EHM 10

EQUALITY FIRST

WASH YOUR HANDS

Karen Davis explains why social justice is at the center of healthcare reform

Didier Pittet focuses on clean care and the global importance of hand hygiene

www.executivehm.com • Q2 2010

THE END

Why healthcare’s heavyweights may not be ready to hang up their gloves

OF HOSTILITIES?

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EDITOR’S NOTE 9

After the vote What does the passage of the reform bill mean for the future of our health system?

M

arch 21, 2010. Mark the date – it may become known as a historic one for healthcare in this country. On that day, after nearly a year’s worth of political wrangling, the Obama Adminstration’s healthcare reform legislation was passed by the House of Representatives, by a vote of 219-212. The legislation will give an additional 32 million Americans access to basic health insurance by 2019.

Put aside the sniping and the sometimes uncomfortably personal tone taken by the bill’s opponents, and the real winners should be us, the American people. More than 94 percent of all nonelderly Americans will have access to health insurance by 2016; the figure currently stands at 83 percent. Health insurers will no longer be allowed to deny coverage based on pre-existing conditions.

And generous subsidies will be offered to lower-income families to help them get the cover they need.

“Our work shows that even if you have health insurance, the adequacy of that coverage has deteriorated, with medical bills and debt now affecting about 72 million adults” Karen Davis, President, The Commonwealth Fund (Page 36)

Despite these obvious benefits, the narrow margin by which the vote passed shows that many remain unsatisfied with the bill. Those who argued against the legislation cited its lack of focus on cost and quality, and the fact that the changes will be funded through increased taxes.

The Republicans have vowed to continue their efforts to derail the reform process. It seems that while this round may have gone to Obama and his government, their opponents are certainly not down for the count.

Another serious health battle currently being waged is the war on healthcare-associated infections (HAIs). HAIs kill 48,000 people in the US every year, making them a serious threat to patients and the hospitals charged with ensuring their health and safety. In this issue, a series of experts, including Patrick Brennan of the University of Pennsylvania Health System and Dennis Maki of the University of Wisconsin-Madison Medical

“Assessing the level of your own institution and working towards the status of a hand hygiene excellence center should be paramount” Didier Pittet, Expert Lead, WHO First Global Patient Safety Challenge (Page 46)

School, tell us how they are working to help prevent infection in all areas of their institutions.

We also hear from Professor Didier Pittet, Expert Lead for the WHO First Global Patient Safety Challenge, about the efforts being made to encourage that all-important first line of defence against infection, hand hygiene.

With critical issues being addressed on so many fronts, the next few months are shaping up to be exciting ones for our health system. And if both sides of the reform battle can be persuaded to hang up their gloves and work together, we could finally see the dawn of a new era in healthcare. n

Marie Shields Editor

“What government has to do is figure out how it’s going to make itself transparent. You need the systems in place to capture data on an ongoing basis” Terry Mason, Commissioner, Chicago Department of Public Health (Page 70)

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CONTENTS 11

46

And the winner is‌ After months of sparring between Democrats and Republicans over healthcare reform, the American public is set to emerge as the victor

Save lives: clean your hands A call to action from Professor Didier Pittet

32 36

70 Streamlining government Terry Mason of the Chicago Department of Public Health on the importance of effective IT to create a Lean government agency

Towards a more equitable health system Karen Davis of The Commonwealth Fund explains why social justice remains at the center of healthcare reform

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CONTENTS 13

80

Staying safe

104

Waste not, want not

PLATINUM SPONSOR

64

Minimizing the preventable

GOLD SPONSOR

SILVER SPONSOR

42 Keeping the airways clear

74 Balancing act

90 Making connections

Robert Kacmarek looks at the causes and prevention of ventilator-associated pneumonia

Scott Dresen juggles people, processes and technology

The use of social media in healthcare, according to Matthew Lees

58 Skin deep

80 Staying safe

92 Playing to your strengths

Marty Visscher discusses skincare hygiene research and its importance in today’s healthcare system

James Koenig on the role of single sign-on in identity access management

How Adam Lynch stays ahead of the game in healthcare IT

86 A wireless world

96 Healthy proďŹ ts

Sarah Morris looks at Wi-Fi in the hospital setting

Why IBM believes that healthcare solutions need to be instrumented, interconnected and intelligent

64 Minimizing the preventable Patrick Brennan explains the challenges of tackling healthcare-acquired infections

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CONTENTS 14

98 Going digital

ASK THE EXPERTS 84 Tim Alsop, CyberSafe 88 Vaduvur Bharghavan, Meru Networks 102 Sid Mandel, Qnomy Inc. 108 Geoff Mayo, American Dawn Inc.

EXECUTIVE INTERVIEWS

IN THE BACK

Nadim Daher on the current state of the PACS market

104 Waste not, want not Anna Gilmore Hall of Health Care Without Harm tackles the messy subject of hospital waste management

114 Prevention is the cure Dennis Maki sheds some light on the prevention of intravascular catheter-related infections

40 Douglas Hansell, Covidien 56 Kathy Powers, Purgo Creations 68 Yon Makino, Henkel Consumer Goods Inc. 78 Jim Bodenbender, RelayHealth

118 Making positive change last longer Culture transformation and patient safety, by Richard Karl

INDUSTRY INSIGHTS

120 Promoting from within Johns Hopkins’ Pamela Paulk explains why hospitals should look internally when searching for experienced staff

94 Bill Nordgren, Flexsim Software Products, Inc

Russia 124 Regional focus: Russia 126 International events 128 Photo finish

ROUNDTABLE DISCUSSIONS 49 Hand hygiene With Ron Cagle of Sprixx, Jane Kirk of GOJO Industries, Jim Ingebrand of 3M Company and Cheryl Littau of Ecolab Healthcare

111 Vascular access With Mark Hunter from Baxter Healthcare and Kerry Edgar from Medegen Inc.

49

Jane Kirk

Balancing act

74

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UPFRONT 18

CUTTING DOWN ON MEDICAL WASTE Hospitals are the second-largest waste producers in the US after the food industry. If hospitals recycled their medical equipment they could save hundreds of millions of dollars every year, according to an analysis by Johns Hopkins University School of Medicine.

Hospitals throw out everything from surgical gowns and towels to laparoscopic ports and expensive ultrasonic cutting tools after a single use. In operating rooms, some

items that are never even used are thrown away – single-use devices that are taken out of their packaging must be thrown out because they could have been contami-

nated. Selecting such good devices tions for office and municipal type for re-sterilization and rewaste, whereas the federal testing could decrease government develops About the amount of needregulations for hazless waste from ardous waste such hospitals. as mercury or raof US hospitals are taking advantage of Many of these dioactive wastes. reprocessing singlewaste streams are After medical use medical regulated at the state wastes were found devices and local level while othamong other wastes washers may be governed by federal ing up on several East Coast regulations. States develop regulabeaches, concern over the poten-

25%

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UPFRONT 19 tial health hazards prompted according to the report. Items Congress to enact the Medical that could be reprocessed inWaste Tracking Act (MWTA) in clude elastic bandages, surgical 1988. The Act required EPA to scissors, pressure infuser bags, create a two-year Medical Waste pulse oximeter sensors, ultraDemonstration Program. For the sound catheters, tourniquet cuffs purposes of this two-year proand drills. gram the MWTA defined medThese items are considered ical waste and those wastes to be Class I and II devices, which regulated; established a cradle to means that they pose low or grave tracking system utilizing a medium risk in reprocessing. A generator initiated tracking further class of items, Class III, form; required management require data proving that reprostandards for segregation, packcessing would be safe and effecaging, labeling and marking, and tive. These include balloon storage of the waste; and esangioplasty catheters and tablished record keepimplanted infusion Hospitals ing requirements pumps. diverted and penalties that While the could be imposed number of hospifor mismanagetals carrying out pounds of medical waste from ment. reprocessing is landfills “No one thinks growing, the pracof good hospitals as tice is not yet widemassive waste producers, but spread, the researchers said. they are,” said the Johns Safety concerns with reprocessHopkins’ study’s lead author ing include possible malfunction Martin Makary, a surgeon and of devices, the risk of transmitAssociate Professor of Public ting infections, and the ethical Health at the school. “There are dilemma that reprocessing premany things hospitals can do to sents given the absence of padecrease waste and save money tient consent to the use of such that they are not currently devices in their treatment. The doing.” The researchers noted government requires all rethat with proper sterilization, reprocessed equipment to be lacalibration and testing, re-use of beled as such, along with the equipment is safe. name of the reprocessing comAbout 25 percent of US hospany. A recent study by the US pitals are taking advantage of reGovernment Accountability processing single-use medical Office concluded reprocessed dedevices as a means of reducing vices do not present an increased landfill waste, according to the health risk over new devices. report, which appeared in the Makary concluded: “Some March issue of Academic people don’t like the idea that Medicine. they’re being treated with In 2008, hospitals served by equipment that has been used one major reprocessor saved before. But these reprocessed $138 million nationwide by didevices are as good as new since verting 4.3 million pounds of the testing standards for re-use medical waste from local landfills. are impeccable and there have That year saw a 20 percent been no patient safety problems increase in reprocessing services, in our analysis.”

NEWS IN PICTURES

Opponents of healthcare reform demonstrate outside George Mason University where President Barack Obama spoke on healthcare reform on March 19, 2010 in Fairfax, Virginia.

4.3 million

Chilean soldiers distribute potable water in a football stadium in Constitucion, Chile.

UNICEF provides psychosocial support for traumatized Filipino children.

A member of a women’s rights group distributes condoms during a protest in front of the Department of Health in Manila on March 1, 2010.

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UPFRONT 20 DAVID BLUMENTHAL, NATIONAL COORDINATOR FOR HEALTH INFORMATION TECHNOLOGY In March 2009, David Blumenthal was chosen by the Obama Administration to take on the role of National Coordinator for Health Information Technology. In this role his main responsibility is the implementation of a nationwide interoperable, privacy-protected health information technology infrastructure as called for in the American Recovery and Reinvestment Act. A $19.5 billion investment in health information technology was included in the economic stimulus package with a view to saving money, improving quality of care for patients, and making the healthcare system more efficient.

Blumenthal’s role at HHS includes bringing the healthcare system into the digital age through the adoption of interoperable health information technology by 2014, with the aim of reducing health costs for the federal government by an estimated $12 billion over 10 years.

Before being chosen as National Coordinator for Health Information Technology, Blumenthal served as a physician and Director of the Institute for Health Policy at Massachusetts General Hospital in Boston. He was also Samuel O. Thier Professor of Medicine and Professor of Healthcare Policy at Harvard Medical School. There, he also served as Director of the Harvard University Interfaculty Program for Health Systems Improvement. Prior to that, he was Senior Vice President at Boston’s Brigham and Women’s Hospital and served as Executive Director of the Center for Health Policy and Management and as a lecturer on Public Policy at the John F. Kennedy School of Government.

From 1995 to 2002, Blumenthal served as Executive Director for The Commonwealth Fund Task Force on Academic Health Centers. He was a grantee of the Commonwealth Fund, an influential non-profit organization that seeks to offer affordable healthcare to those with lowincomes.

In January of 2007, Blumenthal became Senior Health Advisor to President-elect Barack Obama’s presidential campaign. In the early part of the campaign, this involvement meant helping to develop a healthcare plan that Obama could run on during the primaries and during the election.

Blumenthal has extensively researched the dissemination of health information technology, quality management in healthcare, the determinants of physician behavior, access to health services, and the extent and consequences of academicindustrial relationships in the health sciences. The transition to electronic medical records has long been the focus of his work.

With degrees in both medicine and public policy, Blumenthal has spent years working on health policy as a Capitol Hill staffer, a Harvard researcher and at foundations dedicated to providing affordable healthcare.

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UPFRONT

UNWELCOME REFORM

21

A survey of 1009 US adults found that most Americans believe healthcare reform would actually make the situation worse for middle-income families in the US. Of those surveyed, 59 percent said the plan would help uninsured Americans, while 56 percent agreed it would benefit the poor. Meanwhile, 44 percent said the plan would make things worst for US middle-income families.

The poll carried out by Gallup is consistent with previous surveys that have indicated negative public sentiment regarding the reforms. According to Gallup, the poll results show that healthcare is a highly partisan issue in the US even at grassroots level.

Only substantial minorities of Democrats believe healthcare reform will benefit middle-income families (37 percent) and themselves (33 percent).

Democratic leaders in Congress are currently trying to convince doubtful colleagues that the US needs public heath reform. The bill is viewed by some as a make or break move in President Obama’s legislative agenda.

SPLITTING HAIRS

findings, with some linking hair loss to an increased risk of prostate cancer. All those that Early hair loss in men could mean a lesser chance took part gave information about their lifestyles, of developing prostrate cancer. That’s acmedical and family history and whether cording to research by scientists at the they had been screened for prosMen University of Washington School trate cancer in the previous five between 40 of Medicine. years. They also revealed and 47with receding They studied 2000 men whether they had used drugs hairlines have a aged between 40 and 47 years that could affect their testosold and found that those with terone metabolism. lower chance of receding hairlines had a 29 to The study did not find a developing 45 percent lower chance of devellink between hair loss in later life tumors oping tumors. and prostrate cancer.

The scientists linked the high testosterone levels associated with baldness with the lower risk of cancer. Prostrate cancer patients are often given drugs to reduce their testosterone levels because the hormone is thought to accelerate the growth of some cancerous tumors.

Speaking to the BBC, Dr Helen Rippon, Head of Research Management at The Prostrate Cancer Charity, said: “Clearly the age at which a man begins to lose his hair is unfortunately not a risk factor for prostrate cancer over which he has any control.

