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CAHQ JOURNALCAHQ JOURNAL Official publication of the California Association for Healthcare Quality
Spring Conference brochure on page 35
Spring Conference brochure on page 35
Rapid Response Teams Run, Don’t Walk...Rapid Response Teams Run, Don’t Walk...
Business Case For Patient SafetyBusiness Case For Patient Safety
Volume 32, Number 1 1st Quarter, 2008
2 CAHQ Journal, Quarter 1, 2008
2007-2008 CAHQBoard Of Directors
President .................................................................................................................................. Julie BoothPresident-Elect .......................................................................................................................Tricia KassabImmediate Past President ...................................................................................................... Ruth CountsSecretary ................................................................................................................................... Val EmeryEducation Co-Chairs ...............................................................................................................Tricia West
........................................................................................................Jada SalamatianTreasurer .......................................................................................................................... Marcie CochranMembership Chair .................................................................................................................. Laura MarxNominating Chair ................................................................................................................. Judy PugachJournal Co-Chair ..................................................................................................................... Pat Lucken
.................................................................................................................... Kathy ChaiFinance Manager.................................................................................................................Janet MarondeAssociation Manager ..............................................................................................................Hellen GattiWebsite Master ..........................................................................................................................Paul Kittle
.....................................................................................................................Gilbert AbellaCPA .......................................................................................................................................... Jim Miller
CAHQ JournalCAHQ Journal is published quarterly. It is the official publication of the California Association for
Healthcare Quality and is a referred journal. Opinions expressed in signed articles or features are those of the author and do not necessarily reflect the views of CAHQ. CAHQ reserves the right to edit mate-rial and to accept or reject contributions whether solicited or not. Advertising in CAHQ Journal does not imply endorsement of products or services. Letters to the Editor, comments, suggestions and requests for information should be addressed to:
Kathy Chai, [email protected]
Pat Lucken, [email protected]
CAHQ Journal Editorial Staff
Catherine Carson-MartinMarilyn Drone
Tricia KassabPamela J. Simpson
CAHQ Journal, Quarter 1, 2008 3
VisionWe will be recognized as a leader in healthcare quality
and patient safety. As a leader, we will:
• Identify and advance best practices
• Promote professional development
• Influence industry trends
Values• Excellence
• Integrity
• Diversity
• Collaboration
• Professional Growth
• Continuous Improvement
MissionThe mission of the California Association for Healthcare
Quality is to develop and promote the healthcare quality
professional through:
• Education and Resources
• Networking
• Leadership in the Industry
4 CAHQ Journal, Quarter 1, 2008
Table Of ContentsMessage From The President
Julie Harmata Booth MS, CPHQ, RHIA•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 6
Messages From The Co-EditorsKathleen Tornow Chai MSN, PhD, CPHQ, FNAHQ & Pat Lucken RN, MSN, FNP-C, CPHQ•••••••••••••••••••••••• 6
Welcome to New CAHQ Members•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 9
The Business Case for Patient SafetyHighlights the benefits of an investment in patient safety initiatives, as well as presents the consequences of not placing
enough emphasis on patient safety.
Fabio Sabogal, PhD., Lumetra, Allison Snow, MHA, Lumetra & Linda Sawyer, PhD., RN, Lumetra••••••••••••••••••••10
NAHQ UpdateThe latest information on NAHQ, including info on the new officers for 2008 and the NAHQ Fellowship Program.
National Association for Healthcare Quality••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 16
Bridging the Gap in Emergency Cardiac CareDiscusses the advances in emergency cardiac care from as far back as twenty years ago.
Brian Hendrickson, EMT-P•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••17
Rapid Response Teams—Run, Don’t Walk...The Rapid Response Team at St. Mary’s Medical Center is an excellent model for other RRTs.
Pat Lucken RN, MSN, FNP-C, CPHQ•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••22
CAHQ Journal, Quarter 1, 2008 5
Rapid Response Teams—Another Organization’s ExperienceDiscusses the Rapid Response Team at Kaiser Permanente West Los Angeles.
Kathleen Tornow Chai MSN, PhD, CPHQ, FNAHQ• •••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••25
Destination Quality—Take The Ride!Spring Conference 2008 Brochure. Includes presenter biographies, registration information, conference hourly agenda and
conference registration form.
March 10–12, 2008•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••35
The bottom Line: Gifts That Keep GivingThe heartwarming story of the events surrounding Christmas at st. Mary’s Medical Center.
Pat Lucken RN, MSN, FNP-C, CPHQ•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••46
Authors BiographiesBiograhies for the authors who contributed to this issue of the journal as well as inadvertently omitted biographies from
previous journal.• •••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••48
California association for Healthcare Quality 2007 Author/Article Index A guide to to the authors and articles for the four CAHQ journals from 2007.•••••••••••••••••••••••••••••••••••••••••••49
Save These Dates!Upcoming CAHQ event dates and information.•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••56
CAHQ Membership Application•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••57
6 CAHQ Journal, Quarter 1, 2008
A Message from the President:
Always Striving
Messages from the Co-Editors:
Julie Harmata Booth MS, CPHQ, RHIA
Those of us working in health care
quality have some of the most fascinat-
ing and yet challenging jobs in the
world. We deal with issues that abso-
lutely need more oversight and attention
for the betterment of all who need care.
Take, for example, our past issue of
the Journal. There, a reader could find
articles on EMS Grand Rounds, Pain
Management, Dealing with Pressure
Ulcers, and the Health Care Quality
of Older Women. We’re dealing with
it all, striving to improve the care that
our family, friends, and neighbors may
experience within their local setting.
During my year as president, I’ve
been able to meet many new people,
and incorporate many ideas and in-
novations in the way quality issues
are handled at my own organization.
In thinking about this past year, I’ve
recalled all the wonderful times when
I’ve had an “aha” experience, whether
it was at a Harvard colloquium or chat-
ting over coffee with a colleague in a
local café.
THIS IS THE LAST ISSUE of the CAHQ Journal during my year as president. I will miss being part of this fine group of individuals who, as our vision states, work toward identifying and advancing best practices, promoting professional deve-lopment, and influencing industry trends.
Kathleen Chai
I’ve also been disheartened this year
over the many challenges to the good
work that’s already been done in the
quality arena. The greatest challenges
perhaps has been the increasing alarm
over methicillin-resistant staphylococ-
cus aureas (MRSA) infections, venous
thromboembolism (VTE), diabetes and
kidney disease . All of these will take a
uniformed team process to control.
In my new role as past-president, I’ll
look forward to continue the effort we
are all putting forward, always striving.
Excelsior!
✦
I am not sure how many of you
remember my last editorial but I wrote
it a few days before leaving on a long
cruise in Asia with my Mom. I was
excited and frantic over what had to be
done before leaving, but looking back,
I am very happy I made the decision I
did.
21 days included trips to Bangkok,
Singapore, Hong Kong, Viet Nam,
Nagasaki, Shanghai, and Beijing.
What a trip! It was my first cruise,
and I am now convinced it’s the only
way to travel. I spent almost 10 hours
with my daughter in Shanghai. I will
never regret spending time with my
CAHQ Journal, Quarter 1, 2008 7
mom, even though it was not always
easy in a 12X12 room. We laughed,
hit the bars together, played Bingo and
had a once in a lifetime vacation. I felt
overwhelmed when I returned to work
and the feeling still has not subsided.
But, the holidays came and went and
I have not panicked. Things at work
go on as they always have, always too
much to do and too little time. One
thing that surprised me
about the trip was how
much my medical and
nursing skills came in
handy. The first day of
the cruise, I heard an
overhead emergency call
at 5am that told me we
had a medical emer-
gency. From what I saw
after that, it seemed that
someone had a cardiac
arrest and we were 12
hours from port. I don’t know what
happened but did find out that the
medical crew was with the patient until
we got to port. The same day it became
apparent that there was an effort to
control the spread of infection. All of a
sudden you saw waiters with gloves on.
Unfortunately as I watched them I no-
ticed that they were going from clean to
dirty and dirty to clean. I felt like I was
prepping someone for JCAHO again!
I spoke with the steward and within
24 hours the practice changed-and that
was a very big ship. I found out later
that we had the dreaded Norovirus
that occasionally affects ship and crew.
Hand sanitation was required prior
to each meal (yes, they watched) and
frequent handwashing was encour-
aged. One of our tablemates told us of
her 48 hour confinement to her cabin
on the first 2 days of the cruise. It was
enlightening.
I saw multiple people with black
eyes, stitches and splints, and even
casts throughout the cruise. I could not
believe all of the medical emergencies
I saw or saw the results from. I decided
that from now on, I
need to travel when I
am fit and able to do
so. Two final experi-
ences made that my
motto. The first was
as we were going into
port in Singapore. We
were all lined up on
the stairs; waiting to
disembark and one of
the ladies in front of me
fell down 2 stairs and
lay on the landing. Her husband and I
rushed to her and as he lifted her flaccid
leg, I could tell her leg was broken. I
asked him to put it down, called 911
on the ship phone and waited for help
to arrive. Crew members were standing
around by that time and I asked them
to get some ice, but they did not re-
spond. I found out later that the cruise
line had recently been sued, and the
current protocol was not to intervene
until a medical person was available.
This reminded me of what sometimes
happens in healthcare organizations.
The last episode took place the day
we were leaving, on our way to the
airport. We were in Beijing, and as a
group was walking out through the
automated door of the hotel, one lady
who had been using a cane during the
cruise, was caught by the automatic
door and fell. As the crowd gathered, I
knelt down and spoke to her. She knew
she had broken a hip, but really wanted
to go home. I told her that would not
be possible and also shared that my
daughter received medical treatment in
Beijing and it was excellent.
All of this has a number of lessons
for me: 1. Take the time to experience
things that you may never experience
again. 2. Nursing is never far away-
whenever you need the information,
it comes back and you remember how
good it is to have that information. 3.
Do what you can do while you are still
able. There is no time to waste! Those
of us who know we will be retiring in
a few years, owe it to the profession of
nurses and other quality managers to
impart what we know and share the
benefit of our experience.
Thanks for listening. Kathy Chai
✦
My daughter and I
8 CAHQ Journal, Quarter 1, 2008
In the quest to attain great
quality outcomes, one cannot afford to
lose sight of the need to also create more
humane, holistic and caring centers of
healing.
St Mary Medical Center, Apple Val-
ley, CA, is a ministry of the St Joseph
Health System (SJHS) of Orange Cali-
fornia. One of our three system-wide
strategic goals are, Perfect Care. Perfect
Care means that every patient receives
the care they need every single time.
Another goal is focused on healthi-
est communities. A priority focus is
addressing childhood obesity. Finally,
we strive to create every encounter as
a sacred encounter. Sacred encounters
include the following traits as de-
scribed by the St Joseph Health System
(McPherson, 5/17/2007).
“S Sensitive and open to the sacred in
our midst
A Attentive to the needs and concerns
of others
C Compassionate interactions distin-
guishes our community
R Respectful and open to the differ-
ences and similarities of all people
E Engaged and enthused employees
and physicians
D Dignity-our core value-is embod-
ied by all within the St. Joseph Health
System.”
This movement is yet a ripple and
hope of what the future may be. Some
of those early ripples are having our
support group participants share their
stories with each other at our an-
nual holiday lunch with staff, who also
shared stories. One shy patient con-
fessed later to me that she felt guilty not
sharing with the crowd of 165 people. I
told her she had already shared because
I used her thoughts in a story to the
group that day. We encouraged her to
journal her thoughts and later received
a beautiful letter from her.
One of our cardiac rehab patients
with Parkinson’s disease also cares for
his elderly wife. His legs have recently
become too weak to attend cardiac
rehab and his doctor is recommending
physical therapy. He just purchased a
new car. He most likely will be unable
to return to cardiac rehab. He has
come to us for years. Each Wednesday
is donut day and he brings us donuts
without fail. He told staff it was okay
to share his condition with others with
just one stipulation, that they share
his phone number with them so he
could hear from those he usually saw at
exercise. I would describe each of these
touching moments as sacred encounters.
I recall a story from my past when
I cared for a woman in the ED who
experienced a miscarriage. Years later by
chance, I met that patient’s aunt. The
aunt had kept my name written on a
little piece of scrap paper in her wallet
all those years to remember my kind-
ness to her niece. The feeling of that
moment she shared with me will remain
with me forever. I felt so humbled that
the care received was remembered by
a family member years later and long
after I could recall any specific details. I
call that a sacred encounter.
I am interested in hearing how your
agencies are improving the quality of
care received and also the recipient’s
perception of care. Are you finding
innovative ways to connect to your
patients and their loved ones? I hope
2008 is a year for CAHQ to collaborate
and to partner more with our member-
ship body. I hope you will reach out
and share.
I hope to see many of you at our an-
nual CAHQ Spring Conference
✦
A Revolution of CaringPat Lucken, RN, MSN, FNP-C, CPHQ
Pat Lucken
CAHQ Journal, Quarter 1, 2008 9
Annette Adams
Phyllis Adams
Amy Ando
Carla Balog
Connie Benson
Kathleen Billingsley
Lori Ellen Brown
Kathleen Burger
Cynthia Cadwell
Veva E. Caldera
Chrysi Canerday-January
Shirley Chaney
Rick Coate
Jennifer Collins
Emesilia Daco-Cueallo
Martha Delgado
Deborah Doherty
Mary Ann Doran
Melanie Eller
Myra Enloe
Mary Ferguson
Rachel Fujii
Andrea M. Galante
Debra Garduno
Pamela George
Sandra L. Gradillas-Spaich
Linda Gregg
Crystal Haenggi
Elizabeth Haren
Rami Hasan
Carlos Hernandez
Sandra Hernandez
Carolina Hiranand
Arlene Ison
Anna Jaffe
Patti James
Cara Jenson
Angela Johnson
Janet Johnson-Yosgott
Betty Jones
Gauri Joshi
Shela Kaneshiro
Darina Kavanagh
Paula Keiser
Sarna Kolvan
Rose Krantz
Lynne Langholz
Kristi Larsson
Susan Lasota
Pamela Loo
Kris Ludington
Cornelia Malicse
Anne Marder
Julie Martin
Diana Matthews
Brian McAlister
Vickie Medlen
Gail Mercer
Yvette Million
V.S. Mitchell
Cashmere Monroe
Charmaine M. Mosher-Carbiener
Lisle Mukai
Kathy Murray
Dana Palacio
Mary Rose Palma-Samela
Martin F Peavey
Barbara Pelletreau
Anne Peterson
Rogene Pinasco
Robert Porath
Paula Radell
Gloria Redden
Blaire Richardson
Mary G. Ross
Connie Rowe
Lori Ruiz
Cristina Salas
Deborah J. Scaife
Janet Schmitt
Terry Schroeder
Yali Shu
Kathy Simmons
Holly Smith
Cindy Snelgrove
Jaspreet Sodhi
Melody Soles
Darlene L. Solis
Heather Van Housen
Tamera Vingino
Kathleen M. Wannemacher
Gay Wayland
Susan White
Valerie Winter
Robin Zudell
Welcome, to all of the new CAHQ members!
