HEALTHCARE QUALITY MANAGEMENT: ALTERNATIVE SOLUTIONS FOR IMPROVING ENVIRONMENT OF CARE Beth Ann Fiedler, Consultant P.O. Box 780121 Orlando, FL 32878; Phone: 810 597-7516 Email:
[email protected]; Atul Agarwal Department of MIS, College of Business and Management, University of Illinois at Springfield One University Plaza, MS UHB 4025, Springfield, IL 62703 Email:
[email protected]; Phone: 217-206-6713 ABSTRACT The healthcare industry continues to face increasing prevalence of hospital acquired infections. The interaction between healthcare personnel, medical equipment, and patients has not been adequately studied in the past. Currently, the cleaning and transfer of medical equipment by non-BMET personnel between patients may only undergo superficial cleansing with minimal effectiveness on bacteria. It calls for effective utilization of Biomedical Engineering Technician (BMET) agents in patient care. This paper examines the industry perceptions of BMET’s role and how its proposed inter-departmental integration might lead to enhanced quality of patient care. Key Words: Health Care Management, BMET, Quality of Care 1.0 INTRODUCTION The literature on healthcare quality management is still limited concerning the role that BMET can play in improving the environment of care in hospitals. Process changes that have the potential to increase organizational performance by reducing medical errors and HAI have brought the role of BMET to the forefront as a potential key to solving systemic issues. The BMET, which originated in the 1960s in response to the need for patient safety for electrical issues in the civilian community, may now be uniquely positioned to provide inter-departmental guidance that contributes to the elimination of preventable errors. Burke (2003) reports the recognition of a causal relationship of the Nosocomial disease to the HAIs and attributes the four most prevalent Nosocomial infections, comprising 80% of all HAIs, to medical devices used in patient care. He specifically cites the four infection types as urinary tract infection (usually catheter-associated), surgical-site infection, bloodstream infection (usually associated with the use of an intravascular device), and pneumonia (usually ventilatorassociated). He concludes by stating that for each of the device-associated infections, the risk factors are usually related to the patient, the personnel caring for the patient, the procedures they use, and the condition of the actual device.
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The growing recognition of a causal relationship between medical equipment and HAIs has prompted a change in payment procedures by the Centers for Medicare and Medicaid Services (CMS). CMS has announced that effective October 1, 2008, it will no longer pay for three infections - mediastinitis, urinary tract infections, and catheter-related blood stream infections - that are deemed preventable. Therefore, it is incumbent on the health care system to proactively tackle these and other HAI infections or face ominous financial overheads, in addition to the obvious mortality rates and negative aspects associated with a worsening environment of care. According to Bowles (2008), since medical devices and equipment are generally monitored by the BMET profession, it is incorrectly assumed that they also handle cleaning which might help reduce the risk of organism spread through the devices. In fact, according to Dr. Roger Bowles, the Chair of the Biomedical Technology program at Texas State Technical College in Waco, TX, “BMETs are responsible for the maintenance, repair and calibration of medical electronic equipment found in hospitals, including ventilators, infusion pumps, patient monitors, defibrillators and ultrasound machines.” However, not only does medical equipment contribute to HAIs, but its failure may result in medical errors and safety issues for patients. Two cases in particular are noteworthy when considering if the medical community is working together to limit the preventable errors. In the first instance, it is generally accepted medical knowledge that premature babies require time to develop their lung tissues. As a result, newborn premature infants will be directed to the Neonatal Intensive Care Unit or NICU of a given health care system for lung development. This practice is most beneficial for premature babies. However, some phototherapy devices are also used in the same area to treat jaundiced babies. These devices consist of internal fans that usually collect dust and should be cleaned after each patient to aid in the development of healthy lung tissue and to protect the general Environment of Care (EOC). In practice, however, the devices generally undergo inspection every six months according to an OEM recommended general preventative maintenance schedule performed by the Biomedical Engineering Department. However, the disassembly that is necessary for thorough cleaning between patients would require a mutual commitment between NICU, Central Sterile, and Biomedical Engineering and is not currently a common practice. In effect, the use of the equipment to treat one set of NICU patients can unintentionally impact the response time for premature babies to adequately develop lung tissue. Also, additional infections may slow the development and prolong the length of hospital stay for the already at-risk premature babies. Simple precautions taken by health care personnel to work cooperatively with BMET personnel to inspect and internally clean all internal fans between patient uses of the phototherapy units can alleviate any potential hazards by providing a more sterile environment that contributes to the overall EOC. The National Neonatal Forum, in their third edition (2006) of Neonatal Equipment Information, has recognized the importance of other factors beyond specific equipment usage that may also contribute to the lack of improvement in high-risk neonates. For example, space limitations, the inherent difficulties in maintaining a germ-free environment, and an industry awareness of a shortage of adequate nursing staff can also directly contribute to the viability of quality treatment and equipment maintenance in the overall EOC.