However if these results are correct, they could be useful in providing us with a greater understanding of how testosterone behaves in the body and how it can affect different tissues.” She went on to say however, that the fact that the results hinge on whether men aged between 40 and 70 actually remember whether their hair was thinning when they were 30 means it is not a 100 percent reliable measurement.

Furthermore, other studies have had contradictory

29-45%

FRESH HOPE

FAST FACT

Deep brain stimulation involves implanting a brain pacemaker into the patient’s brain Deep brain stimulation therapy could bring that then sends electrical impulses to specific parts of it. new hope to epilepsy sufferers, acSimon Wigglesworth, Deputy cording to researchers from Out of a Chief Executive of the charity Stanford University. group of epilepsy Epilepsy Action told the BBC: Out of a group of patients treated with “We have been hopeful for epilepsy patients treated deep brain stimulation some time that deep brain with deep brain stimulation, stimulation may be a treat41 percent showed a reducshowed a reduction in ment option for some people tion in seizures after 13 seizures after 13 with epilepsy.

This study is excitmonths. While 56 percent of months ing news and could be an important those tested showed improvement development in the treatment of epilepsy in the after two years. Each of the patients tested suf30 percent of people whose seizures don’t refered from long term epilepsy and had not prespond to traditional drug therapies. viously responded to drug treatment.

41%

Alopecia affects

0.1%-0.2% of humans, occurring in both males and females

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UPFRONT 22

KICK IT OUT Ghanaian campaign group United Against Malaria has plans to use this year’s World Cup in South Africa to boost awareness of malaria prevention, which kills one million Africans each year – 85 percent of which are children under five years old. Nine football teams are already involved in the campaign that hopes to use the excitement surrounding the World Cup as a catalyst for highlighting the importance of public health and the eradication of malaria, which is both treatable and completely preventable.

With the slogan of “victory is in the net”, the group have already broadcast on Ghanaian radio, reminding pregnant women to take their anti-malarial drugs and for all families to sleep under the treated bed-nets provided. In addition, they have also awarded Ghana FA President Kwesi Nyantakiyi his own ‘golden boot’ for his contribution to fighting the disease.

SOUND MEMORIES A 12-week program at Artsdepot, an arts venue in London, UK, is harnessing memories to powerful effect by using theater and stage to reignite the lost memories of dementia sufferers.

The project, In The Limelight, has witnessed small glimmers of hope by bringing out people’s personal stories through their re-inactment on the stage, with especially vivid images being termed the “reminiscence bump” by David Rubin, Professor of psychology at Duke University in North Carolina.

With long-term memory remaining intact in dementia sufferers years after their short-term memory recall has disintegrated completely, it has also been found that the recollection of music can often remain unimpaired for even longer. Combining these factors, the program hopes to reunite families, albeit only for a few hours a week, with the person they once knew – free from the anxiety and stress that overshadows the disease.

SAFE WATER Reports from the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) says the world is on track to meet or even exceed the drinking-water target of the Millennium Development Goals, which aims to halve the number of people who don’t have access to healthy drinking water. However, the report notes that while approximately 5.9 billion people use safe drinkingwater sources, a staggering 2.6 billion people don’t use improved sanitation.

Moreover, 4000 deaths per day occur as a result of unsafe water and poor sanitation. WHO and UNICEF report that a lack of access to water, sanitation and hygiene affects the health, security and quality of life for children.

Evidence also suggests that girls and women are more affected than men and boys, as unfortunately they tend to be the ones burdened with collecting drinking water.

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BEAUTY TEENS The Physician’s Coalition for Injectable Safety has sent out a worldwide warning against “Teen Toxing” – the administration of Botox and other injectable products to individuals under the age of 18 for cosmetic reasons. It follows after a story in which a UK mother was criticized for administering Botox injections to her 15year-old daughter. The Coalition believes that this disturbing report may be an indicator of other questionable procedures, and is keen to highlight the potential complications and risks of injecting at such a young age; especially as Botox doesn’t actually prevent natural ageing – so the adage of “preventing wrinkles” lacks credibility. To counteract this growing trend, the Coalition is raising the question of responsibility and strongly advising that all medical procedures for teens, plastic surgery or otherwise, should be reviewed with a board-certified physician.

TRAVEL CHOICE A Polish pro-abortion feminist group, known only by the acronym SROM, has caused a recent uproar by launching an ad campaign promoting the travel of women over to the UK in order to take advantage of the free abortion clinics offered by the NHS. The poster ad, featuring a spin on the classic Mastercard campaign, ends with the strapline “For everything else, you pay less than an underground abortion in Poland.”

Under EU regulations, Britain has a reciprocal agreement with Poland to provide free medical care for anyone needing treatment. However, a spokeswoman for the UK Department of Health declared that there is no provision for Polish women to travel to the UK for abortions. With one of the strictest abortion laws in Europe, Poland views abortion as illegal unless the woman’s life or health is at risk, or the pregnancy is the result of a criminal act.

BACK TO WORK The British Medical Journal website has just published a study delivering evidence that a program of integrated care, directed at both the patient and the workplace, can help people with chronic low back pain return to work, on average, four months earlier than those receiving the usual standards of care. Researchers based in the Netherlands and Canada evaluated the effectiveness of an integrated care program in 134 patients with chronic low back pain. The patients were split into integrated care, consisting of adjustments to the workplace and a graded exercise program to teach patients how to move safely while increasing activity levels; and ‘usual care’, which was built on normal pain treatment and little to no workplace involvement.

Over the 12-month study period, patients on the integrated care program returned to sustainable work after an average of 88 days, compared with 208 days for the ‘usual care’ patients.

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MALARIA BREAKTHROUGH Scientists across the globe have long hunted for a vaccine against malaria – a disease that claims roughly one million lives each year. But now, after decades of searching, the creation of a malaria vaccine have begun to look more and more likely.

Pharmaceutical giant GlaxoSmithKline announced it would take the significantly unprecedented step of

sharing its scientific data and laboratories to help fight the good fight against tropical countries. According to reports, Andrew Witty, Chief Executive of the firm and the driving force behind the initiative, said the drug company has a “genuine appetite to change the landscape of healthcare for the world's poorest people.”

RISE IN PRODUCT RECALLS pharmaceutical recalls are due The number of product recalls to incorrectly labeled or packand safety alerts for pharmaaged goods, and nine percent ceutical products and medical are due to compromised devices more than sterility owing to quadrupled in the packaging errors UK between or poor struc2004 and 2008, tural integrity. a new study of pharmaceutical recalls are due to In 2007 the by customer incorrectly labeled or European management packaged goods Commission reagency leased figures reBlueview Group vealing a five-fold reveals. The study, increase in fake pharmaceuticals which pulls together UK govacross Europe, with 2006 seizures ernment and European Union hitting an all-time high of 2.5 figures, shows that over the million items. The worrying infive-year period starting in crease in the incidence of coun2004, recalls and product alerts terfeit drugs and the growing in the pharmaceutical sector sophistication of the lengths that rose from 22 to 94. counterfeiters are now prepared Nearly two thirds of these to go to are a constant source of actions are down to defects in concern for drug manufacturers, the manufacturing or perforprompting ever more research mance of a medical device with into new technologies and strate62 percent of recalls or alerts in gies to protect the pharmaceutithe sector being issued for this cal supply chain effectively. reason. Another 12 percent of

12%

FROM THE VAULT In Q4 2009 of EHM, MARY GREALY, President of the Healthcare Leadership Council, outlines how collaboration in the industry and the council’s lobbying efforts are bringing about change. “Innovation is one of the key principles that we feel strongly about – we want to ensure what we do as part of healthcare reform that we protect and foster innovation.”

To read more go to www.executivehm.com

GATES PLEDGES $10 BILLION FOR VACCINES At the reccent World Economic Forum in Davos, Switzerland, revered business tycoon and founder of computer software giant Microsoft, Bill Gates, announced with his wife that they will commit $10 billion over the next decade to help research, develop and deliver vaccines for the world’s poorest countries.

According to Mrs. Gates, the vaccines are now the “number one priority” of the Gates Foundation because of the “incredible impact” they

have on children’s lives. Bill Gates added that the next 10 years must be defined as “the decade of vaccines”.

The boost comes after a model used by the Foundation and developed by a consortium led by the Institute of International Programs at the Johns Hopkins Bloomberg School of Public Health stated that significantly scaling up the delivery of vaccines in developing countries could prevent the deaths of some 7.6 million children.

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UPFRONT FIVE-MINUTE EXECUTIVE

26 CHANGING THE WAY THE WORLD TAKES TEMPERATURE A world leader in industrial and medical non-invasive temperature technology, Exergen has hit new levels of recognition with its innovative Temporal Thermometer.

FRANCESCO POMPEI sheds some light on this awardwinning product.

Why all the attention to a medical device in the public press?

Francesco Pompei. Taking temperature is by far the most common medical test performed – approximately 10 billion times per year worldwide, at all care levels including at home, and is a shared experience by all people. It is also one of the few things in medical care that everyone, including the patient, understands. The idea of accurate temperatures with a gentle forehead scan renders the insertion of thermometers into body cavities obsolete, which immediately improves everyone’s medical care experience and appears to be a natural attention-getter.

Was cost a major issue?

FP. Yes. Improving care without reducing costs is only one-half of an innovation. Both are necessary in order for an innovation to succeed in a lasting way. The reduction in disposable use associated with temporal thermometry is a major financial benefit, as well as a major reduction in waste. Combined with the care benefits of gentleness, speed, and non-invasiveness, everyone wins.

Was reluctance to change a major issue?

FP. Yes. There is a natural predisposition in medical care to resist change, which is healthy and appropriate most of the time. In our case, we were proposing a new method of taking temperature employing the forehead, a site that has been used for 5000 years for fever detection, but no one had ever been able to be make it accurate enough to replace the body cavity thermometers. It has taken us 10 years from the initial market introduction, more than 30 published studies, and about 2.5 billion temperatures taken with the

The Exergen Temporal Thermometer was recently honored in a list of 25 Smartest Products of the Decade, along with iPod, Netflix, Blackberry, Google, and other well known innovations. The list was compiled in the December 2009 issue of Inc. Magazine, a widely read and respected journal focused on entrepreneur executives.

The Temporal Thermometer was described as making a “world of difference” and an example of how “inexpensive medical technologies pay huge dividends”.

A few years earlier, Exergen received the New England Innovation Award for “revolutionizing the oldfashioned, often awkward thermometer into an accurate and easy magic wand”.

about 25 years. In addition there are always entrenched competitors protecting traditional technologies, many of them much larger than the innovating company, which need to be overcome. Fortunately early adopters, particularly large teaching hospitals, are usually willing to give an innovation an opportunity to succeed in the face of fierce entrenched competition. However, a successful new technology draws other competitors who try to copy the idea, which requires expensive perseverance to protect patented technology – 10 years and still ongoing for us.

There is always an opportunity for a good idea to succeed, but the entrepreneurial company must have both the will and wherewithal to persevere. Big changes in any field do not happen overnight.

Where do you expect to be in the next five years?

FP. We continue to move both the science and technology of temporal thermometry forward, integrating it with the latest patient care methods, and making it the standard for patient care. Hopefully in five years we will all be wondering why we ever used such primitive methods as inserting thermometers into body cavities. As stated in the Inc. Magazine article naming the Exergen Temporal Thermometer one of the ‘smartest products of the decade’, everyone will wonder: ‘how did we ever live without them?’

Francesco Pompei is Founder and CEO of Exergen Corporation, and holds 60 US patents in noninvasive thermometry for medical and industrial applications. He holds BS and MS degrees from MIT, and an SM and a PhD from Harvard.

Temporal Thermometer, to achieve today’s level of acceptance. There still remains some skepticism, which we are working to overcome.

It appears perseverance is important to change what you do.

FP. Perseverance is absolutely essential. It really starts with the scientific development of the technology, which in our case took about 15 years, making the total perseverance time

Governor MITT ROMNEY having his temperature taken with a Temporal Thermometer during a visit to Exergen to promote job growth in Massachusetts.

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THE TRUE COST OF WASTE SERVICES US hospitals spend over $10 billion annually in healthcare-related waste. Do you know your actual ‘true’ cost for waste services? Do you know your compliance risks?

Typically this area has not garnered much attention in hospital executive suites, but this is all changing. Early adopters have unlocked the secret to making waste and waste vendors work for them. If a 15-25 percent reduction in waste spending (typically over $2,000,000 in a 2000-bed health system) is of interest to you, then read on.

Waste in healthcare includes municipal solid waste, regulated medical waste, hazardous waste, pharmaceutical waste (now coming under increasing scrutiny), recycling, confidential documents, electronic waste and construction and demolition waste.

Opportunities abound in all these areas.

Understanding price versus true cost can often be a rude wake-up call. Most health systems are surprised to learn that the price negotiated by Purchasing

is not the actual cost being paid for waste services. For example, one health system believed they were paying $0.25 per pound for regulated medical waste, but found their real cost was $0.48 per pound.

Having a defined baseline consisting of weight, volume and price to determine true cost is the only sure way to measure savings and identify additional opportunities. No guarantee is valid without a baseline.

Although it was passed many years ago, regulators are just now starting to use the power of RCRA regulations to discipline health systems that allow pharmaceutical waste to enter the watershed. A proper RCRA hazardous waste program is essential to being green and avoiding the regulator’s wrath. An RCRA program begins with an understanding of the formulary and proper classification of wastes. Having a working team in place is often enough to keep the wolves at bay.