10 CAHQ Journal, Quarter 1, 2008
The Business Case for PaTienT safeTy
Fabio Sabogal, PhD. Allison Snow, MHA Linda Sawyer, PhD, RN
LumetraInvesting in patient safety initiatives makes good business sense. Proactively investing in error-reduction initiatives provi-des a hospital with a strategic business position to compete in the marketplace. Demonstrating the case for patient safety helps California hospitals to prioritize investments that foster the delivery of safe, efficient, and high quality care. This ar-ticle presents the dramatic costs of patient safety violations, shows the benefits of patient safety interventions, and high-lights the directions where safety leaders are investing in cost-effective, evidence-based patient safety solutions.
1. The Economic Burden of Patient Safety Violations and Medical Errors
Medical errors are prevalent, expen-
sive, and often preventable. Consider
this case: “A Denver hospital gave a
newborn infant a tenfold overdose of
penicillin in case it had been infected
with syphilis from its mother. Nurses
balked at giving the baby five injec-
tions so administered the medicine in
what turned out to be an unusual and
improper way—intravenously. The baby
died, and the autopsy showed it did
not have syphilis and never needed the
treatment in the first place.”1, 2
Medical errors affect a hospital’s
bottom line. Accidental deaths and
serious injuries compromise patient
care, increase economic burden, im-
CAHQ Journal, Quarter 1, 2008 11
pair profitability, and weaken organi-
zational performance and staff morale.
Hospitals suffer substantial personnel,
regulatory, marketing, and legal costs
because of medical errors and patient
injuries. It is estimated that within
U.S. hospitals, medical errors could
unnecessarily cost the healthcare
system between $17 to $29 billion
annually causing up to 98,000 deaths
per year.3, 4
Costs of adverse drug events are
a major economic burden to hospi-
tals. Patient injuries resulting from the
medication process alone are one of the
most common types of medical errors.
Nationwide, at least 1.5 million prevent-
able adverse drug events occur in the
United States each year causing 106,000
deaths annually.2, 5, 6 In the hospital
setting, between 380,000 to 450,000
patients experience a preventable
adverse drug event adding about $3.5
billion per year to total hospital costs.2
Medication errors occur throughout the
entire process, but are most common in
the ordering and administration phases.
This is especially true among pediatric
care in hospitals.
Adverse drug events increase risk
of injury and mortality. Adverse drug
events (ADEs) double the risk of death.7
Serious ADEs are the fourth leading
cause of death.8
Preventable adverse drugs events
increase length of hospital stay.
Patients who experience ADEs are
hospitalized an average of 8 to 12 days
longer than patients who do not suffer
these events, and their hospitalization
costs $16,000 to $24,000 more. The
ADE Prevention Study estimates that
the additional length of stay associated
with a preventable ADE is 4.6 days,
with an increase in total cost of $8,750
in 2006 dollars.2, 9 The annual costs
attributable to preventable ADEs for a
700-bed teaching hospital result in an
additional $2.8 million per year.9
Hospital admission costs related to
a previous ADE increases economic
burden. Hospital admissions due to a
previous ADE are expensive, mostly se-
vere, and often preventable.10 A study in
one tertiary care hospital found that 1.4
percent of admissions were caused by a
previous ADE with estimated costs of
$16,177 per ADE, $10,375 per prevent-
able ADE, and $1.2 million per year for
preventable ADEs.10
Emergency room costs related to
a previous ADE are considerable. A
cost analysis of drug-related illnesses
associated with visits to a 560-bed
teaching hospital emergency depart-
ment found an estimated 66 percent of
preventable ADEs with $391,342 in an-
nual Emergency Department (ED) and
hospital costs in 1994.11 The previous
costs of treatment among those with a
preventable ADE were $308 for those
who were not hospitalized and $2,752
for those who were.11
Emergency department adverse
drug events are preventable and
costly. In a study of preventable
medication-related emergency depart-
ment visits, of the 253 patients inter-
viewed, 71 patients (28.1 percent) had
a medication-related visit.12 Of the 71
patients, 50 (70.4 percent) were prevent-
able with an average cost of $1,444 per
each preventable medication-related
visit.12
Hospital-acquired infections are
substantial and compromise the bot-
tom line. About two million people
annually acquire an infection at U.S.
hospitals at a total cost of more than
$4.5 billion.13, 14, 15 Mortality associated
with hospital-acquired bloodstream
infections is 23.8 percent to 50 percent
and 14.8 percent to 71 percent for
pneumonia.14 The excess length of stay
due to these infections is one to four
days for urinary tract infections, 7 to
8.2 days for surgical site infections, 7
to 21 days for bloodstream infections,
and 6.8 to 30 days for pneumonia.14
The estimated average cost is $2,734 for
each surgical site infection, $3,061 to
$40,000 for each bloodstream infection,
and $4,947 for each pneumonia.14 Hos-
pitals lose from $583 to $4,886 for each
hospital-acquired infection.14 MRSA, a
type of bacteria (Staphylococcus aureus)
resistant to many antibiotics, is a major
healthcare-acquired infection. In fact,
26.6 percent of patients with MRSA are
hospital-onset associated.16
Medical errors have major financial
impact. Hospitals are major targets
of personal injury lawsuits. Patient
safety initiatives mitigate medical errors
preventing financial losses associated
with these events. Patient safety viola-
tions consume additional resources
since hospitals have to pursue litigation
defense, paying awards and settlements.
The average claim related to liability
for an adverse drug related event is
estimated to be between $376,00017 and
$668,000.18 A study found that claims
for ADEs were in excess of $19 million
for the 10-year period of the study.17 In
an ADE study of the Veterans Adminis-
tration (VA) facilities, 37 percent of tort
claims resulted in payments that aver-
aged $138,800.19 Another study found
40 cases of wrong-site surgery among
1,153 malpractice claims.20
Malpractice litigation affects
hospitals, providers, and patients.
Malpractice litigation has substan-
tial effects on hospitals and providers
including lost practice time, damage to
reputation, emotional stress, and insur-
ance losses.17 Providers may perceive
malpractice litigation as a barrier for
reducing errors.21, 22 Similarly, patients
suffer financial, physical, and emotional
consequences because of medical errors
and litigation.
Organizational Benefits of Investing in Patient Safety Initiatives
Areas Impact of Patient Safety Violations Impact of Patient Safety InitiativesFinancial Decrease profit margins•
Increase direct and indirect costs•
Threat to organizational survival•
Decrease costs•
Prepare for pay-for-performance •
Increase capacity and infrastructure•
Clinical Compromise quality of care•
Reduce organizational performance•
Promote variability in service delivery •
Increase inappropriate care•
Promote costly duplication of services•
Improve clinical quality indicators•
Increase adherence to care guidelines•
Provide better patient care•
Increase workflow efficiencies•
Enhance process design•
Technological Use paper-based patient chart that was •
developed over 100 years ago
Write illegible and incomplete orders fraught •
with errors
Decrease medication errors •
Support coordinated care management•
Optimize access to clinical data•
Increase ability for electronic ordering•
Culture Promote a “blame” culture •
Increase fear of error disclosure•
Foster a culture of safety •
Maximize error interception•
Legal Consume additional resources pursuing •
litigation defense, paying settlements and
awards
Avoid exposure to liability•
Increase documentation accuracy•
Reduce insurance premiums•
Legislation Potential sanctions and litigation• Comply with patient safety standards•
Human
Resources
Increase recruitment costs of scarce human •
resources
Compromise employee morale•
Reduce patient and family satisfaction•
Increase provider and patient satisfaction•
Increase provider-patient communication•
Higher productivity with efficient process•
Ease provider recruitment•
Measurement Threaten transparency and accountability•
Reduce provider and system feedback•
Delay patient safety improvement•
May compromise HIPAA requirements•
Enhance surveillance and monitoring•
Prepare for public reporting•
Enhance benchmarking and goal settings•
Increase patient confidentiality•
Marketing Tarnish reputation and brand identity•
Decrease public confidence•
Decrease new business initiatives•
Build good will and reputation•
Elevate brand image and differentiation•
Increase revenue by bringing new patients•
Accreditation
Stakeholders
Increase regulatory costs •
Duplication of efforts and messages•
Uncoordinated safety requirements•
Maintain accreditation•
Simplify HIPAA compliance•
Align with other organizations•
CAHQ Journal, Quarter 1, 2008 13
2. Patient Safety Interventions Make Good Business Sense
Hospitals that are investing in patient
safety decrease costs, improve clinical
quality indicators, increase workflow
efficiencies, and avoid exposure to mal-
practice litigation. The following table
presents a summary of organizational
costs and potential benefits of patient
safety practice initiatives over multiple
organizational areas.
The benefits of creating safe operation
of systems and processes that mini-
mize errors and accidental injury are
substantial:
Patient safety initiatives increase
efficient workflow redesign and
provider time for patient care. Safety
culture and workflow redesign initia-
tives streamline clinical processes and
decrease administrative time. Health-
care providers and patients often report
positive satisfaction levels in highly
efficient healthcare systems. Increased
workflow efficiencies result in less time
for administrative and redundant tasks,
and more time for patient care.
Patient safety and quality improve-
ment interventions make good busi-
ness sense. A pilot project conducted
by Virginia Health Quality Center
(VHQC)-RAND for the Centers for
Medicare & Medicaid Services (CMS)
concluded that electronic health
records, patient registries, reminder sys-
tems, and standing orders save money
and improve clinical outcomes.23 These
quality improvement interventions can
decrease costs, increase revenues, and
lead to increased profitability.
Patient safety initiatives establish
infrastucture to facilitate evidence-
based care. Research has documented
considerable savings from adherence
to evidence-based quality and patient
safety guidelines. Clinicians are more
likely to promote evidence-based care
and achieve better clinical outcomes
and patient satisfaction. Systems
improvement increases a hospital’s
bottom line, reduces staff turnover, and
produces better care.
Safer practices foster better com-
munication, care coordination, and
patient outcomes. Safer clinical proce-
dures improve provider-patient com-
munication, reduce fragmentation of
care, and produce better clinical health
outcomes. Also, higher patient satisfac-
tion is associated with perceptions of
safer procedures, physician communica-
tion, and team coordination.30, 31, 32
The Business Case for Quality and Patient Safety in Hospitals: A Pilot Study
Patient Safety and Quality Improvement Pilot ProjectSystem Change Strategies are Cost-effective in Hospitals. Standing orders, clinical pathways, fast track protocols, and •
comprehensive case management systems reduce the average length of stay, improve clinical outcomes, increase patient
satisfaction, and produce annual savings that range from $15,000 to $187,000.23
Standing Orders and Clinical Pathways. A large, acute-care hospital invested $3,674 to develop and implement a set •
of standing orders and clinical pathways for its 400 acute myocardial infarction (AMI) patients each year. This process
change has reduced the average length of stay, resulting in a financial benefit of $53,000 annually.23
Fast Track Protocol. Heavily publicizing a new fast track protocol for patients with chest pain allowed an acute care •
hospital to admit additional patients while reducing average length of stay (ALOS), increasing patient profits by nearly
$135,000 annually and reducing the hospital’s exposure to denials of payment for unnecessary admissions.23
Clinical Pathways. Creating a set of clinical pathways allowed one hospital to ensure that its pneumonia patients receive •
antibiotics more quickly. This intervention resulted in a sizeable average length of stay reduction and staff efficiencies,
saving the facility more than $30,000 annually.23
Comprehensive Case Management System. One urban medical center developed a comprehensive case management •
system for pneumonia patients, involving standing orders, physician reminders, and patient education resulting in
$187,000 in annual cost savings as a result of an average length of stay reduction.23
Source: Virginia Health Quality Center. Quality Makes Good Business Sense. Key Findings From
The Making the Case For Business Benefits of HCQIP Projects.” Special Study, 2003.
14 CAHQ Journal, Quarter 1, 2008
Savings from Adherence to Evidence-Based Quality and Patient Safety Guidelines
Condition Reported Cost SavingsHeart Failure In patients with a diagnosis of heart failure, exposure to angiotensin converting enzyme (ACE) •
inhibitor therapy is associated with fewer hospitalizations and lower total costs (mean $2,397) than
no ACE inhibitor therapy.24
Pneumonia Effective pneumonia treatment - early initiation of antibiotic therapy in the emergency department and •
the use of a case manager responsible for evaluating adherence to practice guidelines - resulted in a
cost savings of $267,410 in a sample of 143 patients.25
Surgical
Complications
Patients who develop surgical site infections have longer and costlier hospitalizations than patients •
who do not develop such infections. They are twice as likely to die, 60 percent more likely to spend
time in an intensive care unit, and more than five times more likely to be readmitted to the hospital. The
median direct costs of hospitalization were $7,531 for infected patients and $3,844 for uninfected
patients. The excess direct costs attributable to surgical site infections were $3,089.26 Programs that
reduce the incidence of surgical site infections can substantially decrease morbidity and mortality and
reduce the economic burden for patients and hospitals.26
Acute
Myocardial
Infarction
As a result of the paper-based reminder system stressing CMS quality performance measures for •
AMI, including early administration of aspirin and beta blockers, smoking cessation counseling, and
administration of ACE inhibitors and aspirin on discharge - one facility was able to decrease the
average length of stay for AMI patients by 0.51 days and improve its quality performance measures.
Assuming a hospital can save approximately $450 in incremental costs for each day subtracted from
the end of a stay, this change saved the facility $1,607 per month due to the average length of stay
reduction.23
Reducing Staff
Turnover
Staff turnover compromises patient safety. In fact, the Joint Commission has concluded that actions •
taken to increase nurse retention improve the business case for patient safety interventions.27 The
Advisory Board estimated an annual $800,000 savings for a 500-bed hospital that reduced staff
turnover rates from 13 percent to 10 percent.28 In addition, the Voluntary Hospital Association (VHA)
has estimated that an average hospital spends $5.52 million per year on turnover costs and that a
reduction in turnover of 20 percent to 15 percent would result in an average savings of $1.38 million
per year. Organizations with high turnover rates (≥ 21 percent) had a 36 percent higher cost per
discharge when compared to those hospitals with a lower turnover rate (>≤ 22 percent). Hospitals
with lower turnover rates (4-12 percent) had a 6 percent higher return on assets when compared to
hospitals with higher turnover rates (> 22 percent).29
Safer hospitals enhance reputation
and protect brand name. Hospitals
can capitalize on an improved reputa-
tion and enhanced community image
by showing superior quality perfor-
mance. Proactively investing in patient
safety enhances prestige and protects
brand names. Hospitals that empha-
size the provision of high-quality,
safety, and efficient healthcare services
attract new patients generating better
revenues.33, 34 They increase reputation,
community image, and have satisfied
patients.35 Organizations can capitalize
on reputation by disseminating superior
quality performance.35 Therefore, proac-
tive investing in patient safety could
enhance prestige, protect brand names,
improving patient volume and high-
quality providers.35
Investing in safety culture im-
proves human capital, which
improves provider and patient satis-
faction. Safer hospitals improve patient
volume, retain high-quality providers,
and enhance satisfaction generating
increased revenues. Hospitals that in-
CAHQ Journal, Quarter 1, 2008 15
vest in safety cultures are more likely to
recruit and retain high-quality employ-
ees. Because patient safety culture and
office-redesign initiatives can stream-
line clinical processes, reduce medical
errors, and decrease administrative
time, healthcare providers and patients
frequently report positive satisfac-
tion levels with use of such systems.36
Increased patient safety standardization
and efficiencies can result in less time
for administrative and redundant tasks,
more time for patient care, and increase
patient satisfaction.