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However, the National Neonatal Forum believes that the ongoing maintenance of the existing equipment, availability of information relating to purchase of new equipment and the ability to properly use common neonatal equipment is highly relevant to the ability of high-risk neonates to increase their rates of improvement. As a result, a BMET may provide critical information to help prepare practitioners for various types of equipment that aid in the reduction of medical errors and/or a decrease in HAI by making pediatricians and health care workers in NICU aware of equipment maintenance issues that require additional considerations beyond minimal maintenance. Another example of the need for inter-departmental communication in regard to medical equipment can be taken from certain older brands of infusion pumps that maintain a Dual Inline Processor setting, otherwise known as a DIP switch, that are still commonly found in many hospitals. The DIP has three settings - macro (discharge rate of 1-9999 ml. in increments of 1 ml.), maintenance, and micro (discharge rate of 0.1-999 ml. in increments of 0.1 ml.) - that are accessed by removing a screw from a small rear panel. Since the rates are similar, without knowledge of the actual DIP switch setting, a health care worker may inadvertently under- or overdose a patient. Because this particular pump is used to inject very critical dosages to terminally ill patients who may not be able to indicate their level of pain, one BMET took it upon himself to address the need to identify the actual DIP setting on the device in order to make certain that proper dosages were administered. The education process began when documentation and training was provided to the head nurse in the department where the device was used. In addition, those staff that had access to the equipment received specific training regarding the macro/micro setting, the proper discharge, and associated drip rates. Each device was also labeled with the actual DIP setting and information was provided that included the proper labeling of the equipment with the default setting, and a cross reference sheet to the specific pharmaceutical dose range. The efforts of the BMET to proactively identify potential handling errors in conjunction with nurse practitioners provided critical information about proper equipment usage and proper dispensing of pharmaceuticals that significantly impacts the EOC. Finally, this situation provides another example where cooperative efforts between the BMET department and areas with high patient contact with medical equipment can decrease the potential for medical errors. 2.0 THEORETICAL FRAMEWORK Organizational Performance Theory has become essential to comprehending the quality of the health care organization since it was first introduced by Donabedian in 1966. The Assessment Measurement Classes of the Theory (known as structure, process, and outcomes) lay a path to quality assurance that has been limited in scope by a management philosophy for quality improvement. This limitation is evident in that most quality improvement measures address only one aspect of an organizational process, which is insufficient to improve organizational performance (Raju, 2001). Flood (2006) distinguishes Quality Assurance as the formal and systemic exercise of identifying problems and designing and implementing solutions that are more consistent with the Operational Performance Theory Assessment Measurement Classes, Measurement Perspective Assessment, and associated tools. Thus, the Organizational Performance Theory approach establishes a method for institutional evaluation, facilitates the - 3243 -
establishment of measurement variables, and provides specific outcome objectives based on preand post-intervention measurements. Subsequently, this theory leads us into our research problem, which can be stated as: can altering the existing hospital organizational structure by integrating a BMET agent into high patient contact areas improve the Environment of Care? 4.0 METHOD OF DATA ANALYSIS Thirteen hundred and fifty-three members of the Biomedtalk-L ListServ online community forum were invited to assess their perception of the health care industry environment of care in relation to their position. Out of 476 responses 182 indicated that they were members of the BMET ListServ. List members represented Clinical Engineers (CE), Biomedical Engineering Technicians (BMET), other medical device equipment and service personnel, and original equipment manufacturers. The survey, which also had participation from non-BMET ListServ members, captured demographic and other industry information through 476 responses, of which 182 specifically indicated that they were members of the BMET ListServ. BMET ListServ and other members of the biomedical