For more information, please visit www.hwsusa.com

ACADEMIC-INDUSTRY COLLABORATION An international consortium of scientists, led by H. Lundbeck A/S and King’s College London, has launched one of the largest ever research academic-industry collaboration projects to find new methods for the development of drugs for schizophrenia and depression.

‘Novel Methods leading to New Medications in Depression and Schizophrenia’ (NEWMEDS) is a unique project, bringing together top scientists from academic institutions with a wide range of expertise, and partnering them with nearly all major global drugs companies.

The main objective of NEWMEDS is to develop new models and methods to enable novel treatments for schizophrenia and depression. The

project will focus on developing new animal models that use brain recording and behavioral tests to identify innovative and effective drugs for schizophrenia. It will also develop the hardware and analysis techniques to apply brain imaging, especially MRI and PET imaging, to drug development. It will examine how new genetic findings (duplication and deletion or changes in genes) influence the response to various drugs and whether this information can be used to choose the right drug for the right patient. And finally, it will try to develop new approaches for shorter and more efficient trials of new medication – trials that may require fewer patients and give faster results.

EXPENSIVE DRUGS

World’s most expensive drugs.

1 2 3 4 5

6 7 8 9

Soliris ($409,500)* Elaprase ($375,000) Naglazyme ($365,000) Cinryze ($350,000) Myozyne ($300,000) Arcalyst ($250,000) Fabrazyme ($200,000) Cerezyme ($200,000) Aldurazyme ($200,000)

*Annual cost Source: Forbes

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REAL TIME LOCATION SOLUTIONS

AUTISM ARTICLE DISAVOWED

Today’s economic challenges have To obtain the maximum benefits of forced healthcare providers to re- RTLS, five critical success factors evaluate their processes and work- have been identified. RTLS performs flows, seeking greater operational most optimally when fully integrated efficiencies that can help drive cost into the fabric of the organization, savings and eliminate waste. Real providing enterprise-wide coverage. time location solutions (RTLS) offer This maximizes user adoption and practical hospital applications that provides the best location awareness save time and money. People are for lost, stolen or misplaced equipsaying, “We expected to purment. Within the healthcare chase six additional space, room level locatransport monitors tion accuracy is es“We expect before the end of sential. Installation to purchase the year. Staff and maintenance now have the need to be simple transport monitors tools needed to and flexible, not before the end of closely track and complex, infrathe year” observe their usage, structure-dependent saving us $248,000 in and costly. Standardsthe planned purchase of based interoperability with more monitors we didn’t need. Our third party applications and the abilinfusion pump rental fees have ity to deliver accurate data to endshown an immediate downward users is important. The RTLS trend in expenditures, from nearly solution provided should be low risk. $8000 in March to $2000 in June, It shouldn’t require a large capital saving us $120,000 in reduced rental purchase or long-term contractural fees over 18 consecutive months.” commitments.

Examples like these demonSkytron Asset Manager, powstrate how ROI can be maximized ered by Awarepoint, delivers cost by keeping track of critical re- saving RTLS solutions that maxisources in real time. Doing so drives mize ROI and the five critical RTLS utilization efficiency, reduces success factors; keeping critical asrentals and redundant equipment sets onsite and in-sight, while incosts and the search time required creasing cost savings, throughput, of staff to locate missing equipment. utilization and quality of care.

A prestigious medical journal has 2004, as scrutiny and criticism of the disavowed an article it published study intensified, 10 of 13 co-authors more than a decade ago linking of the 1998 autism article publicly autism in children to a common disassociated themselves from it. childhood vaccine. The original arti- Paul Offit, a vaccine researcher at cle raised widespread concern Children’s Hospital in about the safety of the Philadelphia, says at least vaccine, prompting 12 studies have been many parents done worldwide worldwide to concluding reco-authors of stop vaccinating peatedly that the the 1998autism article their children.

MMR vaccine publicly disassociated themselves In 1998, a does not cause from it high-profile article autism. published in the British “We’ve reached the medical journal, The Lancet, many hundreds of thousands announced a link between autism mark of children who did or didn’t reand the MMR vaccine, used against ceive MMR to see whether risk of measles, mumps and rubella. There autism was greater in the vaccinated had been no established cause shown group and it wasn’t; consistently, refor autism, a disorder that affects a producibly, redundantly,” he says. “I youngster’s social skills and ability to think the problem is there are people interact with the outside world. who simply don’t believe the science.

In the original paper, British gas- They hold on to this notion that troenterologist Andrew Wakefield MMR causes autism or that vaccines described a small sample of 12 chilcause autism much as one holds a dren, eight of whom showed religious belief.” evidence of autism Source: voanews.com. shortly after receiving

six additional

10 of 13

the vaccine. However, subsequent investigations by British regulators led to charges that Dr. Wakefield falsified data and was paid by the parents of autistic children. In

FAST FACT

1% of children aged 3 to 17 in the US have an autism spectrum disorder

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FAST FACT According to the WHO,

4000 people die every day around the world as a result of unsafe water and poor sanitation

COMPANY INDEX Q2 2010 Companies in this issue are indexed to the first page of the article in which each is mentioned.

3M Company 15, 49, 54, IBC AcroMetrix 66 American Dawn Inc. 108, 109 B David Company 60 Baxter Healthcare 110, 111 Biolmagene 25 Chicago Department of Public Health 70 Cincinnati Children’s Hospital 58 Covidien 40, 41 CyberSafe Limited 84, 85 Ecolab Healthcare 10, 48, 49 Exergen 4, 26 Flexsim Software Products, Inc. 94, 95 Frost & Sullivan 98

GE Healthcare 101 GOJO Industries IFC, 49, 50 Health Care Without Harm 104 Henkel Consumer Goods Inc. 68, 69 Hôpitaux Universitaires de Genève 46 HWS 6, 27 IBM 96 Johns Hopkins Hospital 120 Kimberly Clark 45 Laserband 76 Leverage Software 91 Massachusetts General Hospital 42 Medegen 12, 111, 113

Medison 17 Meettheboss.com 77 Meru Networks 88, 89 Molnlycke Health Care 63 Patricia Seybold Group 90 PeopleClick 123 Popstar Networks/Canvys 31 PricewaterhouseCoopers 80 Purgo Creations 56, 57 Qnomy Inc. 102, 103 RelayHealth 2, 78, 79, OBC Skytron 28, 29 Spectrum Health 74 Sprixx 49, 52 Staff Knex 73 Surgical Safety Institute 118

Teleflex 8 The Commonwealth Fund 36 The Regence Group 92 University of Pennsylvania Health System 64 University of Wisconsin 114 Wi-Fi Alliance 86 World Health Organization 46

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Cover Story_16 nov 23/03/2010 10:30 Page 32

COVER STORY

winner

And the

32 www.executivehm.com

Cover Story_16 nov 23/03/2010 10:30 Page 33

is...

After months of sparring between Democrats and Republicans over healthcare reform, it is the American public that is set to emerge victorious following President Obama’s controversial restructuring of the health sector. By Ben Thompson

I

t was, remarked one observer, like a scene from the civil rights era Republican Scott Brown’s defeat of Democratic candidate Martha Coakley in a half-a-century ago. Rallies outside the Capitol are typically orderSenate special election in Massachusetts – one of the Democrats’ safest seats – ly affairs, with speeches and well-behaved crowds; this one had sent shockwaves through Washington and re-energized GOP activists. Almost baton-wielding police separating furious demonstrators from the overnight, the passage of healthcare reform had gone from being a mere members of Congress making their way to vote on the divisive Congressional formality to a mathematical uncertainty as the Democrats lost the issue of healthcare reform. Racist and homophobic slurs all-important 60-vote super-majority that would have virtually guaranteed were repeatedly hurled at pro-reform lawmakers the bill’s success. And while polls demonstrated overwhelming biwalking by; another was spat upon. Democratic Whip Jim partisan support for individual components of reform, the Clyburn, who led fellow black students in integrating South Republicans seized upon Brown’s victory as being represenThe US spends about Carolina’s public facilities a half century ago, called the betative of public unease with the process by which the arguhavior shocking. “I heard people saying things today that ments were being won. a year on its healthcare I have not heard since March 15, 1960, when I was The result has been months of wrangling, sniping system, which includes marching to try to get off the back of the bus,” Clyburn and political maneuvering. But in the last few weeks, private, federal and told reporters. Clearly, the issue of healthcare reform is Obama has taken strong action to bring what has been a employer schemes bringing out the nastier side of American politics. year-long legislative showdown over his top domestic priIndeed, such venomous exchanges have been symptoority to a close. “Everything there is to say about healthcare matic of President Obama’s attempts to push through the healthhas been said, and just about everybody has said it,” he asserted care restructuring plans that provided his presidential campaign with at a recent briefing. “Now is the time to make a decision about how to such a strong and popular platform. The debate should have been about docfinally reform healthcare so that it works, not just for the insurance compators, patients, insurance, drug companies and coverage; instead, much of the nies, but for America’s families and America’s businesses.” attention has been focused on the legal and constitutional processes required And on March 21, he finally got his wish. The healthcare reform legislato get any potential reform bill passed into law. tion passed by the House of Representatives by a vote of 219-212, effectively Make no mistake: this has been an exhausting campaign for people on ends a year’s worth of political horse trading and lobbying, and gives an adboth sides of the political divide. Back in December it had only seemed a matditional 32 million Americans access to basic health insurance by 2019. And ter of time before comprehensive healthcare reform became a reality. But even though it is projected to cost $938 billion over the next decade, it is also

$2.2 TRILLION

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Cover Story_16 nov 23/03/2010 10:30 Page 34

The case for healthcare reform

1

One in every six dollars in the US economy is spent on healthcare today

8

The number of people every minute who are denied coverage, charged a higher rate or otherwise discriminated against because of a pre-existing condition

41

The percentage of adults under the age of 65 who accumulated medical debt, had difficulty paying medical bills or struggled with both during a recent one-year period

50

If you’re an American under the age of 65, there’s a 50/50 chance that you will find yourself without coverage at some point in the next decade

$115 625 34 www.executivehm.com

The average monthly premium for employersponsored family coverage in 2009

The number of people who lost their health insurance EVERY HOUR in 2009

President Barack Obama and Vice President Joseph Biden leave after making a statement at the White House after the US House of Representatives passed healthcare reform legislation set to reduce the budget deficit by $138 billion over the same period, according to the Congressional Budget Office.

It is the first major revamp of America’s costly and unwieldy health insurance system in decades, and Obama has been keen to stress that the victory is one for America as a whole rather than one for him and his party. “I’ve got a whole bunch of portraits of presidents around here, starting with Teddy Roosevelt, who tried to do this and didn’t get it done,” the President said during a televised inquisition by Fox News in the Blue Room of the White House as the campaign neared its climax. “But the reason that it needs to be done is not its effect on the presidency. It has to do with how it’s going to affect ordinary people who right now are desperately in need of help.”

Indeed, the true winners of the reform process could be the American public. Over 94 percent of all non-elderly Americans will have access to health insurance by 2016, versus just 83 percent now. Health insurers won’t be able to deny coverage based on pre-existing conditions. And generous subsidies will be available to lower-income families to help them get cover. The bill also expands eligibility for Medicaid as part of its coverage mechanism, as well as increasing Medicaid reimbursements, which will make it easier for patients on Medicaid to find doctors who take their insurance. The so-called ‘donut hole’ coverage gap in Medicare Part D plans is also set to be closed.

The influential American Public Health Association (APHA), for one, congratulated the House of Representatives on its historic decision. “For nearly a century, providing quality, affordable care to all Americans has eluded our grasp; today’s vote, however, changes all that,” said Georges C. Benjamin, Executive Director of APHA. “Passing this measure will strengthen our public health system, invest in prevention, improve the health of the American people and move us closer to providing comprehensive and affordable health coverage for all Americans.”

Cover Story_16 nov 23/03/2010 10:30 Page 35

Breakdown of US federal health expenditure, 2007 There was support from the private sector, too. Gary Lauer, Chairman and CEO of eHealth, Inc., also sees the bill’s passage as significant. “With final legislation awaiting the President’s signature, strategies for implementation of reform and enrollment of Americans in health insurance coverage will be the next and most important order of business,” he says. “We believe that the technologies that have been developed by private sector players are key to ensuring Americans find and receive the coverage this legislation would mandate.”

Of course, the bill as it stands today is far from perfect. And according to Michael Cannon, Director of Health Policy Studies at the Cato Institute, it is unlikely that the health legislation signed into law by President Obama will look the same when it takes effect in four years’ time. “It creates too many unstable situations that Congress will have to address,” he says. For instance, under the new law, insurance companies will have to offer coverage to children with pre-existing conditions within the next six months. But it is not clear how much they will charge. And, Cannon says, young people and healthy individuals will have an incentive to drop their coverage now, knowing that they will be offered a cheaper alternative in the future. That could cause private health insurance markets to implode.

9.5% 4.2% 4.5% 24.7%

57.2% “We proved that this government – a government of the people and by the people – still works for the people” Such ambiguities mean the debate on the merits of the healthcare plan look set to run on well into the second half of Obama’s term – and possibly decades into the future. Insurance companies – despite gaining access to an additional 32 million taxpayer-subsidized customers (Forbes called the new legislation a “cash for clunkers program for HMOs”) – are amongst those disenchanted with the move. “WellPoint is disappointed that after more than a year of debate, Congress has approved healthcare legislation that does little to reduce cost and improve quality – two important elements to building a sustainable healthcare system that provides affordable coverage for all Americans,” stated Kristin Binns, a spokeswoman for Wellpoint, in the aftermath of the vote.