On the other hand, unsafe hospi-
tal practices make it more difficult
to recruit clinical staff. Unsafe work
environments and inefficient clinical
processes are unattractive for health-
care workers. Patient safety violations
increase recruitment costs, affect
employee morale, and reduce provider
satisfaction. Medical errors also make
it more difficult to attract high-quality
staff. Turnover compromises coordina-
tion of care, increases stress on exist-
ing staff, and negatively affects patient
safety and outcomes. Not surprisingly,
there is public dissatisfaction with
healthcare safety and quality. In a 2004
national survey, half of patients are wor-
ried about the safety of their care, and
55 percent said that they are currently
dissatisfied with the quality of health-
care.37 Forty percent believe that the
quality of healthcare has “gotten worse”
in the past five years, whereas only 17
percent think it is better.37
Investing in patient safety technol-
ogy reduces serious medical errors
and produces positive return on
investment. “Wired hospitals” have
higher productivity, better control of
expenses, and more efficient utiliza-
tion management than non-wired
hospitals. Electronic healthcare record
systems maximize access to informa-
tion, increase workflow efficiencies,
support fully-integrated patient care,
provide population management, sim-
plify HIPAA compliance, and prepare
for pay-for-performance initiatives.
Health information technology return
on investment is positive with increas-
ing gains depending on the level of
functionalities. Consider the following
statistics:
Clinical Decision Support Systems Increase Healthcare Quality and Patient Safety
Condition Reported BenefitsReduce Medication
Errors
A clinical decision support system in conjunction with a CPOE produced a 83 percent reduction
in serious medication errors at an academic medical center.33, 40
Improve Preventive
Care
Computerized reminder systems increase the use of preventive services and are more cost-
effective than non-computerized reminders. Two meta-analyses showed that reminder systems
improve clinicians’ use of blood pressure assessment, Papanicolaou tests, vaccinations, and
colorectal and breast cancer screenings exams.41, 42
Improve Management
Care and Quality
Clinical information systems are effective in supporting provider and patient reminders and in
assisting with patient education and treatment planning. A review of 98 randomized clinical
trials to assess the clinical value of computerized information services found that provider
prompts and patient reminders, and computer-assisted patient education and treatment planning
were significant interventions to improve clinical outcomes.43
Reduce Drug Cost Because physicians have access to evidence-based information through Electronic Health
Record systems, they can reduce medication costs. In a study, researchers estimated that
6-month savings from new prescriptions and refills were about $3,450 per clinician.44
Improved Drug
Administration
In a 650-bed community teaching hospital during a 6-month period, a computer alert
system fired 1,116 times: 596 were true-positive alerts (53 percent).45 These alerts identified
opportunities to prevent injury at a rate of 64 per 1,000 admissions. A computer alert system
can effectively prevent injury from adverse drug events.45
Other Benefits Decision support systems can also reduce length of stay and decrease time needed for ordering
appropriate treatment.34, 46
16 CAHQ Journal, Quarter 1, 2008
A study estimated a net benefit ••
from using an EHR system for
a five-year period at $86,400 per
provider.38 The financial benefit of
implementing an EHR system was
positive in the long run.
A study of a 40-physician ambula-••
tory care medical group found an
estimated net present value for the
EHR system of $279,670.39 Finan-
cial benefits come from savings in
drug expenditures (33 percent),
improved utilization of radiology
tests (17 percent), improvements
in charge capture (15 percent),
and decreased billing errors (15
percent).38
Other clinical support technolo-••
gies in conjunction with a Com-
puterized Physician Order Entry
(CPOE) system produced an 83
percent reduction in serious medi-
cation errors with savings of $5
million to $10 million annually.33, 40
Investing in patient safety initia-
tives improves performance measure-
ment and public reporting. Safer
hospitals improve performance mea-
sures and incident reporting systems.
There is a national movement toward
incident reporting systems, publicly
reported measures, and pay-for-perfor-
mance initiatives that is accelerating the
implementation of patient safety initia-
tives. The core of this movement is the
concept of transparency, accountability,
and measurement.47 The process of
developing, validating, standardizing,
reporting, and providing feedback to
healthcare providers is creating mo-
mentum among hospitals, purchasers,
providers, safety organizations, and the
general public.47
Hospitals that accelerate incident re-
porting systems and performance-based
measures using the following principles
designed by the Institute of Medicine
will be successful in patient safety stan-
dard reporting requirements:
Comprehensive measurement••
Evidence-based goals and measures••
Longitudinal measurement••
Supportive of multiple uses and ••
stakeholders
Measurement intrinsic to care••
Patient and population level ••
measurement
Shared accountability••
Independent and sustainable learn-••
ing system
Greetings, NAHQ members!
The beginning of a new year brings a
fresh start for new officers, volunteer
opportunities, and continuing steps
toward NAHQ’s vision of being univer-
sally recognized as an essential connec-
tion and leading resource for healthcare
quality professionals.
NAHQ 2008 OfficersWe are pleased to welcome NAHQ’s
2008 Officers:
President: Thomas M. Smith, MA ••
RN CPHQ
President-Elect: Catherine Munn, ••
MPH RHIA CPHQ
Immediate Past President: Heidi ••
Benson, MS RN CPHQ FNAHQ
Secretary-Treasurer: Sandra ••
Grinder, MSN RN CPHQ
Professional Development Direc-••
tor: Linda Scribner, BA CPHQ
Member Services Director: ••
Lenard L. Parisi, MA RN CPHQ
FNAHQ
HQCB Chair: David S. Loose, ••
MSN CNAA RN CPHQ
Executive Director: Stacy ••
Sochacki, MS (ex-officio).
The deadline for nominations for
2008 was January 18, 2008.
FellowshipThe NAHQ Fellowship Program was
developed by the Healthcare Quality
Foundation both to recognize NAHQ
members who have made outstanding
contributions to the field of healthcare
quality and to act as a blueprint for an
ideal career path in the healthcare qual-
ity profession.
Consideration of an applicant for
fellowship includes review of the appli-
cant’s credentials, employment back-
ground, and education. The NAHQ
NAHQ Update
See Patient Safety on pg. 27
CAHQ Journal, Quarter 1, 2008 17
Fellowship Review Board (FRB) deter-
mines the granting of Fellowship based
on an evaluation of the applicant’s
contributions to the field of healthcare
quality in the following categories:
Leadership and Service••
Published Works••
Lectures and Presentations••
Mentorship.••
We strongly urge you to set aside
some time to review the NAHQ Fel-
lowship application before you apply;
changes occur from year to year. De-
clare your intent to apply by sending a
letter to the NAHQ FRB Chair, Sandra
Robinson, by January 15, 2008. This
can be sent via e-mail and should be
addressed to [email protected].
NAHQ is proud to offer the Fellow-
ship program. Recognition of outstand-
ing leaders in the association benefits
not only those honored but also those
who seek role models in the healthcare
quality field.
For more information, please visit
the NAHQ Web site or contact NAHQ
headquarters at (800)966–9392. Best of
luck with the application process!
NAHQ. Together we define excel-
lence in healthcare quality.
NAHQ also awards grants in a num-
ber of categories throughout the year.
To see what is available, click here for
more information.
A message from the NAHQ Office
National Association for Healthcare
Quality
4700 W. Lake Avenue, Glenview, IL
60025-1485
Toll Free: (847)375–4720;
(800)966–9392
Fax: (877)218–7939
www.nahq.org
According to the Centers for
Disease Control and Prevention
(CDC), the number one lead-
ing cause of death in the United States
is heart disease (National Center for
Health Statistics [NCHS], 2007). Even
if we as individuals take a proactive
approach to fight our own battle against
cardiovascular disease, there is no
guarantee that someday we will not suc-
cumb to a heart attack. What can we
expect if that day comes? Take a brief
journey back in time and explore the
treatment and outcome that might have
awaited us just twenty short years ago.
An advanced life support (ALS) am-
bulance would respond to your house.
That unit would be staffed with a well-
trained paramedic without the ability to
perform a 12 lead EKG. They had the
ability to provide minimal treatment
and transportation to the nearest hospi-
tal. They might be able to provide you
with temporary relief, but the bottom
line is the need for timely diagnostic
and therapeutic intervention. You may
have received thrombolytic therapy
at the receiving facility, or you maybe
were fortunate enough to end up at a
hospital that had the ability to perform
cardiac catheterization and if needed,
heart bypass surgery. Your chances for
survival would be fair. If you did not ar-
Bridging the Gap in Emergency Cardiac CareBrian Hendrickson, EMT-P
18 CAHQ Journal, Quarter 1, 2008
rive at an interventional site, this might
entail another ride to another hospital
with diagnostic and open heart surgical
abilities. Delays in care result in delays
to coronary reperfusion and time is
muscle. Today’s call for assistance in a
cardiac emergency reveals a difference
with improved patient outcomes. In
2008, a 911 call for chest pain runs like
this:
A 76-year-old male has an episode of
chest pain and activates the 911 system.
Approximately five minutes after
the call, a well equipped and trained
paramedic arrives and begins the
assessment. The findings point consis-
tently to a myocardial infarction (MI).
The paramedic recognizes the need to
perform a 12 lead EKG. The findings
are ST elevation in 1, AVL, and V-1
through V-6 with reciprocal changes in
II, III and AVF (Antero-lateral wall MI)
pictured below. The paramedic decides
that the patient must go to a hospital
that is capable of percutaneous coro-
nary intervention (PCI). This patient is
fortunate that his heart attack occurred
in 2008.
There is currently a push to develop
what is known as STEMI (ST Eleva-
tion Myocardial Infarction) centers.
These hospitals specialize in reducing
the time that a patient must wait to
receive definitive intervention such as
angiography and angioplasty. The pa-
tient was immediately transported to a
“STEMI” center, and while en route he
receives care with oxygen, nitroglycer-
ine, and morphine and two intravenous
lines. Upon arrival at the hospital, the
emergency room physician confirmed
the suspicions of the paramedic. Within
forty-eight minutes of the patient’s ar-
rival at the emergency room, the patient
receives balloon angioplasty to the left
anterior descending coronary artery
which was 99% occluded. The patient
tolerates this procedure well and is dis-
charged with a good prognosis within
seventy-two hours of the procedure.
When we look at a case such as this,
it is evident that we are on the right
track making a tremendous impact
on the survival rates of heart attack
victims. The new and emerging tech-
nologies such as pre-hospital 12 lead
EKG, are just one facet of improving
outcomes and survival rates. In order
for us to continue on this path, it is
imperative that we build a solid bridge
between Emergency Medical Service
crews, the Emergency Room, and the
Cardiac Catheterization lab. A shared
vision is needed.
One such vision is the American
College of Cardiology’s (ACC) Door
to Balloon Alliance (D2B). The project
was introduced at the November 2006
American Heart Association’s (AHA)
National Meeting. The goal of the
D2B is to achieve a PCI time equal to
or less than ninety minutes in 75% of
Pre-hospital EKG: Acute Antero-lateral Wall MI
CAHQ Journal, Quarter 1, 2008 19
STEMI cases. The project is a collabo-
ration between the ACC, AHA and
the National Heart, Lung and Blood
Institute (NHLBI). A list of participat-
ing California Hospitals is provided at
the end of the article (D2B, 2007).
Counties across the country are
developing pre-hospital 12 lead EKG
protocols with rapid transport protocols
to a STEMI center. Most protocols
involve the bypassing of other facili-
ties if within a thirty minute response
time in order to transport STEMI
patients to the closest STEMI receiving
center. Some remote regions also use air
transport to expedite care for STEMI
patients. Several counties in Southern
California have already developed
STEMI centers including, Los Ange-
les, Orange, Riverside, San Diego, and
Ventura counties. The Inland County
Emergency Medical Agency (ICEMA)
recently finished presenting a draft 12
lead EKG policy and chest pain desti-
nation policy for public commentary
(ICEMA, 2007).
One may draw parallels for STEMI
centers from the golden hour of trauma
and use of EMS to transport those in
need of trauma care to the most appro-
priate centers. STEMI centers deliver
expeditious coronary reperfusion with
onsite surgical back-up teams. Progress
continues as counties work within their
regional emergency medical agencies
to improve emergency cardiac care by
a collaborative effort between EMS
and hospital staff and EMS regulatory
bodies.
There are still many areas in need of
improvement, those areas include; early
recognition of the signs and symptoms
of a heart attack and activation of the
EMS system. According to the National
Institute of Health and the National
Heart, Lung and Blood Institute,
(NIH, NHLBI, 2001) over one million
people die of a heart attack nationally
each year. Of those who die, nearly half
die before ever reaching the hospital.
Often STEMI patients arrive by private
vehicle and do not benefit from the
advanced care initiated in the field.
Healthcare professionals can teach the
signs and symptoms of cardiac emer-
gency and encourage basic life support
training for lay persons and early activa-
tion of the Emergency Medical System
(EMS).
An exciting endnote to this discus-
sion of early reperfusion to save lives is
the American College of Cardiology’s
D2B Alliance includes enrollment of
many International participants as well
as National participants. They include
Spain, Canada, Brazil, United Arab
Emirates, India, Saudi Arabia, Thai-
land, Poland and Taiwan (D2B, 2007).
We are bridging the gap in emergency
cardiac care and the gap is closing.