engineering community responded to questions regarding the role of the CE/BMET community within the health industry environment of care. 5.0 RESULTS Results are based on 182 BMET ListServ members who responded to the survey. The organizational structural characteristics of the BMET ListServ respondents reveal that 76.37% are Joint Commission accredited while the others cite state, regional, or international affiliations due to the location of their facility. The two primary facility types listed are 60% hospitals and 25% Biomedical Engineering Facilities. The study sample appears to over-represent the Midwest region and under-represent the Northwest region. The location responses reveal that 29.67% of facilities are rural, whereas about 68% are urban. Results also indicate that 48/105 or 45.71% hospitals can be designated as small for the purpose of this study, while 57/105 or 54.29% are designated as large. Of the 182 that self-identified as Biomedtalk-L ListServ members, 74/182 or 40.66% (74/170 or 43.53% of those who responded) self-identified as some type of management while 96/182 or 52.75% (96/170 or 56.47% of those who responded) were non-management. Table 1: Infectious Disease Tracking and Access to Information Frequency
Percent
Adjusted
Response
Response
Percent
(n=182)
Response
Infectious Disease Tracking Yes
127
69.78
85.23
No
22
12.09
14.77
Yes
22
12.09
13.92
No
136
74.73
86.08
Access to Infectious Disease Tracking
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As shown in Table 1, nearly 70% indicated that their facility tracked infectious diseases, only 12% were privy to that information. Commentary from one respondent clearly demonstrates a break in communication between Joint Commission tracking requirements and the dissemination of information to healthcare workers. One of the respondents expressed that there were other prevailing reasons why only a handful of medical personnel and administrators have access to the data: “At previous facilities, you would be fired if the matter (infectious diseases) was discussed.” Although the profession was established in the civilian population during the 1960s in response to concern for patient safety, many respondents believe that they are still unrecognized even within the hospital EOC. For example, the biomedical engineering technician community indicated that 31.87% of respondents perceived that “most people did not understand what they do” and that included other medical professionals. Figure 1: Perception of Biomedical Engineering Technician Position Value
Note: Responses are as follows- (1) Most people don't understand what I do; (2) Most medical personnel don't understand what I do; (3) Some people, including medical personnel understand what I do; (4) I am valued within my department; (5) I am valued and recognized within the entire organization that I represent; (6) Other Not Listed.
According to Figure 1 about 32.97% believe that only “some people, including medical personnel, understand what I do”. This particular question allowed for multiple answers and provided the highest response rate of 93/182 or slightly more than half who responded that they still felt ‘valued within my department”. Figure 2 indicates that increasing general awareness of BMET abilities and education, in cooperation with other healthcare personnel (96/182 or 52.75%), would encourage other healthcare professionals to better utilize their skills.
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Figure 2: General Environment Perception of the Biomedical Engineering Technician
Note: Responses are as follows- (1) Increasing general awareness of BMET abilities, (2) Specific education in conjunction with other health care personnel, which helps them do their job better by understanding their connection to the BMET function, (3) Inter-departmental training that is required by accreditors, (4) Organizational action that corporately examines such long term problems as hospital acquired infectious diseases, or (5) Other Not Listed.
Slightly less, at a rate of 90/182 or 49.45%, believed that some form of education that connected the function of other medical personnel to the BMET function would encourage administration, management, and clinical services to more efficiently utilize their skills. 10.0. CONCLUSION A wide range of suggestions to improve the current accreditation process included accountability, education that required inter-departmental cross-training, licensing requirements headed for include other medical personnel and even accreditors, and increased staff responsibilities in regards to medical equipment readiness. One suggestion included setting the bar beyond the immediate EOC to include the establishment of emergency response procedures.
(References Available Upon Request)
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