“We will continue to advocate what we believe is in the best interest of our customers and the country – affordable, quality healthcare that is accessible to all.”

Likewise Jeffrey Kang, Chief Medical Officer at health insurance giant Cigna, believes the legislation only addresses part of the problems facing the healthcare system. “The bill really only deals with the coverage issues or the expanded access issues, and doesn’t deal with the cost or quality issues,” he says. “So you find the expanded coverage is financed by lots of increased taxes.”

There is certainly a case to be made that reforms are going to prove costly. The overhaul will largely be paid for by cuts in Medicare, new taxes on investment income and fees on various industry participants that will almost certainly be passed along to the general public. And while government subsidies for people who cannot afford insurance and insurance exchanges to help people get coverage will not be operational before 2014, the increased costs will begin next year.

But despite continued opposition to the program of changes, the Democrats are entitled to feel that a significant victory has been achieved. A new Associated Press-GfK Poll finds a widespread hunger for improvements

Other Military (serving) Veterans

Medicaid (Low-income families)

Medicare (Elderly 65+))

Total $754 billion to the healthcare system amongst the American people, which suggests that Obama has a political opening through which to push his plan. Half of all Americans say healthcare should be changed a lot or ‘a great deal’, and only four percent say they are happy with the status quo. Democrats hope that such a groundswell of support for change will be enough to counter the fact that more than 80 percent of Americans say it’s important that any healthcare plan have support from both parties, and that two-thirds believe the President and congressional Democrats should keep trying to cut a deal with Republicans rather than pass a bill with no GOP support.

Such a scenario means the opinion polls over the next few weeks will make for interesting reading. Can success breed further success and enable the President to steam ahead with difficult laws on immigration and the environment? Or will the protracted nature of the healthcare battle leave his party feeling burnt out, beaten up and short on favors to call in?

If the President himself is in any doubt, he’s not showing it, preferring instead to concentrate on the historic significance of an achievement that has proven too great for every American leader before him. “At a time when the pundits said it was no longer possible, we rose above the weight of our politics,” he said, shortly after the bill was passed. “We pushed back on the undue influence of special interests. We didn’t give in to mistrust or to cynicism or to fear. Instead, we proved that we are still a people capable of doing big things and tackling our biggest challenges. We proved that this government – a government of the people and by the people – still works for the people.” n

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Karen Davis ED_16 nov 23/03/2010 10:12 Page 36

THE BIG INTERVIEW

TOWARDS A MORE EQUITABLE HEALTH SYSTEM Karen Davis of The Commonwealth Fund explains why social justice remains at the center of healthcare reform.

By Natalie Brandweiner 36 www.executivehm.com

P

reviously serving under President Jimmy Carter as Head of Health Policy for the US Department of Health, Karen Davis has had plentiful experience in developing a national health plan. Her appointment to The Commonwealth Fund followed her four-year tenure in government and saw her publishing a book by the Johns Hopkins University on the issues of long-term care, as well as being Executive Director of a Commonwealth Fund commission looking at the problems faced by the elderly living alone. Through a repertoire of established academic work, Davis set out her goal of supporting vulnerable populations and the Fund has long had a commitment to social justice.

Davis explains the objectives of the Fund and its commitment to distinguish the promising from the proven: “The Fund from its beginning has had a commitment to helping those who are most vulnerable, whether they are low income, minorities, uninsured people or frail, elderly people or young children. My background in health policy and health services research positioned me to carry on those traditions established from the very beginning by Anna Harkness, who established the Fund in 1918.

“We’ve also used commissions very effectively since I’ve been president.

Right now we have a commission that developed a lot of the data on the need to improve the performance of the health system and how it’s a bigger problem than just insurance coverage and it’s also changing the delivery system,” she says.

Davis’ work has not gone unnoticed. In 2009 she was listed in Modern Healthcare’s ‘Top 25 Women in Healthcare’, but does she think it’s important for the industry to have female leaders? “I do, and if you look around at the current debate you see Secretary Sebelius at the Department of Health and Human Services – she served on The Commonwealth Fund task force on the future of health insurance for five years, from 1998 to 2003.

Karen Davis ED_16 nov 23/03/2010 10:12 Page 37

“Then you have Nancy Ann DeParle who heads the Office of Health Reform at the White House. You’ve got Jeanne Lambrew who heads the Office of Health Reform within the Department of Health and Human Services. And you’ve got women leaders like Dr. Margaret Hamburg at the Food and Drug Administration and Nicole Lurie who heads up preparedness efforts for the department, and you’ve got Speaker Pelosi in a very critical leadership role in the House.

“Many of the top health officials are women, and it obviously makes sense to tap the talents of all kinds of leaders. It benefits the nation to have this kind of a talent pool available at a time like the one we’re in, the historic opportunity that we’re in right now to really bring coverage and health reform to everyone.”

“Many of the top health officials are women, and it obviously makes sense to tap the talents of all kinds of leaders” Healthcare reform Davis cites the recent healthcare reform passed under the Obama Administration as long overdue in the US – it has been on the government’s cards for almost a century, starting with Teddy Roosevelt in 1912 – and also long overdue in the sense of the system’s rapid decline.

“The numbers of uninsured are growing to about 50 million people without health insurance, but our own work shows that even if you have health insurance the adequacy of that coverage has deteriorated, with medical bills and

Karen Davis

medical debt now affecting about 72 million working age adults, most of whom have insurance but still have problems paying their medical bills or they have unpaid bills that have accumulated over time.

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Karen Davis ED_16 nov 23/03/2010 10:12 Page 38

Mission statem

ent

“Reform is needed. It’s needed to age under Medicaid for families with inThe Comm cover people and certainly about twocomes under about $30,000. What it doesonwealth Fund was philanthro established thirds of the uninsured would be covn’t do is cover undocumented residents. So pist Anna by Harkness ch in 1918 wit arge to en ered, anywhere from 31 to 36 million the Congressional Budget Office estimates hance the h the broa common g d The Fund people. It would also help people who that there are about eight million uninsured o o d . is a private foundatio promote a now have coverage by making sure who aren’t eligible because it excludes people n that aim high perfo s to rming hea achieves b lthcare sy that there’s a standard benefit package who are not legal residents of the US. etter acces stem that s, improved efficiency, quality an ceiling on out-of-pocket expenses “It’s hard to figure out who the others are particularl d greater y for societ including y’s most vu and income-related subsidies for that are uninsured. Some may be high-income low-incom lnerable, e people, American the uninsu people to pay for it. It would change families, but would rather just pay the modest s, young ch re d, minority ildren and elderly ad It carries o the delivery of healthcare services, penalty and not be covered, but a lot of the u lts. ut this ma ndate by su independen improve quality and slow the problem really is being eligible but not enrolling. pporting t research on health making gra care issues growth in healthcare costs. When So if you make enrollment easy, if it’s automatic nts to imp and ro ve healthca p o li cy . An intern our board set up our commission – for example, if you use the tax system and say re p ra ct ice and ational pro gram in h designed on a higher performance health you’re automatically covered unless you pay the ealth policy to stimula te innovati is in the Unit ve policies system they asked it to do what I fine and don’t opt for coverage – then I suspect it ed States and pract and other ices industriali think of as a win-win-win. Find would get closer to universal coverage, except for zed countr ies. win-win-win solutions that lead to the issue of people who are not legal residents.” better access, improved quality Medicare has also been on the priority reform and greater efficiency and they’ve certainly identified ways of doing that. list, and Davis so far believes Obama’s reforms to Many of them are reflected in health reform.” have made a down payment on it. The Fund estimates that it is likely to slow the Davis points to the Fund’s own study that suggests that reform would slow growth in Medicare spending from 6.6 to 4.5 percent a year, which she describes the growth of the cost of healthcare from 6.6 to six percent a year. Although the as “extending the salt of the sea of the Medicare hospital trust fund”. She adds cost would still be over $4 trillion by 2020, it would at least cover nearly everythat this will eliminate the overpayment of Medicare managed care plans and inbody. She explains that the way to do this without adding to the deficit is to find stitutes productivity improvement requirements on hospitals and other savings that would provide greater efficiency and productivity in the healthcare providers. “Those are where the savings come from, but those are the kinds of system, which would ultimately change the incentives for private care and precost slowdowns that are both reasonable to expect and would add to the solvenvention. Most importantly, she notes the move away from fee-for-service paycy of the program. ment to global fees for primary, acute and comprehensive care.

“One thing that hasn’t been talked about very much is that there’s a new “If Congress can finish its work and cover 31 to 36 million people, that provision in both the House and Senate bills for community living assistance means that at least 94 percent of the US population would be covered,” Davis for supportive services. It’s a new voluntary long-term care benefit funded by explains. “The Congressional Budget Office estimates that there would still be premiums that people pay during their working years and then they get a monthabout 23 million people without health insurance coverage, but for those, first ly payment if they are limited in their ability to take care of themselves. So they of all, it establishes a benefit standard of which employers should cover and either need an aided home or need to be in assisted living facility or a nursing requires employers to either offer coverage or make a contribution to coverhome, then they would get a monthly check to help defray that cost. age. So that’s going to improve the situation.

“Having said that, the retirement of the baby boomers starting in 2011 will “It provides income-related subsidies for families with annual incomes require additional action. Obviously it’s going to take a combination of measures, to about $90,000, and so helps pay the premium and any out-of-pocket exsome of which may be tax increases. The payroll tax, which funds the hospital penses for even middle-class families. There’s also comprehensive free coverpart of Medicare, hasn’t been increased since the early 1990s. Probably also we’ll

The Commission on a High Performance Health System In establishing the Commission on a High Performance Health System in 2005, The Commonwealth Fund’s board of directors recognized the need for national leadership to revamp, revitalize and retool the US healthcare system. The Commission’s 17 members – a distinguished group of experts and leaders representing every sector of healthcare, as well as the state and federal policy arena, the business sector, professional societies and academia – are charged with promoting a high-performing health system that provides

38 www.executivehm.com

all Americans with affordable access to high-quality, safe care while maximizing efficiency in its delivery and administration.

During its inaugural year, the Commission ignited considerable public interest and attention. Its greatest accomplishments so far have been to highlight for the public specific areas where health system performance falls short of what is achievable, and to make the case for a holistic approach to reforming healthcare.

Karen Davis ED_16 nov 23/03/2010 10:12 Page 39

need to have fundamental provider payment reform. It’s important that that be a comprehensive system that affects what private insurers pay doctors and hospitals, as well as Medicare. You can’t just squeeze what Medicare pays without hospitals, thinking, ‘We can make more money if we take care of no Medicare patients.’ It needs to be a comprehensive solution,” she says.

Research The organization’s research activities for the past year at least have been dedicated to health reform, which has been under the auspices of its commission on a high performance health system that the board set up in 2005.

In February 2009, the commission issued a report, Path to a High Performance Health System, which laid out the framework for health reform and depicting what both the House and Senate bills would encompass.

The commission conducted separate work on all of the major elements: setting up health insurance exchange, income-related premium assistance and cost sharing assistance; the requirement for individuals to have coverage; shared employer financial contributions; and then changing the delivery system. As early as November 2008, a report was put out examining the options for improving quality and achieving savings, and many of those are incorporated in the health reform bill of 2009.

As well as this, the Fund also produced a report by a professor at William & Lee University on health insurance exchanges and how to make those work.

“We’ve done a lot of work over the last couple of years on what are the problems with the health insurance system,” she says. “The fact that you’ve got gaps in coverage and that there 25 million people who are under-insured: they have insurance, but it’s not adequate. Then there are the special problems of young adults and older adults before they’re eligible for Medicare.” The Fund also put out the first national and state scorecards on health system performance, using comparisons of international health systems, which have been used in the health reform debate.

The organization understands greatly the need for partnerships and has been responsible for funding the Urban Institute as well as investigator Jon Gabel at the National Opinion Research Center to conduct research that has contributed to the bill, the former being cited by Secretary Sebelius in the debate. The Fund has also done work around models of high performing health systems, Medicare managed programs and a patient center medical home concept.

This research has been supported by testimony given in front of a wide variety of groups. “We were invited to over 75 meetings with individual members of Congress, different groups like the Republican Health Reform Caucus, the Democratic Blue Dog Coalition, the new Democrat coalition and the progressive Democrats. Speaker Pelosi asked me to do a lot of briefings of freshman Democrats and of the Democratic Policy and Steering Committee and the Democratic caucus,” explains Davis.

“We have had lots of opportunities to present to members and we also put on a bipartisan health policy conference every year where we get both Republicans and Democrats to come and speak to each other civilly, which is the only forum maybe where they’re able to do that. We’ve been doing that since 1998 and have built up relationships with a number of leaders in Congress so they know we’re a trusted source of independent information on these issues.”

The rolling out of the government’s reform bill will certainly make 2010 a dramatic year for healthcare and for The Commonwealth Fund, and watching its research come to fruition will be no less exciting. n

History of The Commonwealth Fund The Commonwealth Fund has its origins in the philanthropic efforts of the Harkness family. Stephen Harkness began his career in New York State’s Finger Lake region at age 15 as an apprentice harnessmaker. Harkness eventually settled in Ohio and became a successful businessman. He invested early in the petroleum refining business and provided funds at a critical moment in the history of the fledgling Standard Oil Company.

Anna Harkness, like her husband Stephen, had a strong civic spirit and believed in encouraging all forms of self-help.

In the years following her husband’s death in 1888, she moved her family to New York City where she gave liberally to religious and welfare organizations, and to the city’s major cultural institutions. And yet she felt keenly the shortcomings of such unstructured personal giving.