ReferencesAmerican College of Cardiology, ❖
D2B an Alliance for Quality. Re-
trieved January 19, 2007, from www.
d2balliance.org
Inland County Emergency Medical ❖
Agency (ICEMA), Retrieved January
19, 2007, from http://www.sbcounty.
gov/icema/
National Center for Health Statistics ❖
(2007, Deaths-Leading Causes. Re-
trieved January 2, 2008, from www.
cdc.gov/nchs/fastats/lcod.htm
National Institute of Health, ❖
National, Heart, Lung and Blood
Institute (NHLBI). Act in Time to
Heart Attack Signs. Retrieved Janu-
ary 19, 2008, from http://www.nhlbi.
nih.gov/actintime/index.htm
Brian can be contacted at hendrick-
✦
D2B Participating California HospitalsAnaheim Memorial Medical Center Anaheim
St Mary Medical Center Apple Valley
Methodist Hospital Arcadia
Bakersfield Heart Hospital Bakersfield
Mills Peninsula Health Services Bulingame
Providence St. Joseph Medical Center Burbank
Mercy San Juan Medical Center Carmichael
20 CAHQ Journal, Quarter 1, 2008
Enloe Medical Center Chico
Sharp Chula Vista Medical Center Chula Vista
John Muir Medical Center, Concord Campus Concord
Citrus Valley Medical Center Covina
Scripps Memorial Hospital Encinitas Encinitas
Palomar Pomerado Health Escondido
Fountain Valley Regional Hospital Fountain Valley
Washington Hospital Healthcare System Fremont
Community Regional Medical Center Fresno
Saint Agnes Medical Center Fresno
St. Jude Medical Center Fullerton
Glendale Memorial Hospital and Health Center Glendale
Marin General Hospital Greenbrae
John F. Kennedy Memorial Hospital Indio
Irvine Regional Hospital Irvine
Sharp Grossmont Hospital La Mesa
Saddleback Memorial Medical Center Laguna Hills
Lakewood Regional Medical Center Lakewood
Lancaster Community Hospital Lancaster
Los Alamitos Medical Center Los Alamitos
Cedars-Sinai Medical Center Los Angeles
Good Samaritan Hospital Los Angeles
UCLA Medical Center Los Angeles
USC University Hospital Los Angeles
Providence Holy Cross Medical Center Mission Hills
Mission Hospital Mission Viejo
Doctors Medical Center of Modesto Modesto
Beverly Hospital Montebello
Garfield Medical Center Monterey Park
El Camino Hospital Mountain View
Queen of the Valley Medical Center Napa
Hoag Hospital Newport Beach
Northridge Hospital Medical Center Northridge
Alta Bates Summit Medical Center Oakland
Tri-city Medical Center Oceanside
St. Joseph Hospital Orange
University of California, Irvine Medical Center Orange
St. John’s Regional Medical Center Oxnard
Desert Regional Medical Center Palm Springs
CAHQ Journal, Quarter 1, 2008 21
Huntington Hospital Pasadena
ValleyCare Medical Center Pleasanton
Pomona Valley Hospital Medical Center Pomona
Eisenhower Medical Center Rancho Mirage
Shasta Regional Medical Center Redding
Riverside Community Hospital Riverside
Mercy General Hospital Sacramento
Sutter Medical Center Sacramento Sacramento
University of California, Davis Medical Center Sacramento
Alvarado Hospital San Diego
Scripps Mercy Hospital San Diego
Sharp Memorial Hospital San Diego
University of California, San Diego San Diego
California Pacific Medical Center San Francisco
O’Connor Hospital San Jose
Sierra Vista Regional Medical Center San Luis Obispo
San Ramon Regional Medical Center San Ramon
Santa Barbara Cottage Hospital Santa Barbara
Dominican Hospital Santa Cruz
Santa Rosa Memorial Hospital Santa Rosa
Stanford Hospital and Clinics Stanford
St. Joseph’s Medical Center Stockton
Encino-Tarzana Regional Med Ctr Tarzana
Twin Cities Community Hospital Templeton
Los Robles Hospital & Medical Center Thousand Oaks
Little Company of Mary Hospital Torrance
Torrance Memorial Medical Center Torrance
San Antonio Community Hospital Upland
Community Memorial Hospital Ventura
John Muir Medical Center, Walnut Creek Campus Walnut Creek
Presbyterian Intercommunity Hospital Whittier
22 CAHQ Journal, Quarter 1, 2008
St., Mary Medical Center
(SMMC) is a one-hundred and
eighty-eight bed acute care
hospital located in the Mojave Desert of
Southern California. SMMC is part of
the St Joseph Health-system (SJHS) of
Orange, California. In 2005, SJHS sys-
tem began developing Rapid Response
Teams (RRT’s) at each of their minis-
tries. The AIM of the SJHS RRT is to
decrease overall codes occurring outside
the ICU 50%, to increase the use of
the medical response over time and to
decrease the number of inpatient deaths
non-severity adjusted (Kassab, 2006).
Tricia Kassab RN, MS, CPHQ is the
AVP for Quality and Patient Safety for
SJHS. Tricia began leading the teams in
2005, providing monthly training and
now quarterly WebEx calls for all the
ministries. Each facility tracks processes
and outcome measures, and reports to
the health system monthly. Recently,
Kathy Duncan a Director at the Insti-
tute for Healthcare Improvement (IHI)
joined one of the conference calls. She
emphasizes the importance of focusing
upon increasing RRT call volumes to
20-25 calls per 1,000 discharges in or-
der for teams to sustain their gains and
realize mortality reductions. Addition-
ally, the IHI has set goals for RRT’s,
one to decrease inpatient non-risk
mortality 25% and the other to reduce
risk adjusted mortality 20% (Duncan,
2007).
SMMC began pilot testing their
RRT in October 2005 on their West
Medical Surgical Unit. The team is
composed of a critical care RN team
leader/break nurse and a respiratory
care practitioner. Administrative coor-
dinators serve as back-up for the team.
Tools from the IHI website (IHI.org)
provided sample documentation records
as well as trigger tools for activating an
RRT call. SMMC educators assist with
educating staff about the RRT and help
to develop competencies for team mem-
bers. SMMC developed a Standardized
Protocol for emergency RRT orders
following the first year of RRT calls.
The Medical Staff accepts use of
the emergency orders and have also
called the RRT themselves when they
required additional assistance. The last
leg of the project will roll out in spring
2008 that is the Pediatric RRT. The Pe-
diatric Advanced Cardiac Life Support
R.N., from the emergency department
will staff the pediatric team along with
a dedicated respiratory therapist.
Rapid Response Teams— Run, Don’t Walk…Pat Lucken, RN, MSN, FNP-C, CPHQ
CAHQ Journal, Quarter 1, 2008 23
Lessons Learned:Some fifty percent of adult calls involve
a hypoxic patient (oxygen saturation less
than 90% despite oxygen). Some fifty
percent of calls are transferred to the
ICU for further care.
We encourage calls to RRT even
when the physician has been con-
tacted by staff as often the patient may
deteriorate quickly especially with
airway emergencies. The standardized
procedure allows the critical care nurse
to transfer the patient into the intensive
care unit if condition warrants.
All out of unit codes are reviewed to
see if staff may have missed an oppor-
tunity for calling the RRT (missed trig-
gers). We recognized some late calls &
missed triggers that resulted in a code
blue with some of our temporary per-
sonnel. We worked with our temporary
agency to ensure that their staff know
that they can call the RRT anytime
while at our facility.
We learned that we were using a lot
of reversal agents for opiate reversal
from a review of the RRT documenta-
tion. One person survived a respiratory
arrest after receiving three milligrams
of Dilaudid by IV push. Luckily, the
nurse on the ward noticed failing
respirations and called the RRT and
the patient survived. Our pain manage-
ment nurse, Sheri King, RN, helped to
coordinate both nursing and medical
education and our reversal use has di-
minished significantly. We were able to
immediately place a warning sign into
our medication dispensing unit that
cautioned staff that one milligram of
dilaudid is equivalent to five milligrams
of morphine sulfate.
One patient returned from the GI lab
and looked like she had white powder
on her face. She had experienced a
rare reaction to the topical anesthetic
spray used to anesthetize her throat.
It is called methemoglobenemia and
basically the medication binds with the
oxygen transporting cells and prevents
proper oxygen exchange. The reversal
agent used is intravenous metheyline
blue. She was transferred to the inten-
sive care unit and survived. The team
responded to a pneumonia patient that
was short of breath. The med neb failed
to work and an EKG showed an acute
myocardial infarction. This patient
went to cath lab and received a stent to
a completely occluded coronary artery.
Along with knowing your call data,
implementing process changes based
upon the what the call’s tell you, it is
helpful to perform a mortality review
of the last fifty inpatient deaths (closed
records). The tools are available on
the IHI website. The tools include the
global trigger tool for assessing patient
harm as well instructions on how to
perform the 2x2 matrix. The goal is to
identify potentially avoidable deaths
and implement strategies to improve
care processes and mitigate patient
harm. We are dedicated to performing
this exercise at least annually to assess
for leading cause of death and potential
harm, failures to plan, communicate or
rescue.
The emergency department team will staff
the pediatric RRT beginning in spring
2008
24 CAHQ Journal, Quarter 1, 2008
SMMC Registered Nurses and Respiratory Therapists respond to RRT calls
Baseline 1.8% in 2005, 1.5% in 2006 and
1.2% in 2007. 34% reduction in non-risk
mortality from 05–07
Baseline 1.05 in 2005, 0.70 in 2006 and
0.75 in 2007. 30% reduction in risk mor-
tality HSMR from 05–07
SMMC Rapid Response Team Percentage Raw Mortality
All Cause Inpatient MortalitySMMC Rapid Response Team
Risk Adjusted Mortality
CAHQ Journal, Quarter 1, 2008 25
SMMC presented a Poster-board at IHI’s National Quality Forum in Decem-
ber 2007 at Orlando, Florida. Contrary to some of the negative press perpetuated
against the effectiveness of RRT’s, our team prefers to run, not walk!
✦
Baseline 10.4 codes per 1,000 discharge in 2005, 6.4 codes per
1,000 discharge in 2006 and 4.25 codes per 1,000 discharge in
2007. 60 % reduction codes per 1,000 discharge from 05–07.
RRT began fall 2005, as a pilot unit. Global to adult inpa-
tient 2006. Including outpatient areas 2007.
2008 final roll-out to pediatric unit.
SMMC Rapid Response Team Number of Codes per 1,000 Discharge
Includes all Inpatients
SMMC Rapid Response Team Annual Number of Calls to the RRT
Not every organization has had
the same experience with Rapid Re-
sponse Teams (RRT). Kaiser Perma-
nente West Los Angeles initiated RRT
mid 2005, rolling out the process on
two units and then spreading it to
others over the next several months.
This was the first Kaiser in Southern
California to implement the program.
From the beginning, staff was eager and
ready to participate. There was some
concern about the extra utilization of
resources, however with the excep-
tion of an already identified need for a
respiratory care practitioner, the plan
was to implement the program in a cost
effective way.
On the other hand, a number of
physicians had a problem with the
lack of comparative research done on
outcomes from RRTs. Also, as reported
Rapid Response Teams—Another Organization’s Experience Kathleen Tornow Chai MSN, PhD, CPHQ, FNAHQ
26 CAHQ Journal, Quarter 1, 2008
in an article published in the Journal
of the American Medical Association
(JAMA), only 10 studies had been
published evaluating RRT implementa-
tion that provided adequate compari-
sons of outcomes between control and
intervention groups. Of these, 8 were
observational and 2 were randomized
(Winters, Pham & Pronovost, 2006).
The article, “Rapid Response Teams-
Walk Don’t Run” went on to discuss
that the implementation of RRTs may
not be for every organization. Knowing
physician practice and training is based
on evidence, it seemed reasonable that
they had reservations. However, the
plan continued.
Initially, it was difficult to determine
what the goals of RRT implementation
should be. While the literature focuses
on decreased mortality, decreased cardi-
ac arrests (Kenward, Castle, Hodgetts,
& Shaikh, 2004) there were additional
reasons that we at KP-WLA wanted to
bring this process forward. Our initial
goals were to:
Identify patients who may fall into
the “failure to rescue” category and
provide support prior to the need for
code blue.
Reduce the rate of Code Blues out-
side of CCU.
Increase knowledge and skill of
nurses related to identification of “fail-
ure to rescue.”
Increase nurse satisfaction.
Provide RRT support with minimal
additional resources.
Reduce mortality rate.
After two and a half years of imple-
mentation, we have learned a lot about
our organization and improved many
things. Initially, we identified that there
had previously been an inadequate
process for identifying the number of
Code Blue calls, which also became the
case with the initial RRTs. Historically,
the organization relied on the number
of completed forms that were submit-
ted to identify the number of Code
Blues. One of the first things the project
manager facilitating the RRT data
noticed was that the number of post-
RRT completed forms was not the same
as the number called as evidenced by
her own tracking of the calls while she
was there. After several permutations,
KP-WLA now uses the Communica-
tion Department’s Emergency Process-
ing Transaction Log. This is the same
process used for tracking Code Blues.
The log information is reviewed and as-
sessed to make sure each entry resulted
in a response before it is included in the
denominator.
The number of RRTs called was
relatively stable until recently, when it
has decreased slightly. The time is right
for a refresher education process that
will be taking place soon. Our mortal-
ity rate has decreased slightly, however
there is no way to directly attribute this
finding to the initiation of RRT. The
number of Code Blues outside the ICU
fluctuates, and no definitive trend has
been seen. However, after the process
had been implemented and was stable
organization wide, we measured the
perceptions of our nurses and found
something exciting.
Seventy-six nurses responded to the
Zoomerang survey and 55% of the
respondents had initiated an RRT. 60%
of the nurses felt that the RRT call
went as they expected it would. Over
80% felt confident that if they called an
RRT, the team would be supportive of
them. 90% of the staff felt that RRTs
had been positive for patient safety.
90% of the staff felt that the implemen-
tation of RRTs made them feel more
comfortable in their practice while 80%
felt that their clinical assessment skills
had improved. Ninety-three percent felt
that patient outcomes had improved
due to the implementation of the RRT
process.
These numbers have been a signifi-
cant driver in the ongoing implemen-
tation of RRTs at West Los Angeles.
While they are just a snapshot, and will
be repeated, they show us the level of
impact this patient safety tool has made
for our nurses. Nursing staff who inter-
view for positions at KP-WLA ask if we
have implemented a Rapid Response
Team and we have been happy to share
the information with them. KP-WLA
is significantly feeling the nursing
shortage and staffing is no easy task. It
is important that our nurses feel that
there is support for care when the need
arises.
The plan is to revitalize our RRT
processes and re-energize staff in this
implementation. We are an organiza-
tion with many initiatives and do not
see that slowing down in the future.
RRTs have become a way of life, a spe-
cial tool that we use to support patients
and staff. In the near future, we hope
to embark on the patient and family
initiated RRT for a specific segment of
CAHQ Journal, Quarter 1, 2008 27
our population. Our goal is to improve
patient care and outcomes while at the
same time support our staff as they
provide the most difficult care.
ReferencesKenward, G. , Castle, N., Hodgetts, ❖
T., & Shaikh, L. (2004). Evaluation
of an emergency medical team one
year after implementation. Resuscita-
tion, 61, 257-263.
Investing in patient safety ini-
tiatives prepares for pay-for-per-
formance and publicly reporting
initiatives. Purchasers and leading
insurers are putting more attention to
patient safety and healthcare quality
using quality measures.35 Initiatives that
reduce errors by adopting health infor-
mation technology (HIT) and other
strategies can provide hospitals with
improved reimbursement rates and pre-
pare for pay-for-performance initiatives.
