. Safety culture scores reflect the comfort level of hospital employees about speaking up about safety concerns. To improve public reporting and benchmarking, hospitals should be required to publicly report their NSQIP outcomes and culture scores. Finally, the Universal Protocol, while important, does not relieve hospital systems from emphasizing individual responsibility in preventing surgical errors.
The Joint Commission introduced the Universal Protocol to ensure the correct patient, site, and procedure. Although it became effective July 1, 2004, there still exists a lack of data about the true incidence of wrong-patient and wrong-site operations, called “never events,” according to new research.
To determine the frequency, root causes, and outcomes of these never events, Dr. Philip F. Stahel of Denver Health Medical Center and the University of Colorado School of Medicine, and colleagues performed a retrospective analysis of the Colorado Physician Insurance Company's (COPIC's) comprehensive database (Arch. Surg. 2010;145:978-84).
Dr. Stahel and his colleagues screened 27,370 physician self-reported adverse occurrences between Jan. 1, 2002, and June 1, 2008. The researchers initially found 119 wrong-site and 29 wrong-patient procedures, but eliminated cases they could not classify as being a factual wrong site or wrong patient. The final analysis consisted of 107 wrong-site and 25 wrong-patient procedures.
Analysis of root causes found errors in:
· Diagnosis, a root cause for 14 (56.0%) wrong-patient and 13 (12.1%)
wrong-site procedures.
· Communication, 25 (100%) wrong-patient and 52 (48.6%) wrong-site
procedures.
· Judgment, 2 (8.0%) wrong-patient and 91 (85.0%) wrong-site procedures.
· Treatment, 22 (88.0%) wrong-patient and 9 (92.5%) wrong-site procedures.
In addition, system issues were a root cause in 21 (84.0%) wrong-patient procedures and 78 (72.9%) wrong-site procedures. This category included time-out not being performed in 77 (72%) wrong-site cases.
Wrong-patient cases often were due to a mix-up of patients' medical records, radiographs, and laboratory or biopsy samples, as well as errors in communication.
Next, the researchers looked at outcomes, namely:
· Death, which occurred in 1 patient (0.9%) secondary to a wrong-site procedure.
· Significant harm, which occurred in 5 (20%) wrong-patient and 38 (35.5%)
wrong-site cases.
· Minimal harm or functional impairment, which occurred in 8 (32%) wrong-
patient and 65 (60.7%) wrong-site cases.
· No-harm event, which occurred in 9 (36%) wrong-patient and 3 (2.8%)
wrong-site cases.
The most frequent specialties involved in wrong-patient procedures were internal medicine (24.0% of cases) as well as family or general practice, pathology, urology, obstetrics-gynecology, and pediatrics (8.0% each). The most frequent specialties involved in wrong-site occurrences were orthopedic surgery (22.4% of cases), general surgery (16.8%), and anesthesiology (12.1%).
Overall, nonsurgical specialties were involved in 14 (48.3%) wrong-patient and 29 (27.1%) wrong-site cases.
“The findings from the present study emphasize a continuing and concerning occurrence of wrong-site and wrong-patient procedures in the current era of the Universal Protocol, leading to frequent patient harm and, rarely, patient death,” the researchers said. “Shockingly, nonsurgical disciplines equally contribute to patient injuries related to wrong-site procedures.”
The researchers believe these findings warrant expansion of the Universal Protocol to nonsurgical specialties.
Limitations of the study include the restricted coverage of the COPIC database to about 6,000 physicians in Colorado; the potential for subjective bias in determining root causes; and the designation of inadequate planning for the procedure, which represents a generic category.
Coauthors on the research analysis reported the following conflicts: Dr. Ted J. Clarke is the chief executive officer of COPIC; Dr. Jeffrey Varnell and Dr. Alan Lembitz are employed by COPIC; and Dr. Michael S. Victoroff and Dr. Dennis J. Boyle are consultants for COPIC.
The Joint Commission introduced the Universal Protocol to ensure the correct patient, site, and procedure. Although it became effective July 1, 2004, there still exists a lack of data about the true incidence of wrong-patient and wrong-site operations, called “never events,” according to new research.
To determine the frequency, root causes, and outcomes of these never events, Dr. Philip F. Stahel of Denver Health Medical Center and the University of Colorado School of Medicine, and colleagues performed a retrospective analysis of the Colorado Physician Insurance Company's (COPIC's) comprehensive database (Arch. Surg. 2010;145:978-84).
Dr. Stahel and his colleagues screened 27,370 physician self-reported adverse occurrences between Jan. 1, 2002, and June 1, 2008. The researchers initially found 119 wrong-site and 29 wrong-patient procedures, but eliminated cases they could not classify as being a factual wrong site or wrong patient. The final analysis consisted of 107 wrong-site and 25 wrong-patient procedures.
Analysis of root causes found errors in:
· Diagnosis, a root cause for 14 (56.0%) wrong-patient and 13 (12.1%)
wrong-site procedures.
· Communication, 25 (100%) wrong-patient and 52 (48.6%) wrong-site
procedures.
· Judgment, 2 (8.0%) wrong-patient and 91 (85.0%) wrong-site procedures.
· Treatment, 22 (88.0%) wrong-patient and 9 (92.5%) wrong-site procedures.
In addition, system issues were a root cause in 21 (84.0%) wrong-patient procedures and 78 (72.9%) wrong-site procedures. This category included time-out not being performed in 77 (72%) wrong-site cases.
Wrong-patient cases often were due to a mix-up of patients' medical records, radiographs, and laboratory or biopsy samples, as well as errors in communication.
Next, the researchers looked at outcomes, namely:
· Death, which occurred in 1 patient (0.9%) secondary to a wrong-site procedure.
· Significant harm, which occurred in 5 (20%) wrong-patient and 38 (35.5%)
wrong-site cases.
· Minimal harm or functional impairment, which occurred in 8 (32%) wrong-
patient and 65 (60.7%) wrong-site cases.
· No-harm event, which occurred in 9 (36%) wrong-patient and 3 (2.8%)
wrong-site cases.
The most frequent specialties involved in wrong-patient procedures were internal medicine (24.0% of cases) as well as family or general practice, pathology, urology, obstetrics-gynecology, and pediatrics (8.0% each). The most frequent specialties involved in wrong-site occurrences were orthopedic surgery (22.4% of cases), general surgery (16.8%), and anesthesiology (12.1%).
Overall, nonsurgical specialties were involved in 14 (48.3%) wrong-patient and 29 (27.1%) wrong-site cases.
“The findings from the present study emphasize a continuing and concerning occurrence of wrong-site and wrong-patient procedures in the current era of the Universal Protocol, leading to frequent patient harm and, rarely, patient death,” the researchers said. “Shockingly, nonsurgical disciplines equally contribute to patient injuries related to wrong-site procedures.”
The researchers believe these findings warrant expansion of the Universal Protocol to nonsurgical specialties.
Limitations of the study include the restricted coverage of the COPIC database to about 6,000 physicians in Colorado; the potential for subjective bias in determining root causes; and the designation of inadequate planning for the procedure, which represents a generic category.
Coauthors on the research analysis reported the following conflicts: Dr. Ted J. Clarke is the chief executive officer of COPIC; Dr. Jeffrey Varnell and Dr. Alan Lembitz are employed by COPIC; and Dr. Michael S. Victoroff and Dr. Dennis J. Boyle are consultants for COPIC.