In 1918, Harkness founded The Commonwealth Fund with the mandate that it should “do something for the welfare of mankind”. Among the first women to establish a foundation, Harkness initially endowed her new philanthropic enterprise with a gift of nearly $10 million. The Fund’s first president was her son, Edward Stephen Harkness, who shared his mother’s commitment to building a responsive and socially concerned philanthropy and who, over the years, gave generously to the Fund’s endowment.

As a first step, Edward Harkness hired a staff of talented and experienced people to help him. As president of The Commonwealth Fund for 22 years, he led that staff to rethink old ways, experiment with fresh ideas, and take chances, a path encouraged by each successive generation of the board of directors.

Through additional gifts and bequests between 1918 and 1959, the Harkness family’s total contribution to the Fund’s endowment amounted to more than $53 million.

Throughout its history and in keeping with its donors’ intent, The Commonwealth Fund has sought to be a catalyst for change by identifying promising practices and contributing to solutions that could help the US achieve a high performance health system. The Fund’s role has been to establish a base of scientific evidence on what works, mobilize talented people to transform healthcare organizations, and collaborate with organizations that share its concerns.

The Fund’s work has always focused particularly on the challenges vulnerable populations face in receiving high quality, safe, compassionate, coordinated and efficiently delivered care.

The foundation’s communications efforts have enabled it to share knowledge and experience and reach influential audiences able to push forward the necessary agenda for achieving a high performance health system.

Source: www.commonwealthfund.org

Karen Davis is President of The Commonwealth Fund.

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EXECUTIVE INTERVIEW

Fighting ventilator-associated pneumonia Douglas Hansell looks at tools and strategies for minimizing the risk of VAP and other pulmonary complications.

Could you please discuss ventilator-associated pneumonia and explain how patients contract it?

Douglas Hansell. We know that the risk for infection increases the longer a patient is mechanically ventilated. There are probably several mechanisms, but certainly a primary one has to do with microaspiration or leakage of secretions around the tracheal tube cuff.

With increasing time on the ventilator and time in the ICU, a patient’s secretions become colonized and the ability to precipitate pneumonia from microaspiration is a real phenomenon. Standard tracheal tube cuff technology hasn’t changed in nearly 40 years. Our new product, the TaperGuard Evac tube, uses a different design that substantially reduces the risk of microaspiration.

VAP is also part of a much broader problem with a very large impact on the healthcare system: post-intubation or post-operative pulmonary complications, sometimes called PIPC. Post-intubation pulmonary complications are surprisingly common and are as-

Douglas M. Hansell, MD, MPH is Medical Director for Covidien. A Harvard-based physician, Hansell has over 20 years of multi-sector healthcare experience. In addition, Hansell has maintained an active clinical practice in Anesthesiology at Massachusetts General Hospital in Boston and has held teaching appointments at Harvard University.

Hansell is board certified in Internal Medicine and Anesthesiology, fellowship trained in cardiovascular anesthesia and experienced in critical care medicine.

sociated with significant mortality. As with VAP, microaspiration may be the primary cause of or may further exacerbate a wide range of these complications.

oral hygiene to keeping the head of the bed elevated, to managing sedation in the ICU and striving for earlier ventilator weaning and earlier removal of the endotracheal tube.

One of the strategies that has also been highly productive has to do with removing secretions from above the endotracheal cuff.

Subglottic secretions drainage with the Mallinckrodt Evac tube has been shown to reduce VAP by up to 75 percent. When we look at the data, combining subglottic secretions drainage with the new cuff may be even more effective in reducing leakage past the cuff.

In summary, attacking the problem is multimodal, and many different techniques and procedural changes in technology have been applied to the problem. The latest technology that can advance this is the TaperGuard Evac tube.

What strategies can hospitals use to help prevent patients from contracting VAP? DH. The problem needs to be attacked with a multitude of strategies, from oral care and

What is the TaperGuard tube and how does it reduce the risk of microaspiration?

DH. The way most endotracheal cuffs are designed hasn’t changed since the mid-1970s.

“For the medical community there are significant opportunities to advance the prevention of VAP and post-intubation pulmonary complications”

Because they’re designed to be larger than the trachea, they tend to form folds or microchannels when they’re inflated in the trachea.

Those micro-channels allow fluid to move past the cuff and down into the lungs. Their ability to seal out fluid has marked limitations.

What’s revolutionary with the TaperGuard tube cuff is that it’s more taper-shaped, which allows the cuff diameter to match the diameter of the trachea at some point along the cuff. That reduces the micro-channels at the sealing zone, and markedly improves sealing characteristics. The TaperGuard cuff offers a 90 percent reduction in micro-aspiration compared to our Hi-Lo tube cuff.

What can be done to eliminate VAP and the broader problem of post-intubation pulmonary complications?

DH. I don’t think we’ll be able to eliminate post-intubation pulmonary complications entirely because they have multiple causes.

They’re dependent on the type of surgery, on pre-existing illness and on the state of the patient coming into surgery. It’s a little like cardiac complications after surgery: we can’t eliminate them, but we as an industry and as a medical community have focused heavily on cardiac complications over the past 10, 15, 20 years or even longer, and we’ve made a lot of headway there.

For the medical community there are significant opportunities to advance the prevention of VAP and post-intubation pulmonary complications. Can we eliminate them? No, but we have the ability with existing technologies and focus to change the game and make some major in-roads.

It’s going to take multiple modalities to go after that, not just the TaperGuard tube, although it will obviously play a role. It will involve getting patients off the ventilator faster.

It will involve technologies for monitoring patients for respiratory compromise even after they’re extubated. We’re looking at this space very broadly in terms of the different technologies and how we can make improvements.

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INFECTION CONTROL

KEEPING THE AIRWAYS CLEAR Robert Kacmarek examines the causes of ventilator-associated pneumonia, and what measures can be employed to counteract it.

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he contracting of pneumonia has always been treated as a serious event in any patient’s medical history; it proves susceptibility to infection whilst leaving the potential for future complications. But for those who are already in a state of vulnerability – specifically those needing artificial respiration – infection often precedes the onset of ventilator-associated pneumonia (VAP), a condition that Robert Kacmarek believes could be completely avoidable, provided the correct hygiene and infection control measures are set in place.

Kacmarek, who is Director of Respiratory Care at Massachusetts General Hospital, defines VAP as “a pneumonia that develops after a patient has been mechanically ventilated for 48 hours that was not present in any way prior to the initiation of mechanical ventilation.” And whilst it is difficult to definitively pinpoint precisely how a patient catches VAP, the most probable route is one of two ways: “It could be aspiration of gastric contents that, because of patient position, their normal path of physiology will regurgitate. They’ll have fluid from the stomach enter the oral cavity and the cuffs that are available under tracheal tubes are not capable, even when inflated properly, of preventing aspiration.

“Later ventilator-associated pneumonia is most likely moved from one patient to another patient by caregivers not being as careful as they should” “There are small channels that do develop when cuffs are inflated and through those channels fluid can move by capillary action during mechanical ventilation. That’s usually what has been referred to as a primary cause for early ventilator-associated pneumonia.

“Later ventilator-associated pneumonia is probably a health providertransferred organism that may exist in the particular ICU or in the hospital, that is most likely moved from one patient to another patient by caregivers not being as careful as they should.”

Indeed, this seems to hold many common characteristics with plenty of other healthcare-acquired infections. However, given the fact that patients who contract VAP are on mechanical ventilation and often sedated – and therefore can’t communicate – it can become problematic to ascertain the specifics of a patient with VAP who can’t flag up the symptoms.

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“It shows the same signs as any other type of pneumonia,” Kacmarek says. “You go from a circumstance where the patient was intubated without pneumonia, to now all of a sudden developing a fever, increased red blood cell count and have a change in the quality and quantity of the secretions that they’re producing. All that would indicate that there is something going on inside the chest that wasn’t there before they were intubated.”

Of course, pneumonia holds various other guises in its infectious form, but it seems as though its introduction through the healthcare setting allows it to become far more aggressive and difficult to combat. “Depending on the particular organism,” explains Kacmarek, “if it’s a hospital-acquired infection, a lot of the organisms are much more virulent. They have

drug resistances to them, so it can be a more difficult organism to treat than you would commonly encounter outside the hospital setting.

Probably more importantly, the patient is already debilitated to begin with if they’re in the intensive care unit.”

“So, they develop a secondary infection on top of their pre-existing problem and it can be overwhelming for some patients. There is a mortality that is associated with VAP.” It goes without saying that the combination of these two factors must be extremely stressful on the patient’s system. Thus, in order to reduce – and hopefully one day completely prevent – the introduction of VAP into further patients, hospitals and staff are beginning to follow more strict guidelines pertaining to general sanitation and infection control.

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Statistics for pneumonia and VAP 60% of adults 65 years and over received a pneumococcal vaccination in 2008 Average length of hospital stay for pneumonia: 5.1 days Percent of current patients with pneumonia as primary diagnosis: 1.5% (2000) Number of deaths due to pneumonia: 55,477 (2006) Deaths per 100,000 population: 18.5 (2006) Percent of hospital inpatient deaths from pneumonia: 5.4%

that are entering the market that seem to perform better in avoiding aspiration. “All of those techniques should be utilized in a VAP-prevention program.”

Despite the differences in origin of infection, VAP is treated just like any other form of pneumonia – with antibiotics specific to the organism – regardless of whether the patient is in hospital or at home. However, a broader kind of problem within which VAP falls is post-intubation, or post-operative pulmonary complications.

This has undeniably had a huge impact on the US healthcare system in terms of cost and mortality.

“There are new cuffs that are entering the market that seem to perform better in avoiding aspiration”

9% – 28% of mechanically ventilated patients contract ventilator-associated pneumonia “What this makes reference to is patients who are elderly, have any kind of co-morbidity, or who have serious abdominal or thoracic surgeries; post-operatively they may run into some difficulty in being able to inhale normally. As a result, they acquire alectasis.

Hospital cost for VAP: $29,000 – $40,000 per patient “That causes a problem with oxygenation,” continues Kacmarek.

“It also sometimes causes secretion accumulation, which Sources: www.cdc.gov/nchs/FASTATS/pneumonia.htm, can get the patient into a vicious cycle of going into respiratory failhttp://nursing.ouhsc.edu/Research/documents/ebp_symposium_2009 ure and requiring mechanical ventilation; at minimum it will require oxygen therapy or aerosolized drug therapy to try and resolve the issue. It can run the gamut of mild secretions accumulation to actually result in “Of course, first and foremost is practicing good hand hygiene,” underintubation and mechanical ventilation.” lines Kacmarek. “In every institution now, practitioners should be using some In order to prevent this, rapid mobilization of the patient is of particular imtype of antiseptic prior to entering the patient’s room to disinfect their hands; not portance. “If the patient can be sat up, can get out of bed, be in a chair or walk; just entering, but also exiting. We use a substance called Cal Stat – an alcoholthe sooner they breathe deeply, then the more likely they are to avoid the pobased substance that whenever we go into a patient’s room and when we leave tential complications. In those patients where it’s not feasible, of course pathe patient’s room, we should be applying that vigorously to our hands. tients are encouraged to cough and deep breathe on a regular basis. If they do “In addition, if you are interacting with patients who are mechanically have any pre-existing pulmonary problems, then they would be administered ventilated, we require that therapists, nurses and physicians wear gloves. drug therapy or breathing treatments of some sort in order to facilitate that They’re going to be interacting with secretions, so it’s unavoidable that recovery.” they’ll need to glove any time they have an interaction with those patients.

With all the new hygiene and sanitation products being introduced onto Other aids that seem to help avoid VAP include raising the head of the market, pressure is undoubtedly growing to significantly reduce the numthe bed by at least 30 degrees and trying to maintain it at that level so there ber of VAP incidents in the US healthcare system, as Kacmarek is quick to isn’t movement of fluid from the stomach into the oral pharynx. Good point out: “There is clearly interest and pressure for it to be decreased. With oral hygiene on a regular basis to ensure the patient’s mouth remains clean many of the factors that result in VAP, the more we learn the more I believe is also of critical importance. “Remember, the patients may be sedated or we can effectively manage patients to avoid VAP. Ideally it should be zero. We at least are not totally capable of functioning as normal. So, secretions achave some work to do, but I think we will see it moving in the right direction cumulate in their oral pharynx that would normally not accumulate, and in the next few years.” n they need to be removed.

The mortality rate for VAP is: 40% – 80%

“We remove them by suctioning. And of course, as I said before, there is leakage passed into the tracheal tube cuffs. You need to appropriately inflate the cuff and make sure that cuff inflation is maintained over time.

In addition, there are some alternate endotracheal tube styles available that will allow continuous suctioning above the cuff. There are new cuffs

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Robert Kacmarek is Director of Respiratory Care at Massachusetts General Hospital and a professor at Harvard Medical School.

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HAND HYGIENE

SAVE LIVES: CLEAN YOUR HANDS A call to action from Professor Didier Pittet, University Hospitals Geneva, Expert Lead for the WHO First Global Patient Safety Challenge.

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ealthcare-associated infection (HAI) occurs in every country and affects millions of patients annually worldwide. As a global issue, HAI has received much attention from healthcare settings and governments, as well as the public and media. The World Health Organization (WHO) made the commitment to address this problem through the successful activities of the First Global Patient Safety Challenge: ‘Clean Care is Safer Care’ launched in 2005.