For example, the Leapfrog Group—a
consortium of companies and health
purchasers—is providing incentives for
hospitals to implement HIT to reduce
medical errors. Hospitals that develop
valid and reliable incident reporting
systems, educate healthcare providers in
medical errors, and adopt technology
and other related strategies to enhance
patient safety, are preparing for pay-
for-performance initiatives. Also, the
PCMS Premier Hospital Quality Incen-
tive Demonstration initiative showed
that hospitals participating in this proj-
ect had significantly higher composite
quality scores in each indicator of the
study (AMI, pneumonia, heart failure),
accelerating the adoption of evidence-
based practices.48
Numerous public and private entities
have begun posting publicly accessible
and searchable indices of a hospital’s
performance in quality care:
CMS Hospital Quality Measures••
Premier Hospital Quality Safety••
US DHHS Hospital Compare••
California Hospital Compare••
National Voluntary Hospital Re-••
porting Initiative
PacifiCare Quality••
Health Scope Hospital Ratings••
California Healthcare Foundation, ••
Patients’ Evaluation of Perfor-
mance in California
The LeapFrog Group••
Health Grades••
Investing in patient safety provider
education and system improvement
are cost effective strategies. Collabora-
tive learning increased patient safety
medications. A quality improvement
project designated to reduce ADEs
within the Veterans Affairs (VA) system
using the Institute for Healthcare
Improvement collaborative methods
avoided between 589 and 740 serious
or potentially life-threatening medica-
tion errors at an estimated direct care
cost savings between $3.47 million
and $12.13 million for the six months
of the study.19 At six month follow-up,
the team remained intact, continued
to collect data, and maintained their
gains.19 A program to reduce injuries
to caregivers in handling patients at
the Veterans Health Administration
(VHA) that involved an ergonomic
assessment protocol, patient handling
technology, decision algorithms to se-
lect equipment, and guidelines for safe
patient handling, decreased incidence
and severity of injuries, produced satis-
faction with the equipment, decreased
workers’ compensation claims $200,000
per year, and a payback of 4.30 years.49
Also, having a pharmacist participating
in patient rounds with the Intensive
Care Unit (ICU) team, Brigham and
continued from pg. 16
Patient Safety
Winters, B.D., Pham, J., & Pro- ❖
novost, P.J. (2006). Rapid Response
team-Walk don’t run. Journal of the
American Medical Association, 296,
1645-1647.
✦
28 CAHQ Journal, Quarter 1, 2008
Women’s Hospital reduced the ADE
rate in its ICU from 33.0 to 11.6 per
1,000 patient day.50, 51
Investing in patient safety initia-
tives helps reduce deficient hospi-
tal care and persistent healthcare
disparities. 52 A broad body of research
has documented deficiencies in patient
safety and healthcare quality: only
50 percent of patients receive recom-
mended preventive care;53 persistent
healthcare disparities across a range of
illnesses and healthcare services has
been found;54 55 and more than half of
patients are worried about the safety of
their care and the quality of healthcare
they receive.37 Researches have found
a major association between a patient’s
health literacy, healthcare provider
communication, and patient safety.56,
57 Investing in patient safety initiatives
that increase healthcare provider-patient
communication, cultural competency,
and language access are valuable patient
safety strategies that help reduce health-
care disparities and improve patient
satisfaction and clinical outcomes.
Consider the high costs of not having
proper communication and linguistic
access:
A 22-year-old, non-English-speaking
man was awarded a lifetime settlement
of $71 million because the emergency
department failed to detect a stroke.
His mother used the Spanish word “ in-
toxicado” but the ED staff understood
that he had a drug overdose.58 Like in
this case, medical errors are prevalent,
expensive, and often preventable. It is
estimated that within U.S. hospitals,
medical errors could unnecessarily cost
the healthcare system between $17 and
$29 billion annually causing up to
98,000 deaths per year.3, 4
The family of a deceased 36-year-old
Low English Proficiency (LEP) woman
received $900,000 in a settlement after
her flu-like symptoms turned out to be
a fatal case of bacterial meningitis. This
hospital ED staff treated and dis-
charged her, using one of the patient’s
semi-fluent friends as an interpreter.
Key symptoms were never interpreted,
leading to misdiagnosis and the pa-
tient’s death.58
Investing in safer patient initiatives
facilitates accreditation and partner-
ships with stakeholders. Stakehold-
ers, accreditation agencies, and patient
safety organizations are working togeth-
er to create an environment that fosters
safety measures. Aligning with patient
safety stakeholders will bring strategic
benefits to California hospitals promot-
ing a unified message, common goals,
and standard measures. CMS’s quality
improvement initiatives; Institute of
Medicine’s reports on patient safety and
medical errors; Institute for Health-
care Improvement’s Five Million Lives
campaign; National Quality Forum’s
“Never Events”; and the Agency for
Healthcare Research and Quality’s
patient safety and quality initiatives, to
name a few, are aligned with the Joint
Commission 2008 National Patient
Safety Goals.
Investing in patient safety initia-
tives moves a hospital toward achiev-
ing the Joint Commission’s 2008
National Patient Safety Goals. Proac-
tive investing in patient safety initia-
tives provides a hospital with a strategic
position to more rapidly achieve the
Joint Commission’s 2008 National
Safety Goals, which are to:
Improve the accuracy of patient ••
identification.
Improve the effectiveness of com-••
munication among caregivers.
Improve the safety of using ••
medications.
Reduce the risk of healthcare-asso-••
ciated infections.
Accurately and completely ••
reconcile medications across the
continuum of care.
Reduce the risk of patient harm ••
resulting from falls.
Reduce the risk of influenza and ••
pneumococcal disease in institu-
tionalized older adults.
Reduce the risk of surgical fires••
Encourage patients’ active involve-••
ment in their own care as a patient
safety strategy.
Hospital acquired pressure ulcers ••
(decubitus ulcers).
Hospitals that invest in error-
reduction initiatives now are better
prepared for patient safety legisla-
tion requirements. Legislation is a
contributing force to adopt patient
safety initiatives in hospitals. About
one-third of the states have established
mandatory reporting of errors following
recommendations from the Institute
of Medicine’s To Err is Human and in
part because of fear of litigation.60 Cali-
fornia legislation mandating a plan to
substantially reduce hospital medication
errors has generated an unprecedented
amount of patient safety activity.61
CAHQ Journal, Quarter 1, 2008 29
Examples of state error reduction
legislation are:
The approval of legislation •• SB 1875
in 2002 that required hospitals, as
a condition of licensure, to create
medication error reduction plans.62,
63
The •• Patient Safety and Quality
Improvement Act of 2005, which
mandates the creation of Patient
Safety Organizations (PSOs) to
collect, aggregate, and analyze
confidential information reported
by healthcare providers.
California Legislation Requires ••
Quality Assurance Programs in
Pharmacies, the California passed
Senate Bill 1339 in 2000, which
requires pharmacies to establish
quality assurance programs to
reduce the frequency of medica-
tion errors and requires the Board
of Pharmacy to adopt a regula-
tion specifying the requirements
of a pharmacy quality assurance
program. A goal of the legislation
was to move the quality improve-
ment process away from blaming
individuals and move towards
improving systems to minimize
future occurrences of medication
errors.
SB 797•• , that establishes a prescrip-
tion-monitoring program in the
Department of Health and Senior
Services.
Selected Organizations Accelerating the Patient Safety Movement
Organizations DescriptionJoint Commission Requires organizations to establish quality and patient safety standards and monitor
performance.
CMS Services Implements quality and safety improvement initiatives in hospitals and other clinical
healthcare settings.
Institute of Medicine Calls for mandatory reporting of medical errors in the U.S.
OSHA Occupational Safety and
Health Administration
Requires reporting of all occupational injuries and illnesses.
National Patient Safety
Foundation
Acts as a resource for improving the safety of patients by bringing together diverse
stakeholders, and holding annual congresses on patient safety.
Agency for Healthcare Research
and Quality
Promotes research in the areas of patient safety and quality improvement.
The Commonwealth Fund Releases a report presenting 10 case studies of healthcare organizations that have
designed and implemented patient safety initiatives.
Institute for Healthcare
Improvement
Accelerates change in healthcare quality and patient safety initiatives.
Leapfrog Group Promotes safety measures: CPOE adoption, evidence-based hospital referral, ICU
staffing by physicians trained in critical care medicine.
United States Pharmacopeia Standards-setting organization for all prescription and over-the-counter medicines,
dietary supplements, and other healthcare products manufactured and sold in the
United States.
National Quality Forum “Never Events” are errors that should never, ever happen such as medication errors
and wrong-site surgery. Never events are clearly identifiable, largely preventable,
and serious adverse events for patients and healthcare organizations.59 NQF
identified 27 adverse events in six major categories: Surgical events, product or
device events, patient protection events, care management events, environmental
events, and criminal events.
30 CAHQ Journal, Quarter 1, 2008
SB 1301•• , that requires DHS to
conduct onsite investigations of
adverse events and complaints
involving general acute care, acute
psychiatric, or special hospitals
within specified timelines, and
requires the department to conduct
periodic unannounced inspec-
tions not less than once per year of
health facilities that have reported
adverse events.
Patient Safety Organizational Needs AssessmentLumetra has developed a patient safety
needs assessment that helps healthcare
organizations identify organizational
needs regarding patient safety issues.
Patient safety POTENTIAL ORGANIZATIONAL GAPS – Which areas represent possible areas for improvement in your organization?
Check all that Apply (√ )
Leadership—Involve senior leaders, CEO, and Board on patient safety issues
Systems—Create patient safety systems, policies, procedures, and processes
Requirements—Fulfill patient safety directives and regulatory requirements
Culture—Establish a culture that makes patient safety a top priority
Education—Conduct house-wide staff training on patient safety principles
Communication—Increase communication between individuals and teams
Quality Improvement—Develop and implement patient safety interventions
Technology—Integrate health information systems and data management
Medication—Implement effective systems to reduce medication errors
Patients—Involve patients, families, and caregivers in patient safety
Coordination—Maintain patient safety that spans the continuum of care
Evaluation—Monitor effectiveness of the overall patient safety program
Other:
Patient safety IMPROVEMENT AREAS – Which areas would be most helpful to improve patient safety in your organization?
Check all that Apply (√ )
Leadership engagement with patient safety initiatives
Process design, implementation, and human factors improvement
Evaluation of current compliance with National Patient Safety Goals
Organizational culture change assessment and improvement
Education and training in patient safety culture, improvement, and results
Situation communications, teamwork training, and Team STEPPS
Identification of patient safety risks and design of improvement interventions
Evaluation of opportunities to integrate information systems and use data well
Medication reconciliation strategies, and prevention of adverse drug events
Patient and family education techniques and programs
Coordination at time of transfer between care settings or providers
Program assessment and evaluation methodology
Other:
CAHQ Journal, Quarter 1, 2008 31
Please review it with your leadership
team to discuss patient safety priorities
and action areas.
Conclusion
Evidence and expert-based patient safety solutionsCurrently, California hospitals are
searching for cost-effective patient
safety strategies. Many are implemented
evidence- and expert-based patient
safety solutions in the areas of:
Linking incident reporting with
provider education and quality
improvement. Incident reporting and
continuous performance measurement
have been successfully used in conjunc-
tion with collaborative learning and
practitioner feedback to educate provid-
ers and organizations in patient safety
culture and improvement.
Systems improvement and process
redesign patient safety solutions.
System-wide patient safety initiatives
such as organizational design, pro-
cess improvement, reminder systems,
clinical pathways, and standing orders
streamline processes, save money, and
improve clinical outcomes.
Creating a patient safety culture.
Hospitals are creating a culture in
which healthcare providers feel respon-
sible for the safety of every patient,
every time. Hospitals are changing
from a culture of blame to a culture of
safety so that providers can report errors
freely. Systems are changed, and staff
are accountable for behavior choices.
Patient safety technology. Health
information technology - including
computerized physician order entry,
decision support systems, electronic
health records, and bar code medication
administration - improve the quality,
safety, and efficiency of hospital care.
Provider’s cross-cultural com-
munication and patient activation.
Hospitals are investing in patient safety
initiatives that focus on the develop-
ment of provider’s cultural competency
including effective provider-provider
and provider-patient cross-cultural
communication to reduce medical er-
rors. Such patient safety strategies are
directed to create effective communica-
tions systems among providers, improve
the accuracy of patient identification,
increase language access, and promote
patients’ active involvement in their
own care.
A growing national movement is
raising the bar for patient safety. Pa-
tient safety organizations, accreditation
agencies, and stakeholders are making a
national call to work together to create
an environment that fosters increased
safety. Investing in patient safety solu-
tions and aligning with stakeholders
will bring strategic benefits to Califor-
nia hospitals promoting a unified mes-
sage, common goals, and standardized
measures.
The benefits of investing in patient
safety initiatives are considerable.
The benefits of creating safer operating
systems and processes that minimize
the likelihood of errors and accidental
injury are substantial: protect the bot-
tom line, provide better patient care,
improve patient satisfaction, increase
employee productivity, prepare for pay-
for performance and public reporting,
build goodwill and reputation, avoid
exposure to litigation, maintain ac-
creditation, and comply with legislation
requirements.
For author biographies see page 48.
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39. Renner K. Cost-justifying electronic
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40. Bates DW, Leape LL, Cullen DJ, et
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41. Hunt DL, Haynes RB, Hanna
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42. Shea S, DuMouchel W, Baha-
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44. McMullin S LT, Rynearson C,
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1998;280(15):1317-1320.
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47. Institute of Medicine. Perfor-
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Improvement. Washington: The
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48. Grossbart SR. What’s the return?
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51. General Accounting Office (US).
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57. Ross J. Health literacy and its influ-
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63. California HealthCare Founda-
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✦
1
MCLE &
CEUs OFFERED!!
Patient Safety & Elder Care IssuesCAHQ Spring Conference March 10 – 12, 2008
conference objectivesStrategically leverage opportunities for integration and col-I.
laboration.
Integrate functions and data for efficient solutions for safer II.
patient care.
Describe changes in regulatory standards and California III.
law.
Network with others to stimulate creative problems solving.IV.
Presenter biograPhiesKathleen Billingsley, R.N.—“Using the CDPH Survey to Your
Advantage”
Kathleen Billingsley. R. N. is the Deputy Director of the Center
for Healthcare Quality within the Department of Public Health.
Having had a great deal of experience in health care admin-
istration and operations, Ms. Billingsley has worked extensively
in the regulatory environment as well as in the areas of quality
improvement. She is committed to working closely with consum-
ers, representatives of the industry and advocates.
Julie Braun J.D., LL.M., MD—“Patient Safety: Legal
Implications”
Julie A. Braun, a graduate of the University of Illinois with a
Master of Laws in Health Law from DePaul College of Law
(Chicago), is a Chicago-based attorney and writer. Ms. Braun,
dedicates her practice to health and elder law with an emphasis on
long-term care litigation. She teaches, writes, and lectures exten-
sively on health, elder law, and long-term care topics. Ms. Braun,
also a physician, is an internationally recognized expert in the field
of long-term care litigation, is a visiting professor at various legal
and medical institutions, including Emory University in Atlanta
and the Universities of Osnabrueck and Witten in Germany.
Steven Charles Castle, MD—“Falls and Restraints: What
Constitutes Abuse?”
Dr. Castle is board certified in Internal Medicine and Geriatric
Medicine. He is a Professor of Medicine at UCLA and the Clinical
Director of Geriatrics at the VA Greater Los Angeles. He has been
recognized with many awards, including Clinician of the Year by
the American Geriatrics Society, and One of LA’s Best Doctors
by Los Angeles Magazine. He has been the recipient of two grants
from the National Institute of Aging, and several teaching awards
at UCLA. He has published over 100 papers, abstracts and book
chapters and given nearly 300 invited lectures.
Alan Y. Endo, Pharm. D., FCSHP—“Black Box Warnings”
Alan Endo, Pharm.D. graduated from University of Southern
California School of Pharmacy in 1971 and has been a practicing
hospital pharmacist since then. He has worked in a number of dif-
ferent practice settings from small community hospitals to major
teaching institutions. He is currently past president and Chairman
of the Board of Directors for the California Society of Health-
System Pharmacists.
Charlene Harrington Ph.D., RN, FAAN—“Quality of Care in
Nursing Homes: Nursing Home Policy Issues”
Charlene Harrington, Ph.D., RN, FAAN, is Professor of Sociology
and Nursing in the Department of Social and Behavioral Sciences,
Identify and assess quality care and the lack thereof in the V.
elderly.
Distinguish the difference between elder abuse medical VI.
malpractice.
Identify legal strategies for protecting your patients, facili-VII.
ties, and staff.
Discover how the NEVER 28 will affect YOU!VIII.
Outline three ways you can use the CDPH survey process IX.
to your advantage.
List 3 things to do and not do during your deposition.X.
CAHQ Spring Conference March 10 – 12, 2008 Patient Safety & Elder Care Issues
School of Nursing, University of California, San Francisco. She
was appointed deputy director of the California Licensing and
Certification program, where she was instrumental in strengthen-
ing the regulation of nursing homes and hospitals in California.
Dr. Harrington served on the Institute of Medicine (IOM)
Committee on Nursing Home Regulation whose l986 report led
to the passage of the Nursing Home Reform Act of l987. She is
Associate Director of the John A. Hartford Center for Geriatric
Nursing Excellence and Director of the new doctoral program in
nursing and health policy at UCSF. She has before the US Senate
Special Committee on Aging, and has written more than 200 ar-
ticles and chapters and co-edited five books while lecturing widely
in the U.S. and the U.K.
Martha J. Hawkins, RN, BSN, CWOCN, GNC, CCM—
“Pressure Ulcers and Wound Care”
Marti Hawkins, is a certified wound, ostomy and continence
(WOCN) nurse, a certified geriatric nurse and a certified case
manager. She is a wound care consultant for St. Alphonsus
Regional Medical Center and Horizon Home Care and Hospice in
Boise, Idaho. Ms. Hawkins has presented nationally at conferences
on prevention and treatment of pressure ulcers and the associated
legal issues.
Mark Kleiman, Esquire—“Whistle-blower... To Be or Not To
Be?”
Mark Kleiman is the former Executive Director of the Consumer
Coalition for Health in Washington, D.C. As a trial attorney for
seventeen years, he has prosecuted doctors, hospitals, and nursing
homes for consumer fraud and malpractice. In the process he has
represented nurses, doctors, engineers as well as other whistleblow-
ers in the defense, construction, and education industries.
Mr. Kleiman has consulted with the U.S. Department of
Health and Human Services, the American Public Health
Association, and the American Cancer Society. He has served on
an FDA Advisory Panel and on the boards of state licensing agen-
cies and national health care organizations.
Mr. Kleiman has served as a Special Master during investiga-
tions of fraudulent medical-legal activities in cooperation with the
California Department of Insurance and the Los Angeles County
District Attorney’s Office.
Jeffrey Levine, MD—“Risk Management in Geriatric Care”
Dr. Levine is a physician with twenty years of clinical and adminis-
trative experience in geriatrics and long-term care. He received his
fellowship training in geriatrics at the Mount Sinai Medical Center
in Manhattan, where he spent much of his career on the clinical
faculty. He currently has a hospital-based wound care practice.
He is board certified in Internal Medicine, is a Certified Medical
Director, Certified Wound-care Specialist, and holds a Certificate
of Added Qualifications in Geriatrics. Dr. Levine’s professional
focus is improving the quality of care delivered to elderly persons.
Della Lin, M.D.—“Protecting Patient Safety During Handoff
Communication”
Della Lin, MD, is a frequent speaker and author in the field of pa-
tient safety, reliability and quality initiatives. She has been on the
National Patient Safety Foundation Annual Conference Faculty
for the last several years, was an inaugural Health Forums Patient
Safety Leadership Fellow in 2003, and is a member of the Estes
Park Institute Faculty. Dr. Lin has served as Department Chief of
Anesthesiology, on hospital MEC, Peer Review and Credentialing
committees, is the Executive Director of Continuing Medical
Education at Queen’s Medical Center in Honolulu and is currently
a board member at various health care entities.
Jones Loflin—“Success Without Getting Squashed”
Drawing on skills honed as an educator, business owner, and
speaker, Jones has created and conducted training programs for
groups ranging from international corporations and trade associa-
tions to governmental agencies and educational institutions. Jones’
insightful programs regularly include the use of humor, powerful
examples and frequent audience involvement and interaction. Jones
is co-author of the book, Juggling Elephants, which is available in
CAHQ Spring Conference March 10 – 12, 2008 Patient Safety & Elder Care Issues
the US and in over 12 foreign countries. He is the author of Prime
Rib or Potted Meat?, a humorous and thought-provoking collec-
tion of his ideas on getting more out of life. Jones is also a member
of the American Society of Training and Development.
Debby Rogers, RN, MS, Vice President, Quality and
Emergency Services California Hospital Association—“New
Regulations and Legal Implications. Serious Reportable
Events: Reporting, Liability, and Press Releases”
Debby Rogers is the Vice President for Quality and Emergency
Services for the California Hospital Association. Debby has an ex-
tensive background in state service. She was the Associate Secretary
for Legislative Affairs for the California Health and Human
Services Agency where she was responsible for coordinating all
legislation within the agency. Ms. Rogers spent 10 years with the
Legislature as a consultant on Health and Human Services issues.
Marcia Ryder PhD MS RN—“Healthcare Acquired Infections”
As a national and international educator and instructor, Dr. Ryder
has conducted over 80 specialty nursing courses and presentations.
Her publishing credits include over 25 articles and book chapters
on topics including biofilm-related infections, vascular access
device selection, central venous catheter complications and other
vascular access device subjects.
Suzanne Williams, RN, CPHQ, FNAHQ
As a healthcare professional with over 25 years of hospital acute
care experience and 10 years plus in managed care, Ms. Williams
has acquired the expertise to develop, establish and lead perfor-
mance improvement, utilization and case management programs.
Elder Abuse Mock Trial Participants
Honorable Judge Bruce J. Einhorn
The Honorable Bruce J. Einhorn has served as a United States
Immigration Judge in Los Angeles since July 29, 1990. In that
capacity, he has presided over civil prosecutions initiated by the
U.S. Department of Homeland Security (DHS) against non-
citizens in the United States whose lawful presence here has been
placed into question by counsel for the government. He has also
received a Lifetime Professional Achievement Award from the
California State Bar. Since 1991, Judge Einhorn has served as an
Adjunct Professor of International Human Rights Law and War
Crimes Studies at Pepperdine University School of Law in Malibu,
California. In 1997, Judge Einhorn received the Law School’s
David McKibbin Excellence in Teaching Award. He is a member
of the Bar of the United States Supreme Court, and the American
Bar Association.
Henry P. Canvel, Esquire Gordon and Rees, LLP
Henry P. (“Rick”) Canvel is a litigation partner practicing exclu-
sively in the defense of elder abuse claims representing primarily
extended care, skilled nursing and residential care facilities, and
further defends hospital and nursing registries.
He received his B.A., summa cum laude, from University
California - Berkeley and his J.D. Degree from University of
California - Hastings. Mr. Canvel has extensive national speaking
experience on elder abuse topics before numerous groups includ-
ing American Baptist Homes of The West, Andrews Publications,
Lorman Educational Services and Covenant Care of California,
Inc. He is also a member of the California Association of Health
Facilities (CAHF), and the American Health Association.
Stephen Garcia, Esquire—The Garcia Law Firm
Stephen M. Garcia has specialized in civil trial practice since 1994,
following nine years of focusing on criminal trial advocacy. He
has served as lead counsel on behalf of disenfranchised consumers
in cases including, insurance bad faith, medical malpractice, elder
abuse and products liability.
Mr. Garcia was trial counsel in the matter of Muccianti vs.
Fountain View, Inc., et al. the largest nursing home verdict in
the history of Fresno County and the then second largest nurs-
ing home verdict in the history of the State of California. The
Muccianti punitive damage award was noted to be one of the ten
largest punitive damage awards in the State of California in the
CAHQ Spring Conference March 10 – 12, 2008 Patient Safety & Elder Care Issues
year 2001. Mr. Garcia is one of the only attorneys in the State of
California to have tried to conclusion multiple matters based upon
theories of elder and/or dependent adult abuse issues. Mr. Garcia
is the only California attorney who has tried multiple elder abuse
actions to have not received a complete defense verdict in any elder
abuse trials.
Peter K. Levine, Esquire—Peter K. Levine Law Firm
Mr. Levine has been practicing law since 1978 and is a member
of both the New York and California Bar Associations. His firm
represents individuals and families in serious catastrophic injury
matters. Mr. Levine’s firm includes practice areas of Medical
Malpractice, Elder Abuse, Wrongful Death, Personal Injury,
Employment Law, Discrimination, and Sexual Harassment.
John Supple, Esquire—Gordon & Rees, LLP
John L. Supple is a litigation partner with the law firm of Gordon
& Rees LLP, and the leader of the firm’s Health Care Practice
Group. Mr. Supple, specializes in the defense of the health care in-
dustry including medical malpractice and all aspects of elder abuse
litigation. Mr. Supple has dedicated his entire career to the defense
of health care providers including physicians, hospitals, skilled
nursing and assisted living facilities.
Mr. Supple is a member of the California Association of Health
Facilities (CAHF), the Northern California Association of Defense
Counsel, the American Society of Hospital Risk Managers, the
California Society of Hospital Risk Managers and the California
Medical Legal Committee.
Mr. Supple was chosen as one of Northern California’s “Super
Lawyers” by his peers in the field of health care for 2006. Mr.
Supple’s successful defense of a nursing home sued for wrongful
death, elder abuse and fraud, was selected by the California Daily
Journal as one of the Top 10 Defense Verdicts for 2006. The plain-
tiffs sought $14 million in damages, and the jury rejected all claims
for compensatory and punitive damages.
Tricia West, R.N., BSN, MBA/HCM, PHN, LNC
CEO P.J. West and Associates, Inc. Medical Legal Consulting
Tricia West is founder and chief executive officer of P.J. West and
Associates, Inc., a medical legal consulting firm. Since 1980, Ms.
West is a legal nurse consultant supporting the legal profession
in all areas of practice, including medical malpractice, personal
injury, elder and dependent abuse, criminal, and billing fraud.
Ms. West is a Past President of CAHQ, past Editor of the CAHQ
Journal and current Education Co- Chair. She is a past President
of the American Association of Legal Nurse Consultants Los
Angeles. She is a member of the Los Angeles County and San
Fernando Valley Bar Associations, as well as an arbitrator for the
San Fernando Valley Bar Association. She is also a member of the
Lumetra Hospital advisory council. Ms. West has numerous publi-
cations as well as more than twenty years of teaching experience to
both professionals and patients.
2008 cahQ education committeeCo-Chair: Tricia West, RN, BSN, MBA/
HCM, PHN, LNC
Co-Chair: Jada Salamatian, RN
Lauri Church, CPHQ
Jennifer Hoke, RN, MSN, RNC II
Tricia Kassab, RN, MS, CPHQ
Eliot Kreun, LVN, CPHQ
Pat Luken, RN, MN, CPHQ
Beverly Roberts,R.N. CPHQ
Debby Rogers, RN, MS, CPHQ
CAHQ Spring Conference March 10 – 12, 2008 Patient Safety & Elder Care Issues
Pre-conference WorkshoP (Sponsored by the Healthcare Quality Certification Board)
Monday March 10, 8:00 AM – 12:00 Noon
Suzanne Williams, RN, CPHQ, FNAHQ
Competency Testing: The CPHQ Exam in Motion
Explore the absorbing process of writing exam items for the
Certified Professional in Healthcare Quality (CPHQ) examina-
tion. Gain valuable information about the process of assessing
competency in the workplace. Gain insight from the discussion of
test-taking philosophies and strategies and the experience of learn-
ing how questions are developed and sanctioned for the CPHQ
exam. Discuss the development of the CPHQ exam. State the com-
ponents of a clear, concise test question. Identify 3 cognitive levels
of thinking. Describe the elements of a valid competency examina-
tion. Discuss the use of this information in the workplace to assess
the competency of employees.
conference information
Who should attend?
Professionals responsible for quality management and/or organizational improvement in all areas of
health care delivery including: Compliance/Safety Officers, Nurse Leaders, Risk Managers, Healthcare
Administrators Consultants, QI/UR Professionals, Legal Nurse Consultants, Managed Health Care
Professionals, PI Professionals, Case Managers, Infection Control Practitioners, Medical Staff Leaders,
Attorneys, Legal Nurse Consultants, Paralegals and Judges dealing with medical related legal issues.
Continuing Education
This program is approved by the California Board of Registered Nursing, provider number 03370, for 20
contact hours. This activity will be submitted to the National Association for Healthcare Quality for 8.0
CPHQ CE credits. Approved for MCLE credits by the California State Bar Association.
Registration
Due to limited space, all registrations must be postmarked by March 1, 2008. You may pay by credit
card or by check, payable to CAHQ. Email confirmation will be sent to each participant – be certain to
provide us with your email address. Registration will only be guaranteed with receipt of payment. On-site
registrations will be accepted with full payment on a first-come, first-serve basis. As it is difficult to predict
room temperature, please bring a sweater or jacket.
Cancellation Policy
ALL CANCELLATIONS MUST BE MADE IN WRITING by mail or fax (see above for contact in-
formation). A $75 processing fee will be charged for cancellations and/or registration transfer. No refunds
will be provided for cancellations received after March 2, 2008. Registrants who are unable to attend may
send an alternate, provided they notify CAHQ in writing prior to March 1, 2008. In lieu of canceling for
a refund, you may transfer your credit to any other CAHQ educational function until July 30, 2008. A
transfer fee of $75.00 will apply.
CAHQ Spring Conference March 10 – 12, 2008 Patient Safety & Elder Care Issues
Tuition
Pre Conference, March 10, 2008 8:00 – 12:00 pm • • • • • • • • • • • • • • • • • • • • • • • •$75.00
CAHQ Member Full Conference• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •$499.00
Conference and Join CAHQ• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •$575.00
Non CAHQ Members • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •$675.00
Mock Trial Only• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •$350.00
Mock Trial is on March 12, 2008
10% discount for groups of 3 or more people registering at the same time, in the same payment.