Hand hygiene has been recognized as the single most important measure in these attempts and is the basis of actions promoted by ‘Clean Care is Safer Care’. As part of this challenge, over 120 ministries of health have pledged their commitment to tackle HAI. Healthcare facilities in many countries will be paying particular attention to taking action at the point of patient care on and around May 5, 2010, as participants in the WHO SAVE LIVES: Clean Your Hands initiative (the next phase of the First Global Patient Challenge dedicated to promoting hand hygiene sustainability).

More than 6000 healthcare settings from 126 countries have already registered for the SAVE LIVES: Clean Your Hands global annual initiative, representing over two million beds and five million healthcare workers.

What can you do?

We ask you to support the call for action by: registering your facility to demonstrate a commitment to SAVE LIVES: Clean Your Hands and/ or asking five others to do the same; sharing your plans and successes with others through local and national publications, as well as with WHO; fi nding out if there is an existing hand hygiene campaign in your country and seeing what you can do to support it; listing five areas for improvement in your facility and discussing these with your managers and staff ; using and promoting a multimodal strategy to ensure sustained hand hygiene improvement; 3, 4, 5 including the WHO’s ‘My 5 Moments for Hand Hygiene’ approach; 6 and participating in the inaugural WHO infection control webinar series as an additional way to improve knowledge. During the week of May 3, 2010, five live webinars will take place, including one by me on May 5.

Where is your institution placed in the crusade for optimizing and sustaining hand hygiene performance and safe patient care? Assessing the level of your own institution, using a specifically designed approach, and working towards achieving the status of a hand hygiene excellence center should be paramount. Using a framework to support such an approach will assess the level and improvements required, within a multimodal strategic context that has been tried and tested as part of ‘Clean Care is Safer Care’. Th is multimodal strategy addresses: system change, healthcare workers’ education and training,

monitoring and performance feedback, reminders in the workplace, and institutional safety climate.

To truly protect patients, it will take leadership, commitment, a range of actions, continuous assessment, experience-sharing, and time.

Be part of a large cohort of observers and participate in monitoring of practices; we encourage healthcare institutions to consider this as part of their May 5, 2010 activities. The power of such an action can ultimately change behavior, improve care and reduce patient harm.

WHO initiative The SAVE LIVES: Clean Your Hands annual initiative is part of a major global effort led by the World Health Organization (WHO) to support healthcare workers to improve hand hygiene in healthcare and thus support the prevention of often life threatening HAIs. This initiative is part of the WHO Patient Safety First Global Patient Safety Challenge, ‘Clean Care is Safer Care’ program aimed at reducing HAI worldwide, which was launched in October 2005. The clear and central feature of Clean Care is Safer Care thus far has been to target efforts on the importance of clean hands in healthcare. The program has galvanized action at many levels including, as at November 2009, Ministers of Health from 121 countries having pledged commitment to reducing HAI and support the work of WHO. Thirty-eight nations/sub-nations have also started hand hygiene campaigns during this time.

SAVE LIVES: Clean Your Hands was deemed a natural next phase of the Clean Care is Safer Care program, moving the call to action from a country pledge of commitment to the point of patient care. The central core of SAVE LIVES: Clean Your Hands is that all healthcare workers should clean their hands at the right time and in the right way.

SAVE LIVES: Clean Your Hands incorporates a global annual day to focus on the importance of improving hand hygiene in healthcare as well as WHO providing information and materials to support these efforts and sharing information on the activities of the many others who take action at local, national and regional level.

A suite of tools and materials have been created from a base of existing research and evidence and from rigorous testing as well as working closely with a range of experts in the field. The tools aim to help the translation into practice of a multimodal strategy for improving and sustaining hand hygiene in healthcare.

Source: www.who.int/gpsc/5may/background/en/index.html

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“We must not forget that hand hygiene is a global issue. Patients are infected in healthcare environments everywhere”

Professor Didier Pittet

Clean care is safer care The critical role of hand hygiene, by Professor Didier Pittet The recent global concerns about influenza A (H1N1) are an important reminder to everyone that hand hygiene is critical. Professor Didier Pittet, lead of the WHO First Global Patient Safety Challenge: Clean Care is Safer Care, said: “To prevent influenza virus spread, cleaning hands with soap and water or an alcohol-based handrub is imperative both at community level, and in healthcare settings.

Although droplets spread through coughing or sneezing is considered a major route of influenza transmission, hand contamination is also a critical contributing factor.

Persons suffering from flu-like symptoms should clean their hands with soap and water or by using an alcoholbased handrub, particularly after touching their nose or mouth, and before contact with another individual or patient. The simple act of hand hygiene will contribute to reducing spread of infection. It is also particularly vital when caring for a vulnerable population, including the elderly and the very young, receiving care in hospitals and other healthcare or social-care environments.”

Source: http://www.who.int/gpsc/pittet_message/en/index.html

Have you considered what the patient safety/infection control research priorities are in your healthcare setting and have you considered publishing your work? WHO identified that studies addressing the cost effectiveness of patient safety activities are important in both developed and developing countries. In developed countries, studies on enhancing communications and safety culture were deemed priority areas.

The WHO Guidelines on Hand Hygiene in Healthcare 3 clearly highlight where specific gaps still exist on this topic and welcome further studies and evidence of improving practices. The WHO First Patient Safety Challenge team is actively facilitating sharing of knowledge between nations/sub-nations running formal hand hygiene campaigns through a dedicated network of campaigning countries.

As lead for this exciting and powerful global movement, I firmly believe that we must not forget that hand hygiene is a global issue. Patients are infected in healthcare environments everywhere. It is our firm resolve to make hand hygiene improvement tools readily available so that healthcare workers regardless of their environment can access and utilize them.

Didier Pittet is Director of the Infection Control Program at University Hospitals Geneva and Expert Lead for the WHO First Global Patient Safety Challenge.

For more information, please see www.who.int/gpsc/, savelives@who.int, www.who.int/ gpsc/5may/news/webinars/en/index.html, www.who.int/gpsc/national_campaigns/en/ WHO tools to support a multimodal improvement strategy in healthcare facilities can be found at www.who.int.gpsc/5may/tools/en/index.html For references related to this article, please see www.executivehm.com/article/Save-livesclean-your-hands/

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ROUNDTABLE

Managing hand hygiene compliance

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n the last issue of EHM, we spoke to renowned infection control expert Elaine Larson about her ongoing research into the use of hand washing to prevent the spread of infectious disease. As well as undertaking a study into hand hygiene and H1N1, Larson, who is Professor of Epidemiology and Director at the Center for Interdisciplinary Research on Antimicrobial Resistance at the Mailman School of Public Health, Columbia University, has participated in the testing of the recently published WHO hand hygiene guidelines.

Part of Larson’s research is aimed at discovering how viruses such as H1N1 spread, and what people can best do to protect themselves. “If we can determine whether alcohol sanitizers or plain soap and water are better, then we’ll know what to recommend for people to use,” she told us. “And a better understanding of where the virus is spreading in houses will help people know what they need to clean.”

With the spotlight firmly on hand washing, and increasing pressure on healthcare institutions to comply with guidelines such as those released by the WHO, EHM gathered some of the industry’s leading experts to examine the challenges, strategies and solutions surrounding hand hygiene compliance.

THE PANEL

CHERYL LITTAU is a Senior Program Leader for Ecolab Healthcare. She holds a PhD in surfactant chemistry from Emory University. Littau is directly involved in the formulation, testing and development of new products for use by healthcare workers. She can be reached at cheryl.littau@ecolab.com

As Marketing Director for 3M’s Infection Prevention Division, JIM INGEBRAND covers a range of markets from medical diagnostics to disposable medical supplies. This diverse set of businesses has the common mission to help 3M customers detect, prevent and control the risk of infectious disease and healthcare-associated infections.

JANE KIRK, MSN, RN, CIC, is the Clinical Specialist for GOJO Industries, Healthcare Division, providing the infection control perspective to the Healthcare Marketing team. Kirk graduated from University of Detroit-Mercy with a Bachelor of Science in Nursing. She received her Master of Science in Nursing from Walden University.

RON CAGLE, VP of Research and Development, is the project leader for Sprixx, overseeing product development, marketing and business development. A 26-year product development veteran, Cagle holds multiple hand hygiene device patents. His 15year computer industry career included nine years as a software engineer developing new entertainment, fitness and business software products. Email rcagle@sprixx.com

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In your view, what are the current main challenges in hand hygiene compliance?

Cheryl Littau. One of the main challenges in hand hygiene compliance is ensuring that healthcare workers wash their hands at every hand hygiene opportunity. There are many factors that influence this, one of which is the interpretation of what constitutes a hand hygiene opportunity. Even though hand hygiene is considered a very basic requirement of a healthcare worker’s job, interpretation of exactly when hand hygiene is needed can be an issue.

“Hand hygiene compliance is a critical component of addressing broader issues of healthcare-associated infections, yet it is easily forgotten” JIM INGEBRAND For example, contact with the patient environment is recognized by the World Health Organization WHO as an indication for hand hygiene, but healthcare workers may not be aware that they have touched a contaminated surface in the patient environment. Second, given the current environment of complex care, decreased staff and heavy work loads, hand hygiene is not always top of mind. Third, hand hygiene products are not readily available.

Finally, skin health plays a vital role in hand hygiene compliance: dry, damaged skin can make hand hygiene a painful process. This can lead to a conscious or unconscious reduction in hand hygiene compliance.

Jim Ingebrand. Hand hygiene compliance is a critical component of addressing broader issues of healthcare-associated infections (HAIs), yet it is easily forgotten. Eighteen months ago when CMS announced it was discontinuing reimbursement for what it called ‘never events’, healthcare facilities increased their vigilance in the areas specifically outlined by the agency.

However, some neglected to look at hand hygiene as a core component of all of those improvements.

The reasons range from systemic, including staff shortages and increased pressure to see more patients in less time, to environmental, such as inconveniently located sinks, a lack of supplies or education, and a lack of involvement among healthcare professionals in product evaluation and selection.

The good news is that there is a renewed commitment to hand hygiene as an important HAI prevention measure, and hospitals across the country are taking action by increasing education and compliance.

Jane Kirk. The biggest challenge that I see with hand hygiene compliance is changing adult behavior so that hand hygiene becomes a habit for healthcare personnel. From my years of clinical experience and as a Director of an infection control program, I believe that healthcare personnel do not intentionally skip hand hygiene when they should be doing it, but rather they just don’t think about hand hygiene, as they are thinking about their next task, the next patient they need to see, etc.

There are some healthcare personnel who are not aware of the guidelines for when hand hygiene is warranted, and the challenge is to get the education presented to them in a way that they can make those opportunities part of

their routine. Finding ways to break through the old habits and instil a culture of hand hygiene awareness and compliance is how we meet the challenge.

Ron Cagle. Change initiatives lack the comprehensive, multi-modal, multidiscipline approach required to be effective with such a tenacious long-standing problem. There is an overwhelming tendency to tinker – trying single or weak interventions, seeing how they work, then trying another. This problem requires a full complement of behavior and system change mechanisms that work in concert to drive change. The finger-wagging approach to compliance is as ineffective now as it was for Semmelweis when he stood over the sink admonishing and lecturing colleagues. Compliance measures that focus on policing providers while limiting system changes pit providers and their leaders against each other in a dysfunctional system. Group measures fail to make any one person accountable; therefore no one is.

Which specific tools and techniques can healthcare organizations use to ensure they are able to meet these challenges?

JK. A healthcare personnel hand hygiene education program, a hand hygiene compliance monitoring process, and sharing of compliance rates with staff and resulting performance improvement programs are the key elements of a hand hygiene program. Having administrative support and the resources (both staff and financial) to implement an effective hand hygiene campaign are key elements for a successful hand hygiene program. Monitoring hand hygiene compliance to identify opportunities is very labor-intensive and ensuring that the hand hygiene program owner has the staff to conduct the audits is imperative to improving outcomes.

Best practices from effective programs across the country suggest that monitoring of compliance using observation methods should be conducted with a team of ‘secret shoppers’ comprised of individuals who are usually

“Achieving infection rate reductions through hand hygiene requires a comprehensive, multi-modal, multidiscipline hand sanitizing system with true point-of-care access to sanitizer” RON CAGLE

rounding on the units, such as wound care team nurses, or medical students.

The WHO, the Centers for Disease Control and Prevention and the Joint Commission Hand Hygiene Monograph all provide many educational tools and ideas to help the process, such as observational tools and education components including videos. Resources and support to implement the program are vital to the IP’s success.

Once observations or audits are completed, that information needs to be shared with everyone involved in patient care, including the staff who care directly for patients. Accreditation bodies such as the Joint Commission expect staff to be able to speak to the process improvement projects their unit is undertaking to improve compliance rates. Making hand hygiene compliance improvement a competition between units or divisions is a means to get staff and

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management engaged. Announcing monthly compliance rates at the manager’s meeting helps to create an environment where successes are celebrated.

Certificates of achievement could be presented to unit directors who show the most improvement and sustain that improvement. It is possible to make hand hygiene compliance competitive and fun!

RC. Achieving infection rate reductions through hand hygiene requires a comprehensive, multi-modal, multidiscipline hand sanitizing system with true point-of-care access to sanitizer. The system should include: personal ergonomic sanitizer dispensers, individual episode performance feedback, multifaceted education, indication training, and a high-degree of leadership involvement. The change initiative should support personal, social and structural motivation and ability to raise hand hygiene to a much higher level of performance and clinical respect.

The WHO’s ‘5-Moments’ indications for hand hygiene have been translated into coming and going from the patient room out of practical necessity given current system limitations. Intra-operative hand hygiene is the key to lowering infection rates. The over-reliance on gloves is a major contributing factor to missed opportunities within the patient environment.