Accommodations
Sheraton Universal Hotel. Special Group Room Rate $189 +
tax. Includes free Internet access. Group rates available until
February 20, 2008. Subject to availability. Make reserva-
tions directly with the Hotel at (818) 980-1212 or through
Sheraton’s Central Reservation Office at 888-627-7186 on
an individual basis, identifying yourself as a member of the
CAHQ group. Visit CAHQ’s website for more information,
www.cahq.org or book your reservation online at
http://www.starwoodmeeting.com/Book/CHC09B
Universal Sheraton Hotel
333 Universal Hollywood Drive
Universal City, California 91608
United States
Phone: (818) 980-1212
Fax: (818) 985-4980
Parking Rates(charged by hotel)
Daily Rates:
$10.00 for self-parking
$14.00 for valet parking
Overnight Rates (with in and out
priviledges)
$16.00 for self-parking
$21.00 for valet parking
conference agendaMonday March 10th, 2008
7:00 – 8:00 am Registration
8:00 – 12:00 pmPre Conference Workshop
Terrace ACompetency Testing: The CPHQ ExamSuzanne Williams, RN, CPHQ
11:00 – 1:00 pm
Registration and meet our ExhibitorsStudio Suites
1:00 pm – 1:15 pmWelcome
Julie Booth, CAHQ President
1:15 pm – 2:45 pmKey Note Speaker: Success Without Getting Squashed—
Juggling ElephantsEast BallroomJones Loflin
CAHQ Spring Conference March 10 – 12, 2008 Patient Safety & Elder Care Issues
2:45 pm – 3: 00 pmVisit our Exhibitors and Enjoy a Snack
Studio Suites
3:00 – 4:00 pm
Track AEast BallroomWhistle-blower…To Be or Not To BeMark Kleiman, Esquire
Track BProducer/Director/WriterRisk Management in Geriatric CareJeffrey Levine, M.D.
4:00 pm – 5:00 pmHealthcare Acquired Infections
East BallroomMarcia Ryder, PhD, MS, RN
Monday (cont’d)
7:00 – 8:00 am Registration and Continental Breakfast with our Exhibitors
Studio Suites
8:00 – 8:15 am Welcome
8:15 am – 9:45 am
Using the CDPH Survey to your AdvantageEast BallroomKathleen Billingsley, Deputy Director of Center for
Health Care Quality, CA Dept of Public Health, Licensing & Certification
9:45 am – 10:10 am Break with our ExhibitorsStudio Suites
10:10 am – 11:10 am
Quality of Care in Nursing Homes—Nursing Home Policy Issues
East BallroomCharlene Harrington, PhD. Professor of Sociology
and Nursing, Dept. of Social & Behavioral Sciences
Tuesday March 11th, 2008
CAHQ Spring Conference March 10 – 12, 2008 Patient Safety & Elder Care Issues
11:10 am – 12:25 am
New Regulations and Legal Implications— A Panel Discussion
East BallroomKathleen Billingsley, R.N., Deputy Director of
Center for Health Care Quality, CA Dept of Public Health, Licensing & Certification
Debby Rogers, RN, MS, Vice President, Quality and Emergency Services California Hospital Association
Tricia West, R.N., BSN, MBA/HCM, PHN, LNC CEO P.J. West and Associates, Inc. Medical Legal Consulting
12:25 pm – 1: 30 pmLunch
Rooftop Garden TerraceAnnual Meeting
1:30 pm – 2:30 pm
Track AProducer/Director/WriterPatient Safety—Legal ImplicationsJulie Braun, J.D., LLM, M.D.
Track BEast BallroomBlack Box WarningsAllen Endo, Pharm. D.
2:30 pm – 3:30 pm
Track AProducer/Director/WriterFalls and Restraints Steve Castle, M.D.
Track BEast BallroomHandoff CommunicationDella Lin, M.D.
3:30 pm – 3:45 pm
Break with our Exhibitors Studio Suites
3:45 pm – 5:00 pmWounds and Wound Care
East BallroomMartie Hawkins, RN, BSN, CWOCN, GNC, CCM
5:00 pm – 8:00 pmCocktail Reception
Roof Top Garden Terrace
Tuesday (cont’d)
CAHQ Spring Conference March 10 – 12, 2008 Patient Safety & Elder Care Issues
7:00 am – 8:00 amRegistration and Continental Breakfast with
our ExhibitorsStudio Suites
8:00 am – 8:15 am
Welcome and IntroductionsEast BallroomTricia West, R.N., BSN, MBA/HCM, PHN, LNC
CEO P.J. West and Associates, Inc. Medical Legal Consulting
8:15 am – 5:00 pm
Judge Bruce EinhornTricia West, R.N., BSN, MBA/HCM, PHN, LNC
CEO P.J. West and Associates, Inc. Medical Legal Consulting
Defense Counsel Rick Canvel, EsquireJohn Supple, Esquire
Plaintiff CounselStephen Garcia, EsquirePeter K. Levine, Esquire
* Due to the dynamic process of the mock trial these times are flexible. Breaks with our Exhibitors will be from approximate-ly 10:00 – 10:20 am and 3:10 – 3:30 pm. Lunch will be served in the Rooftop Garden Terrace from 12:15 – 1:20 pm
Wednesday March 12th, 2008
registrationName _______________________________Title ________Organization ______________________________Mailing Address ____________________________________________________________________________City __________________________________________________State _____________Zip _______________Telephone ( ________ ) ______________________E-mail __________________________________________Master Card Visa Number _______________________________Exp. Date _______________ADA/Dietary Requirements __________________________________________________________________ __________________________________________________________________________________________Registration _____________________________________$ ________________Total $ ________________
Mail to:
The California Association
for Healthcare Quality
P.O. Box 70819
Pasadena, CA 91117-7819
Please mail by March 1, 2008
Or Fax Credit Card Registrations to: (626) 793-7417
(If you fax this form, please do not mail the original)
For more information, contact CAHQ at 1-800-230-3163 or
(626)793-7125
CAHQ Spring Conference March 10 – 12, 2008 Patient Safety & Elder Care Issues
SAVE THE DATE
THANKS TO OUR SPONSORS
2008 Healthcare Quality Overview and Certification Workshops
Offered by Janet Brown and CAHQ
Thursday and Friday July 24 – 25, 2008
Thursday and Friday October 16 – 17, 2008
Avatar Medmined
LifeStar
Peminic Mercy Air St. John’s
46 CAHQ Journal, Quarter 1, 2008
In the November 2007 issue of The Bottom Line, Donna Grant described
the use of “My Story.” This tool is used by both hospital staff at St Mary
Medical Centers ICU as well as the patients they serve. Each learns more
about each other and thus care is more holistic.
I learned that our local Apple Valley Fire Department (AVFD) finds a way
to also connect with those they serve. A few days before Christmas, AVFD
staff came to SMMC along with Santa. They planned to visit the pediatric
unit but ended up touring most of the hospital.
On one unit that we had not planned to visit, a patient’s wife greeted the
AVFD staff and asked which station they were from. She recognized them
from the 911 rescue call they responded to which brought her husband to
the hospital. Tears filled her eyes as she thanked them for the card they sent
to her home. Each crew member had signed the card. They do this routinely
not just at the holidays. She could not thank them enough as she had
obviously been very touched by this caring.
Santa and the firefighters went to her husband’s bedside and silently paid
their respects. He had suffered a massive stroke. One of the AVFD disaster
preparedness personnel had tears in her eyes. She was not aware that they
had done this before. I was also holding back tears. I took Santa and his
helpers to see the, “My Story Board,” inside our ICU. I showed the one of
Denise Nunez, (who was featured in the bottom line in November). It just
happened that Denise was steps away and got to greet the crew. The fire
chief received a copy of a My Story kit; he felt it was very nice. The crew
remarked that they should come to visit the folks that they rescue more often.
Gifts That Keep on GivingPat Lucken, FNP-C, CPHQ
What a lovely thought that these men & women who would give their
life to save you, who serve 24/7 for unforeseen disasters and everyday
emergencies could care so much.
Also, while touring the facility I noticed a woman hand gifts to a staff
member on the maternity ward. No fanfare, just a quick anonymous hand
off of the gifts. Later when I told our medical staff director Anna Beber
about the day’s events she told me of yet another story of caring. Anna
mentioned an anonymous physician who, is a member of the Cardiology
Division of Upland Anesthesia Group, comes in each Christmas to give gifts.
He cannot find a Santa suit to fit his daughter so he dresses her as an elf.
They are not of a Christian tradition but he wants his daughter to know the
values of compassion and giving.
Reflecting about cards sent to the home of a family in crisis, a visit to the
hospital by a rescue crew, a post discharge phone call from a staff member
or an anonymous gift left at the hospital during the holiday, one can see
the privilege of caring . How truly magnificent this sacred work could be if
spread throughout healthcare. One would have a revolution of caring.
Happy New Year
Pat Lucken
CAHQ Journal, Quarter 1, 2008 47
48 CAHQ Journal, Quarter 1, 2008
Authors’ BiographiesBiographies inadvertently
omitted from November 2007 issue
Martie Hawkins, RN, BSN,
CWOCN, CGN, CCM is a certified
Wound, Ostomy Continence Nurse
Consultant at St. Alphonsus RMC in
Boise, Idaho. She also consults with
Horizon Home Care and Hospice. She
has presented at several conferences
around the country on topics such as
prevention and treatment pressure ul-
cers and the legal issues associated with
pressure ulcers.
Martie can be reached at marti-
Susan Moss. Susan is a Quality Spe-
cialist for American Medical Response
(AMR).
Susan can be reached at Susan_
Donna Grant, RN. Donna is a
Registered Nurse and Supervisor of the
Intensive Care Unit at St. Mary Medi-
cal Center in Apple Valley, Ca. Donna
can be reached at Donna.Grant@stjoe.
org
February, 2008Kathleen Tornow Chai is an ener-
getic proponent for healthcare quality.
For the past two years she has been the
Director of Education and Quality at
Kaiser West Los Angeles. In this role
she currently oversees quality, patient
safety, risk management, medical staff
office, inpatient medical records, and
staff education. Prior to that Kathy
worked full time for her own consulting
firm, KTC Consulting, and traveled
nationally providing assistance to
organizations needing advice in quality,
accreditation and licensure and nursing
areas. As an educator, Kathy uses every
opportunity to use her educational
skills. She currently teaches in the
California State University Dominguez
Hills Masters and Bachelors in Nurs-
ing programs, the institution from
which she earned her MSN and BSN.
An energetic learner, Kathy completed
her Ph.D. in Education at Claremont
Graduate School. Her dissertation
focused on the impact of learning style
and computer and information literacy
on learning by nurses pursing post RN
degrees. Her commitment to the profes-
sional development of others frequently
extends beyond her formal professional
roles.
Kathy believes that one of the stron-
gest tools used by a quality professional
is networking and has held a number of
positions both locally with the Califor-
nia Association for Healthcare Quality
and nationally with the National Asso-
ciation for Healthcare Quality, includ-
ing Board positions. It keeps her head
filled with new ideas from the people
she meets and constantly searching for
new ways to meet the challenges in
today’s healthcare environment.
Brian J Hendrickson, EMT-P has
over 25 years of service in Public Safety
covering most all aspects related to
Emergency Medical Services (EMS).
His current positions include, Vice
President/Co-Founder – Immersive
Learning Technologies, Inc. Clinical
Coordinator/Instructor - Victor Valley
College Prem Reddy School of Health
Sciences Paramedic Academy. He is
active in Community Service and serves
with the following organizations. San
Bernardino EMS Officers Committee,
Inland County Emergency Medical
Authority Protocol Task Force, North
end (CA High Desert) EMS Q/I Com-
mittee, Member National Association
of EMS Educators
Brian can be reached at hendrick-
Pat Lucken, MSN, FNP-C, CPHQ
received her MSN/FNP from Azusa
Pacific University in Azusa Ca. She is
currently Director of Cardiac Service
Line at St Mary Medical Center, in
Apple Valley, Ca (part of the St Joseph
Health system of Orange, Ca). Pat
serves the Board of CAHQ as Journal
Co-editor for 07-08. She also serves on
the Board of Inland County Emergency
Medical Agency (ICEMA) as Secretary
for the North End Quality Committee
for 07-08.
Fabio Sabogal, PhD has more than
20 years of experience as a university
professor and researcher, and has writ-
ten more than 50 peer-reviewed journal
articles. He is a Senior Health Care
Information Specialist for the Scien-
tific Analysis Department at Lumetra,
responsible for synthesizing evidence-
based information for the Physician
Office, Health Information Technology,
Managed Care, Underserved, Hospitals,
and Home Health projects.
Fabio can be reached at Fsabogal@
caqio.sdps.org
Linda M. Sawyer, PhD, RN has
more than 30 years of expertise as a
Registered Nurse with clinical, re-
CAHQ Journal, Quarter 1, 2008 49
search, education, quality improvement
and administrative experience in diverse
healthcare settings. She is the Chief
Operating Officer at Lumetra.
Linda can be reached at Lsawyer@
caqio.sdps.org
Allison Snow, MHA is the vice
president for healthcare process
improvement at Lumetra, serving as
the organization’s chief quality and
performance improvement officer. She
provides strategic direction and opera-
tional and fiscal oversight for managers
and staff. Ms Snow represents Lumetra
to key organizations, customers, and
stakeholders to foster collaboration
at the state and national levels. She
also promotes visibility for Lumetra at
national meetings with key constitu-
ents. Allison can be reached at Asnow@
caqio.sdps.org
✦
2007 First Quarter Journal
Janet Brown, BA, BSN, RN, CPHQ, FNAHQ
Catherine Martin, BA, BSN, RN, CPHQ, FNAHQ
A Look Back Over the Past 30 Years for California Association of Healthcare Quality•••••••••••••••••••••••••••••••••• p 5
California Association of Healthcare Quality2007 Author/Article Index
CAHQ expresses gratitude for those whom have contributed articles,
press releases, reflections, book, conference and movie reviews over the past year.
A special thanks to our graphic designer Colin MacGregor!
thAnnive
rsary
thAnnive
rsary
Official publication of the California Association for Healthcare Quality
Volume 31, Number 1 1st Quarter, 2007
In this issue...
CAHQ Celebrates Years –
What is Complementary and Alternative Medicine
Physician Patient Communication and Self Management Support
In this issue...