CL. First and foremost, healthcare organizations must have multidisciplinary, multi-faceted hand hygiene programs that are championed by strong administrative support. Clear, consistent communication that proper hand hygiene is important and valued by the organization is essential. Second, in order to make performing hand hygiene as time efficient as possible, it is important to provide a product as close to the actual point of care as practically possible.

If the alcohol-based hand rub is immediately at hand, the barrier to use is dramatically reduced.

Third, hand hygiene opportunities should be clearly defined. The WHO’s ‘My 5 Moments for Hand Hygiene’ is an excellent tool to help reduce confusion about when hand hygiene is needed. Finally, assessment of worker satisfaction with the available soap and sanitizer products is key. Many of the latest generation of products are formulated to help maintain skin integrity through inclusion of moisturizers and emollients.

JI. Ideally healthcare facilities will institute compliance programs that fully address the intellectual (knowing the right thing to do), emotional (wanting to do the right thing) and behavioral (making it easy to do the right thing) aspects of the problem. Education is perhaps the single most important tool to increase hand hygiene compliance. From the top-down, it is essential to create a culture of compliance and develop the tools that fit within the culture.

Many facilities provide updates on new products and directly involve healthcare professionals at every level in the trial and evaluation of these products, helping to increase adoption and acceptance. Others are conducting annual, validated competencies on application and purpose of hand hygiene for all staff to ensure ongoing compliance.

3M has worked with facilities across the country using industry-leading Six Sigma methodology to improve hand hygiene compliance. One project, initiated in 2006 – and still ongoing – with HealthEast Care System of Minneapolis and St. Paul saw an increase in hand hygiene compliance from 36 percent to 70 percent. Continuous compliance monitoring and the identification of physician role models further increased physician compliance to 90 percent or greater.

What role does good hand hygiene play in the prevention of MRSA? RC. The fact that MRSA is being singled out is testament to how the current working interpretation of the CDC guidelines is failing to control emerging antibiotic resistant threats. When the guidelines came out, US hospitals responded by hanging wall-mounted sanitizer dispensers at patient room entrances, displaying educational hygiene posters and tracking soap/sanitizer inventory records. Wall-mounted dispensers are not true point-of-care access to hand sanitizer but a budget and operational-friendly approach that fits current attitudes. The 2008 Rupp et al. study demonstrated how the current working interpretation is failing to reduce infection rates.

The primary battleground for MRSA is within the patient environment.

Ergonomic personal sanitizer dispensers give providers the ability to respond to every intra-operative hand hygiene opportunity, especially during peak workloads. With effective training, personal dispenser use becomes a second nature habit. Impeccable intra-operative hand hygiene is possible and the single most effective way to reduce MRSA rates.

JI. Hand hygiene helps remove soil, debris and micro-organisms from hands and forearms, keeping patients and other healthcare providers safe from bacteria that could lead to infection. More than any other intervention to prevent and control HAIs, including MRSA, hand hygiene remains the most effective and least costly intervention.

“Many of the latest generation of products are formulated to help maintain skin integrity through inclusion of moisturizers and emollients” CHERYL LITTAU JK. Good hand hygiene plays a key role in the prevention of the spread of MRSA in healthcare facilities. The number one way germs are spread from one patient to another is on the hands of healthcare personnel. In the CDC hand hygiene guidelines, many studies are discussed that demonstrate that hand hygiene, using either soap and water, or an alcohol-based hand sanitizer (ABHS) will kill MRSA on hands. Studies have shown that when hand hygiene compliance increases, healthcare-acquired infections decrease and MRSA transmission rates decrease.

In an abstract to be presented at the 2010 Fifth Decennial International Conference on Healthcare Associated Infections, scientists will present a study that demonstrated that ABHS and 0.3 percent Triclosan, an antibacterial hand wash, were effective against MRSA, reducing levels on human hands by approximately 99 percent. The study also showed that four percent Chlorhexidine Gluconate (CHG) was less effective against MRSA, suggesting that CHG may not be appropriate hand hygiene for MRSA, particularly after a single use.

CL. Hand hygiene is critical to prevent transmission of MRSA. Colonization with MRSA is frequently undetected. There is clear evidence to suggest that MRSA is carried from one person to another via the hands of the healthcare

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worker. Hands are easily contaminated during caregiving or from contact with environmental surfaces in close proximity to the patient. Hand hygiene after such events has a very important role in preventing the transmission of MRSA. In situations where hands are not visibly soiled, alcohol-based hand rubs are very effective at killing MRSA, as well as many other organisms, providing both a rapid and high level of kill.

What recommendations would you make to healthcare organizations looking to introduce or improve their hand hygiene strategies?

JI. Considering that hand hygiene compliance is everyone’s responsibility, a culture of compliance must begin with top management and extend to everyone who comes into contact with patients. Understanding what drives compliance within your institution is pivotal. Talk to your healthcare professionals and understand their challenges and needs. Consider Six Sigma projects to drive sustainability by improving processes, reducing variation and establishing changes that become permanent practice.

In addition, partnering with industry leaders with proven expertise in hand hygiene technology – who understand the critical factors when developing and executing a hand hygiene compliance program – will improve hand hygiene strategies dramatically. Researching emerging technologies to help improve compliance will also play a significant part. 3M, for example, is collaborating with Patient Care Technology Systems on technology that uses real-time locating systems to automatically and continuously evaluate staff members’ hand hygiene activities throughout a patient encounter. Reports can be generated from the information captured during the hand wash and used for performance improvement projects and for training purposes.

fections warrants serious reflection on our practices, budgets and attitudes.

Significant improvements require new thinking, systems and commitment that reflects the cultural values to which healthcare aspires.

System change combined with new tools and approaches make it possible to significantly improve upon current hand hygiene standards. System change combined with effective hand sanitizing tools can transform hand sanitization from a friction-inducing tension between providers and their leaders into shared solutions that support intrinsic values. Everyone at every level – from the board to the housekeeping staff – needs to embrace significant change and personal responsibility for clinical hand hygiene evolution.

JK. I would recommend that the administration get involved and support the hand hygiene improvement projects and set an expectation of all staff to become engaged in the improvement of hand hygiene compliance and patient outcomes. Encouraging creativity and providing resources to implement the program has also been key in facilities that have seen improvement in hand hygiene compliance. Empowering the IPs to utilize the full resources of the facility, such as the media department for creating hand hygiene program initiatives, provides the support and encouragement an IP needs.

The organization needs to ensure that hand hygiene products are easily accessible and readily available so that staff can perform hand hygiene as recommended by the CDC. Safety issues such as hand sanitizer dispensers in the psych ward can be addressed by ensuring that the staff have personal carriage hand hygiene products. The cost of healthcare-acquired infections far exceeds the cost to provide staff with adequate hand hygiene products. ■

“ The organization needs to ensure that hand hygiene products are easily accessible and readily available” JANE KIRK CL. Studies have shown that taking a multimodal approach to improving hand hygiene is superior to any particular single intervention for achieving and maintaining improvement in hand hygiene compliance rates. For example, Ecolab’s multimodal Hand Hygiene Compliance Monitoring program helps hospitals to address the Joint Commission’s National Patient Safety Goal 7A (that is, to comply with the CDC or WHO hand hygiene guidelines). The patient empowerment aspect of Ecolab’s multi-modal Hand Hygiene Compliance Monitoring program (‘It’s OK to Ask’) also helps hospitals to specifically address the Joint Commission’s National Patient Safety Goal 13; that is, to actively encourage patients’ involvement in their own care.

Identifying and recruiting physicians and hospital administration as hand hygiene ‘champions’ can also be very beneficial in sending the message that proper hand hygiene is the responsibility of everyone within an organization.

RC. Start by putting clinical hand hygiene into perspective. Hand hygiene is the flagship of patient safety. The overwhelming cost of hand-transmitted in-

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EXECUTIVE INTERVIEW

Putting alcohol-based hand sanitization on the frontlines of infection control

By KATHY POWERS Why has hand sanitization become such an imperative in health management?

Kathy Powers. Two reasons – because we need it, and because it works.

Statistically, the spread of infection is imperative enough. More than 880,000 Americans are diagnosed with MRSA (staph) infections each year, killing more people than HIV and AIDS – and millions more are at risk and don’t realize it. Those are germs that can easily be prevented with consistent hand hygiene practices such as using soap and water when available, or using an alcohol-based hand sanitizer.

The H1N1 virus experience has also taught us how pervasive and potentially deadly the ramifications of poor hand hygiene can be.

Aside from the human element, the rise of litigation related to healthcare-acquired infections (HAIs) is staggering.

The changes in regulations, reimbursement practices and legal standards have combined to create a serious threat to healthcare facility finances.

But information about the efficacy of alcohol-based hand hygiene from the World Health Organization tells us that we already have successful tools to stave off infection. We simply need to use them.

So hospitals can protect not only their patients and personnel, but also their bottom line?

KP. Absolutely. Professor Didier Pittet, Director of the Infection Control Programme at Geneva’s University Hospitals has noted that, “Hand hygiene remains the primary measure to reduce healthcare-associated infection and the spread of antimicrobial resistance.” He’s right, but the current protocols do have some holes.

So the use of alcohol-based hand rubs provides an effective, convenient way to promote hand hygiene in a healthcare setting. Alcohol-based hand rubs take less time to use than traditional hand washing, and are far more con-

“The use of alcohol-based hand rubs provides an effective, convenient way to promote hand hygiene”

How did you come up with the idea for Pure-Go? KP. My husband Jeff travels frequently and conducts business internationally. He recognized the need to develop a discreet, convenient and uncomplicated way to cleanse hands. Something to augment traditional hand washing, not replace it.

We worked diligently on the design, intellectual property, and market research. We ultimately patented the Pure-Go, a unique yet simple tool that everyone can use.

There are several products on the market that dispense hand sanitizer.

Is it that ‘simplicity’ that differentiates the Pure-Go? KP. Both the simplicity and convenience, yes. There are indeed many products out there, and we encourage the use of any alcohol-based hand sanitizer when soap and water isn’t available. The Pure-Go allows people to sanitize their hands anytime, anywhere. Worn on the wrist, like a watch, Pure-Go is a refillable silicone device that can be filled with any alcoholbased hand sanitizer solution. Unlike other devices that involve pockets, belts, or other cumbersome tethers that can inhibit use, the Pure-Go is the only one that is truly hands-free.

That’s key for health management entities. As we discussed earlier, hand hygiene protocols are becoming more prevalent in the face of HAIs, but compliance remains a big issue. With the Pure-Go, healthcare workers have a constant, physical reminder right at their fingertips.

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venient. In an eight-hour shift, it’s estimated that a full hour of an ICU nurse’s time will be saved by using an alcohol-based hand rub.

Similar barriers exist for the general public. Nearly 22 million school days are lost annually due to the common cold alone. Workplace absenteeism is a huge expense globally, with one estimate citing the cost to the American economy $200 billion. Compliance with improved hand hygiene protocols will go a long way toward getting those productivity hours back.

Looking ahead, how do you see hand hygiene evolving?

KP. It’s clear that this is an area of health maintenance and prevention that will continue to gain momentum. The rise of HAIs is just one reason.

Increased accessibility to global travel is another. Demographics will also play a part, as people in most parts of the world are living longer. By 2040, the global population is projected to have 1.3 billion older people – accounting for 14 percent of the total.

We believe alcohol-based hand rubs will be the standard not just for today, but for the future. And we hope the Pure-Go can play a key part in how society eliminates the spread of germs and infection. n Kathy Powers graduated from Western Michigan University in 1984. Jeff Powers graduated from Bowling Green State University in 1984. Kathy and Jeff maintain Purgo Creations as a family-owned and operated business, incorporated in 2004. They oversee an advisory board with global reach and expertise in epidemiology, health policy, disaster preparedness, marketing and product distribution.

For more information please visit www.cleanhandsnow.com

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INFECTION CONTROL

SKIN DEEP

Marty Visscher assesses the state of skincare research in the US healthcare system and offers potential routes towards a solution.

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he healthcare system is in a state of perpetual motion when it comes to infection control; constantly updating guidelines and hygiene regulations to reduce healthcare-acquired infections; devising new techniques to sanitize equipment and ensuring a successive flow of outpatients continue to receive the highest possible levels of hygiene outside of hospital are all part and parcel of the battle to prevent infection. Yet, given all the technology and research available today, there is one potential infection site that continues to be overshadowed with presumption. Welcome to the world that skin built.

Having started out working in skin R&D at Proctor & Gamble, Marty Visscher has devoted herself to the unraveling of skin infections and complications. Now Director of The Skin Sciences Institute at Cincinnati Children’s

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Hospital Medical Center, Visscher was originally part of a collaboration that pooled together all possible technical and intellectual capabilities with a compassion and interest in skin, into one comprehensive organization aimed at tackling the lack of skincare related research and issues head on.

“It was also at the time important for hospitals and healthcare settings, in the US particularly, to be looking at other ways of doing work other than just standard NIH and government funding,” comments Visscher. “So, we thought this institute could collaborate across multiple partners including the government grand funding process, as well as the healthcare industry and the skincare industry.”

And it worked extremely well. Having collaborated with plastic surgeons on skin restoration – the taking of damaged skin and finding treatments and procedures to try and restore that skin back to a former appearance and func-

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tion – the team also focuses on damage that’s caused by ultraviolet exposure. “People are aware of that. Now, they weren’t maybe 20 years ago, and there’s a lot of emphasis on improving appearance, which is important to the patient. The patient wants to look and feel as good as possible, so that becomes a driving factor for what the surgeons and physicians are asked to do.”