CAHQ Celebrates Years –
What is Complementary and Alternative Medicine
Physician Patient Communication and Self Management Support
50 CAHQ Journal, Quarter 1, 2008
Tricia West RN, BSN, MBA, CHN, LNC
What is Complementary and Alternative Medicine•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 7
Pamela Simpson, RN, MSA, CPHQ
The Alexander Technique: A Better Way to Use Your Body•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 9
National Institute of Health Press Release
Older Americans Not Discussing Complementary and Alternative Medicine Use with Doctors• •••••••••••••••••••••• p 12
Nancy Lee, MS, BSN
Robin Diane Orr, MPH
The Patient Experience: Quality as a Dimension of Culture••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 13
Steven Hilles, DC, CPHQ
Lars Youngquist, DC, LAC, CPHQ
Applying Evidenced-Based Medicine to Complementary Healthcare•••••••••••••••••••••••••••••••••••••••••••••••••• p 16
Pamela Simpson, RN, MSA, CPHQ
Managing Quality in Massage Therapy••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 20
Sally Lett, DC, RN, LNC
Personal Injury: Chiropractic Medicine and Medical Legal Nurse Consultation••••••••••••••••••••••••••••••••••••••• p 22
Pamela Simpson, RN, MSA, CPHQ
Craniosacral Therapy: A Helpful Modality or a Waste of Money•••••••••••••••••••••••••••••••••••••••••••••••••••••• p 23
Pamela Simpson, RN, MSA, CPHQ
What is Six Sigma? A book Review••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 25
James Reason, Professor Emeritus, University Manchester
Beyond the Organizational Accident: The Need for “Error Wisdom” on the Frontline••••••••••••••••••••••••••••••••• p 26
The Institute for Healthcare Improvement Research Findings
IHI Press Release••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 31
Julie Booth, RN, MS, CPHQ, RHIA
Notes from Speech by JCAHO President Dennis O’Leary•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 31
Liz Augusta, RN, MSN, CPHQ, LNCC
Identification and Evaluation of one Organization’s Punitive Response to Error••••••••••••••••••••••••••••••••••••••• p 32
CAHQ Journal, Quarter 1, 2008 51
Julie Harmata Booth, RN, MS, CPHQ, RHIA
You: The Smart Patient an Insider’s Handbook for Getting the Best Treatment; A Book Review••••••••••••••••••••••• p 37
Marcie Cochran, RN, CPHQ
Setting the Table: The Transforming Power of Hospitality in Business; A Book Review• •••••••••••••••••••••••••••••• p 38
Tricia West, RN, BSN, CHN, LNC
Medical Errors and Medical Narcissism•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 40
2007 Second Quarter Journal
Jennifer Hoke, BSN, MSN, RN
Tricia West, RN, BSN, CHN, LNC
California Association of Healthcare Quality’s First Mock Trial a Success•••••••••••••••••••••••••••••••••••••••••••••• p 7
Kathleen Tornow Chai, MSN, PhD, CPHQ, FNAHQ
California Hospital Assessment and Reporting Taskforce•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 8
Debbie Rogers, RN, MS
Legislative Update••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 9
Kathleen Tornow Chai, MSN, PhD, CPHQ, FNAHQ
Learn More About National Association for Healthcare Quality•••••••••••••••••••••••••••••••••••••••••••••••••••••• p 10
Kathleen Tornow Chai, MSN, PhD, CPHQ, FNAHQ
Pandemic••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 11
Julia Slininger, RN, BS, CPHQ, Lumetra
Lessons Learned From California’s Surgical Care Improvement Collaborative••••••••••••••••••••••••••••••••••••••••• p 13
thAnnive
rsary
thAnnive
rsary
Official publication of the California Association for Healthcare Quality
Volume 31, Number 2 2nd Quarter, 2007
In this issue...
CAHQ’s First Annual Mock Trial A
Success!
Legislative Updates
Leasons Learned From California’s
Surgical Care Improvement Collaborative
52 CAHQ Journal, Quarter 1, 2008
Fabio Sabogal, PhD, Lumetra
Mindy Coots-Miyazaki, MSN, CPHQ, Lumetra,
James E Lett, MD, CMD, Lumetra
Ten Effective Care Transitions Interventions: Improving Patient Safety and Healthcare Quality••••••••••••••••••••••• p 15
Sharon Mass, PhD, ACM
Case Management A Collaborative Journey: Are we There Yet?••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 20
Debbie Buzzard, NPSGO
Pat Lucken, RN, MSN, FNP-C
The Bottom Line. Mr Hernandez, a reflection• ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 22
2007 Third Quarter Journal
Compiled by Catherine Carson, BSN, MPA, CPHQ
Modified by Kathleen Tornow Chai, MSN, PhD, CPHQ, FNAHQ
Surgical Care Improvement Project Compendium:
Operational Approaches to Improve Clinical SCIP Measure Results•••••••••••••••••••••••••••••••••••••••••••••••• p 10
Barbara Furry, RNC, MS, CCRN, FACCN
Acute Coronary Syndrome: Defining the Difference•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 14
Pamela, Simpson, RN, MSA, CPHQ
What is Managed Care and How is it Regulated?••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 15
Kathleen Tornow Chai, MSN, PhD, CPHQ, FNAHQ
Notes from NAHQ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 17
CAHQ JOURNALCAHQ JOURNAL Official publication of the California Association for Healthcare Quality
Earn CEUs for articles in this issue!
Supporting Care Management,
Improving Care Coordination:
�e Role of Electronic Health Records
Acute Coronary Syndrome: Defining the
DifferenceSurgical Care Improvement Project Compendium: Operational Approaches to Improve Clinical SCIP Measure Results
Volume , Number rd Quarter,
CAHQ Journal, Quarter 1, 2008 53
Fabio Sabogal, PhD, Lumetra
Ashley Antler, BA, Lumetra
Ana Perez, MSN, CDE, CPHQ, Lumetra
Physician-Patient Communication and self-Management Support:
Enhancing Quality of Care for the Hispanic Elderly•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 18
Dr Syed Raza, MD, FACC
Pat Lucken, RN, MSN, FNP-C
In Search of Perfect Healthcare for Heart Failure••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 26
Fabio Sabogal, PhD, Lumetra
Joseph Scherger, MD, MPH, Lumetra
Ida Ahmadpour, MPH, CHES, Lumetra
Supporting Care Management Improving Care Coordination: The Role of Electronic Health Records•••••••••••••••• p 29
Brian Hendrickson, EMT-P
Lifeguard•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••p 44
Pat Lucken, RN, MSN, FNP-C
The Bottom Line. Watercolors, a reflection•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 46
Tricia West, RN, BSN, PHN, MBA, HCM, LNC
Sicko a Review••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 47
2007 Fourth Quarter Journal
Susan Moss, Quality Specialist, American Medical Response
EMS Grand Rounds: Pre-Hospital Airway Emergency•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 11
CAHQ JOURNALCAHQ JOURNAL Official publication of the California Association for Healthcare Quality
�e Power of One: Impacting Patient Outcomes by Returning to the Basics
Pain Management
& Care of the Dying
Pressure Ulcers: Updated Definitions, Recognition & Treatment
�e Power of One: Impacting Patient Outcomes by Returning to the Basics
Pain Management
& Care of the Dying
Women’s Health Gaps: A Forgotten
Group
Women’s Health Gaps: A Forgotten
GroupPressure Ulcers: Updated Definitions, Recognition & Treatment
Volume , Number th Quarter,
54 CAHQ Journal, Quarter 1, 2008
Michael Pesce, M.D., J.D.
Pain Management and Care of the Dying••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 12
Kathleen Vollman, MSN, RN, CCNS, FCCM
The Power of One: Impacting Patient Outcomes by Returning to Basics•••••••••••••••••••••••••••••••••••••••••••••• p 15
Fabio Sabogal, PhD, Lumetra
Linda Sawyer, PhD, Lumetra
Saleema Hashwani, PhD, Lumetra
Older Women’s Health Gaps: A Forgotten Group••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 20
Notes from NAHQ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 29
Julie Harmata Booth, MS, CPHQ, RHIA
Harvard Colloquium••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 30
Martie Hawkins, BSN, CWOCN, CCM
Pressure Ulcers-Updated Definition Recognition and Treatment•••••••••••••••••••••••••••••••••••••••••••••••••••••• p 32
Office of the Governor: Press Release Legislative Update•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 56
Deborah Buzzard, NPSGO
Apple Pies•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 57
Donna Grant, RN
The Bottom Line. My Story a reflection••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• p 58
✦
CAHQ Journal, Quarter 1, 2008 55
Do you want to write an article for the CAHQ Journal?Article Submission Criteria
We at CAHQ are extremely interested in anyone who would be willing to write and share their articles with us for inclusion
in the Journal. Please submit your articles to the Co-Editors Kathy Chai at [email protected] or Pat Lucken at pat.lucken@stjoe.
org by the deadline dates of Oct 1, Jan 1, April 1, and July 1.
Article Length: Article submissions should be between 2,500 and 3,500 words.
Software: Submit articles as MicrosoftWord or CorelWordPerfect documents.
Margins: Set all margins at one inch, header and footer at 0.5 inches.
Font: Use Times New Roman or Ariel, 12 pt throughout (including title, headlines, subheadlines, etc.)
Titles: Make titles flush left and bold, in sentence format. The first word is capitalized, the rest lowercase, unless one of the
words is a proper noun.
Headlines: Make headines as short as possible and avoid punctuation. The first word is capitalized, the rest lowercase, un-
less one of the words is a proper noun.
Author: Include the author(s) name underneath the headline with all of the titles correlating to the author
Spacing: Set spacing for single space between lines of text; do not double space between paragraphs.
Alignment: Set for flush left throughout.
Paragraphs: Indent the first line of each paragraph one half inch using <Tab> instead of indent formatting or multiple
spaces. Indented quotation margins are one half inch on the left with the first line tabbed at one inch.
Bold, Italic and Underline: Do not underline anything. Make titles and first level headings bold, sentence format, no
periods. Make second level headings italic, sentence format. Avoid third level headings if possible. Use italic for emphasis
within the body of the article.
Bullet Points: If applicable, use round dark bullet points, flush left alignment.
Footnotes/Endnotes: In Microsoft Word (Windows) go to Insert > Reference > Footnote. In Microsoft Word (Mac) go to
Insert > Footnote. In Word Perfect go to Insert > Footnote/Endnote.
Graphics: If graphics are included in the article document for plaement, also submit the graphic file separately. Avoid using
graphics obtained from the internet as they are usually very poor quality. Any photographs and raster images should
be desired dimensions at 72 ppi. Accepted file formats include: JPEG, TIFF, BMP, Adobe Photoshop (PSD), PDF and
PNG. Illustrations and vector graphics (including tables and graphs) should be in one of the following formats: Adobe
Illustrator (AI), EPS, PDF or SVG.
Biography: Include a brief author’s biography of no more than 50 words at the end of the article (article authors only).
Article Summary: Include a 25-40 word summary description of your article for use on the Table of Contents.
56 CAHQ Journal, Quarter 1, 2008
Guidelines for Articles on Hospital Quality ProjectsStyle and Information SheetThe questions below can act as a guide in helping you write your article.
1) When did you start working on the project?
2) What was the purpose of the project? What were your goals?
3) What clinical measures did you work on improving?
4) Where is your hospital located?
5) What is the size of your hospital?
6) What is the size of the hospital staff? Quality improvement team staff (if applicable)?
7) What is the average patient to nurse ratio?
8) Did you or your team attend any training? Please describe.
9) Did you provide any training? To whom? Please describe.
10) What improvements did you experience and when? (Please be as specific as possible and use data, percentage points,
etc.) Provide graphs if possible.
11) Did your project result in any tools you can share? If so, please include.
12) Did you experience any other accomplishments?
13) Did you have any lessons learned that you are willing to share.
14) Who were the primary champions of the project (names and titles). Include a team picture if you can.
Save These Dates! Healthcare Quality Overview and Workshops
Janet A. Brown, BA, BSN, RN, CPHQ, FNAHQ
Janet Brown is well known in the
field of healthcare quality as a consul-
tant and educator. She is the author of
The Healthcare Quality Handbook:
A Professional Resource and Study
Guide, in its 22nd annual edition (July
2007), and has taught more than 95
Workshops nationally for healthcare
quality professionals preparing for the
CPHQ Certification Examination.
She is also co-author of Managing
Managed Care II: A Handbook for
Mental Health Professionals, in its
second edition, and a complementary
Casebook. Janet is owner of JB Quality
Solutions, Inc., and has been actively
involved with healthcare organizations
making strategic system changes for
quality improvement, resource and risk
management, and managed care. She
has served on the CAHQ Board, was
the first Chair of the National Health-
care Quality Foundation, received the
National Association for Healthcare
Quality’s National Distinguished Mem-
ber Award, and is a Past President and
current Fellow of NAHQ.
Thursday & Friday
7/24/08 – 7/25/08 &
Thursday & Friday
10/16/08 – 10/17/08
CAHQ Journal, Quarter 1, 2008 57
Thursday & Friday
7/24/08 – 7/25/08 &
Thursday & Friday
10/16/08 – 10/17/08
CAHQ, P. O. Box 70819, Pasadena, CA 91117-7819 800-230-3163 626-793-7125 FAX: 626-793-7417 www.cahq.org Tax ID #95-3647787
New Application Renewal Referred by: __________________ Date Mailed: _________
Regular Dues $85 Discounted Dues $75 (prepaid by 12/31 for next year) Organization Membership $300 Student Dues $45 (Submit copy of Student ID with application.) Student membership limited to a maximum of one year.
SAVE EVEN MORE with added discounts BY EXTENDING YOUR MEMBERSHIP FOR 2 OR 3 YEARS NOW: Prepay $140 for a discounted 2-year membership or $200 for a 3-year membership. Organizational members can save by
taking advantage of a $500 prepaid 2-year membership or prepay $720 for a 3-year membership.
Mail completed application and check payable to CAHQ to the address above or pay by credit card:
MC/Visa/Amer Exp ________________________________ _____________________________ _____________ (circle one) Credit card # Signature Exp. Date
Name:
Business: Facility Name:
Title
Address
City: State: Zip:
Home: Address:
City: State: Zip: Business phone: e mail address: Fax number: Home phone: For publication in the CAHQ Directory, use my business home address.
For mailings, use my business home address. Omit my name from lists CAHQ shares with non-affiliated organizations. (You will still receive all CAHQ mailings.) I hold active status as a Certified Professional in Healthcare Quality (CPHQ). I am a current member of the National Association for Healthcare Quality (NAHQ), a CAHQ affiliate. RN Calif. license #_______________ Registered Health Information Administrator (RHIA)_____________ MD/DO license #________________ Registered Health Information Technician (RHIT) ________________ Cert. Med. Staff Coord. (CMSC) #__________ Cert. Prof. Cred. Specialist (CPCS) #___________________ Certified Risk Manager Other professional license/certification/accreditation. Type_______________________ #_________________ Type_______________________ #_________________
In which type of organization/facility do you currently work? (Select the 1 most appropriate description)
Acute care hospital or medical center Outpatient clinical facility Home health/hospice Behavioral health facility Specialty healthcare facility (e.g., chemical dependency or rehab.) Long term care facility Corporate or network/system headquarters Government agency (non-hospital) Licensure or accreditation body Insurance company/PPO Managed care organization Consultant Private review organization Health maintenance organization None of these apply
What is/are your area(s) of expertise? (Check all that apply)
Quality management/improvement Risk management Care/case/utilization management Medical staff services Managed care Administration Information management Patient safety Corporate compliance Ambulatory/rehabilitative care Infection Control Long term care Home care Behavioral health Nursing
Which best describes your current position? Senior management Supervisory Middle Management Consultant Staff How many years of experience do you have in the healthcare quality field? ________________ Have you been a CAHQ member before? Yes No If yes, when? __________(year) 11/07
California Association for Healthcare Quality MEMBERSHIP APPLICATION