Whilst further industry-based collaborations have taken place with Cincinnati Children’s Hospital, perhaps the greatest advantage of working in an academic health center is the opportunity to collaborate with clinical staff and work ‘on the pulse’ in actual clinical settings. Visscher admits that while some of her work will inevitably involve using laboratory methods, such as culture systems to study changes in pigmentation, in reality there is no substitute for real skin.

“Our view is that the skin is involved in every patient care interaction. So, if you go into an office for an EEG or an EKG, you’re going to stick those electrodes to the skin’s surface and get information about the internal organs. Conversely, you’re going to look at person’s appearance and visual coloration and make a decision about if they look healthy or not. For example, we look at newborns all the time to see if they have jaundice.

“Interacting with the skin is absolutely critical for patient care, yet it’s easy to forget about the skin for two reasons. One: the skin will heal itself. If you cut it or scrape it, it’ll take care of itself because it’s designed to.

It’s too important. You can’t damage the skin and have it not repair itself or you’d lose water and wouldn’t survive. It’s an exquisite organ that way.

“The other reason is that it can be the least of people’s problems. If they’re coming in because they have chronic lung disease, that’s what the focus is. In the western medical model of disease and organ focus, it’s easy to miss the skin because it goes across a lot of departments – surgery, dermatology; it doesn’t reside in just one place.

Primary interface “And for patients, how their skin looks and feels is a very important part of their existence; if they have any sort of trauma to their skin on top of what they’re in hospital for it’s just an added burden. So, we look at the skin as basically an interface for primary care. There’s so many common things that all patients or all people have to deal with and those are things most of the time that are considered to be nursing-related matters.”

However, what has become clear is that while nurses are viewed as accountable for skincare, they are far from being empowered with the methods

or evidence to fulfill that role. To combat this, Visscher and her staff collaborate with many of their nursing counterparts; they help with the research, and in return the nurses get taught the necessary methods. “We’re a very unique institute in terms of not knowing anybody else who has this kind of setup,” asserts Visscher.

“We know lots of people in different institutions who have a lot of the same areas of research, but we don’t know anybody who’s put it in the context of ‘what do we need to do to improve patient care’ and ‘what do we need to do to understand this complex biology of what goes on with skin’, because the skin is the absolute first defense against infection. Its barrier properties are all that’s needed to keep you from having an infection. Yet what happens if skin gets damaged; you expose the immune system and you have to catch up and rely on other mechanisms for protection.”

Throughout its existence, the organization has focused on infant skin development, skin pigmentation, skin restoration and using non-invasive quantitative ways to measure skin damage and repair. In addition, Visscher’s secondary focus is on hand hygiene and irritant dermatitis in healthcare workers.

“The patient wants to look and feel as good as possible, so that becomes a driving factor for what the surgeons and physicians are asked to do” “They’re very interested and have their own issues with hand hygiene, so it’s a very receptive audience to work with, especially in terms of collaborating in research and having the nurses serve as research key personnel. We can really answer some of their questions, address some of their unmet needs and basically elevate the importance of skin in the whole institution. For the past two and a half years, we’ve had a significant effort in the question of pressure ulcers, which is a huge problem worldwide. We had to understand what our population looked like; we thought pediatric patients – particularly babies – don’t get pressure ulcers.

“Well, in fact, that’s not true because three years ago we did our first house-wide evaluations and found that over nine percent of inpatients had one or more pressure ulcers; the reports in the literature were around four percent for the national average. So, we launched a big effort to try and understand what these were, where they were coming from, who was getting them and how the adult literature ‘played’ with pediatrics.”

The evidence showed that while there were certainly some similarities, there were also some significant differences. As such, Visscher now plans to undertake further research projects to see if they can identify the potential even earlier, be it at a pre-stage or even pre-ulcer level, and avoid it. Indeed, the context the industry as a whole finds itself in is really driving this notion of “drilling down on some of the basic questions”. The sheer lack of data, specifically with infant skin work, has caused many problems all across the board.

“We’ve focused a lot on it lately,” expands Visscher. “We’re attempting to create more data in an area where there is little data. What happens without data is that individual institutions have to try to figure it out on their own. So, you’ve

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got a whole lot of people with the same problem and the same question trying to figure it out; there’s benefit in trying to set up a structure that allows these simple questions to be addressed and it brings in the industry people who make products for use on patients together to say, ‘how do we do this better? How do we do this collectively and in everybody’s best interest?’”

“Some of the work that’s been done in the last 10 years is very interesting because it shows that the skin can respond to stress just like the brain” Stress reduction Another topic of interest is psycho-neuro immunology, which essentially details the idea that the skin itself is able to make stress hormone, and therefore produce cortisol. “Some of the work that’s been done in the last 10 years is very interesting because it shows that the skin can respond to stress just like the brain; it interacts with its environmental effects.

“So, what we find is that skin-based treatments like skin-to-skin contact reduces cortisol. If you reduce stress and reduce cortisol, your skin barrier is in better condition and wound healing is faster. If you have a lot of stress, those things don’t happen as well. If you have a sick patient or a patient in the intensive care unit, they’re going to be under a skin stressful setting. It’s part

of the job to figure out how to reduce that stress, particularly in infants, because stress will interfere with neurodevelopment.”

With this being a relatively new area, it’s important for all relevant data to be included. This means inviting information spanning across both the skincare and cosmetic industries and attempting to collate these findings into digestible chunks for the medical world. “That’s kind of the golden standard because the clinician can integrate everything together,” explains Visscher. “If I have a dark-skinned patient, I can’t see if the skin is red; I’m limited by the pigment. It’s not because I’m not trying. It’s because there are limitations, and if I’m looking at the skin, I can’t tell if the blood flow is adequate because that’s below the surface.

To combat issues such as this, Visscher and her team have started borrowing imaging methods from the cosmetics industry; it’s non-invasive and uses high-resolution photography and profusion imaging to understand precisely what is going on over a period of time, and respond accordingly. “It’s the kind of imaging where you can’t get the information from standard magnetic resonance imaging or CAT scans or ultrasound. It’s more surface imaging. Like how do you tell if a burn scar is smaller? You’ve got to measure the height. You’ve got to measure the three dimensions.

“Part of what we are finding now is this is a big need that hasn't been addressed in health care, and we think that once we get some of these methods in place – sometimes it's as simple as taking photographs with standard lighting, standard color correction and standard positioning – you can get a lot more information than you thought you could.”

Preaching that message is top of Visscher’s agenda list; second is recognizing that the topic of skin transcends across departments within the insti-

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tution. However, in order for this to become a reality, Visscher needs to be in tion differences due to the way skin is formed – or other conditions such as constant battle to obtain sources of funding – a challenge considering she also atopic conditions – we know the primary problem is inflammation, so idenhas to ultimately remain clinically specific and is accountable to peer review. tifying subpopulations and understanding what ingredients are most benefi“In terms of tackling them, I think what we have started to do is recogcial is the next step in terms of designing products that are more well suited nize that we can be proactive. We can start approaching people and say, for this particular problem. ‘would you be willing to enter into a research agreement with us to look at something?’ Another question is: ‘how do we interact with the National Institute of Nursing Research, because that’s where skin really has a home – how do we serve the needs and understand the needs of our patients and families?’ Skin is disproportionately important to patient’s families. If the patient is hooked up to monitors, they’ll cope with that, but then if a patient gets a skin breakdown or a tear from tape or diaper dermatitis, parents get very upset, and it’s understandable because they feel like that’s something they ought to be able to control.”

“So, patients have a lot of interest in skin. The world has a lot of interest in skin. Everybody could go home and be a skincare consumer, and this question of hand hygiene is another one that I think illustrates the point that repet“The other issue is that when designing products, sometimes they'll test itive hand hygiene works. It’s effective at reducing transient bacteria, but over them on normal skin, and sometimes they use the forearm. The problem is and over again, the data set comes back saying the reason for low compliance that health care workers don’t have normal skin to start with. So, part of it is is that their skin is so damaged. evaluating products in the context of the real skin condition the “We started doing work with them in 2004, looking at health care worker has because you're going to get a different irritation, dryness, erythema, et cetera, and trying to comanswer if you use normal, healthy, intact skin than if you In three days pare it to other kinds of skin damage we see. It was siguse dry, irritated skin.” healthcare nificantly worse than people were describing. The With a large proportion of the problem stemming workers will have reason for it is the number of procedures they’ll do in from the fact that while the majority of evaluations are a three-day period. undertaken on ‘animal models’, at some point there will “We’ll have a person work a 12-hour shift, and need to be a transfer into the human model and see if it’s they’ll usually work three days in a row and then have as successful in the ‘real world’. Combined with that is the hand hygiene three days off. So, within those three days, they’re going difficulty in defining a subpopulation within a workforce, events to have well over 100 – if not closer to 200 – hand hygiene where the vulnerabilities are such that if you can find someevents where they’re using soap and water or a hand sanitizer. thing effective, then by definition you’ve covered a selection of peoBiologically, the skin just can’t recover. It doesn’t recover during the time ple who don’t have as significant a response. off. So, then we’re back in this dilemma of if their skin is cracked, it hurts “I think the skin community and skin research community is starting to put on an alcohol-based sanitizer, so they’re not going to do that. to admit they don’t have as much information about how common moisThey’re going to go back to using soap and water because, temporarily at turizers of one type or another work, so we need to get to work in underleast, water will not sting. standing that better and formulating based on that understanding. The

“Patients have a lot of interest in skin. The world has a lot of interest in skin. Everybody could go home and be a skincare consumer”

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Low compliance What then becomes explicitly clear is that compliance levels aren’t prone to rising. Indeed, there are other factors at play, but the driving force behind this is undoubtedly hand-skin conditions. Published a few months ago, Cincinnati Children’s Hospital Medical Center undertook a study to see what would happen if healthy care workers were told they had to use treatments 10 times a day. The results concluded that whilst their skin conditions improved, the data showed that it was dependant on the products used.

Moreover, it exposed the need for a balance in skin repair and ignited discussion about healthcare worker’s skin conditions.

“Part of what we’re trying to do is educate,” affirms Visscher. “We’re trying to use sets of products that are less damaging to the skin than others and we know there’s differences in products; that’s supported in the literature.

However, I think there’s a whole lot more that can be done to design products. Some people have more irritation than others, even though the setting they’re in and hand hygiene they’re in is the same. Because there are popula-

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next step will be understanding factors that influence the response to topical ingredients, whether they’re topical from a hand-washing product to a hand hygiene product. And then the other area is in looking at the role of the skin response in infant development and skin-based modalities, looking at that on things like sleep and behavior – particularly in hospitalized infants.”

With the need for new skincare products for healthcare workers, and a significant amount of research left to do in order to provide useable data, it is clear that Visscher and her team at Cincinnati Children’s Hospital Medical Center have a long way to go to bring skincare hygiene to the level it needs to be at. However, with the healthcare and medical industries already heavily invested in infection control and processes of sanitation, it should only be a matter of time before a fully understood partnership between the cosmetic, skincare and clinical industries emerges – bringing with it the methods needed to evolve the state of skincare research and hygiene. n Marty Visscher is Director of The Skin Sciences Institute at Cincinnati Children’s Hospital Medical Center.

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INFECTION CONTROL

Minimizing the preventable Patrick Brennan explains the challenges facing today’s medical staff in tackling healthcare-acquired infections.

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panning decades of medical and healthcare practice, hospital-acquired infections have always been of primary concern to patients and staff alike. As the understanding of what exactly caused infections and their related conditions in hospitals gathered speed, a whole new spectrum of potential infection entered the scene. Patrick Brennan, Chief Medical Officer and Senior Vice President for the University of Pennsylvania Health System, walks us through the modern day world of healthcare-acquired infection.

Reporting to the Chief Executive Officer, Brennan is responsible for the quality of care delivered and the development of strategic plans related to

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those areas. In addition, he concerns himself with the acquisition of resources and is responsible for the outcomes of implemented plans relating to, amongst others, infection control.

Whilst hospital-acquired infections are precisely that – infections acquired from hospital environments – healthcare-acquired infections span the entire continuum of services. “Historically, the healthcare industry and the medical professions have focused on hospital-acquired conditions and hospital-acquired infections, but we know that infections can be acquired during the delivery of healthcare in the home, in an outpatient setting and ambulatory practices. The difference is that in most of those settings, we don’t have good methods of surveillance and a good understanding to the extent to which these events occur – except when there’s an outbreak.

“In contrast, in the hospitals,” continues Brennan, “we have a very good understanding of the incidence of these diseases, the means by which they are acquired and even the means by which they can be prevented; but because the infrastructure is lacking in non-hospital settings, we don’t have a rich understanding of these processes.”

In an attempt to change that, Brennan and his team now undertake more work outside the hospital setting than they have done in previous years.

“We’re learning a great deal about some of these infections through outbreak investigations, and we’re in the process of trying to translate the recommendations from inpatient settings into the ambulatory arena because many of them are fundamental.

“Hand hygiene is fundamental. Sterilization is fundamental. There are a lot of prevention practices that are easily translated from one area to the other, but the ambulatory settings have historically not been part of a system in the same way that an inpatient hospital unit is. Staff often lack the training and the oversight to ensure these practices are carried out appropriately. And that’s something that is being looked at that the moment.”

Th is sentiment of inadequate training and knowledge highlights just how serious healthcare-acquired infections have become. “They’re a serious issue fi rst because of their impact on patients. They range in nature from the very mild to potentially life threatening, and when patients enter the healthcare system they don’t expect these events to happen. Many of them are entirely preventable, and we need to do our best to ensure that patients are not exposed to these threats.

“The second reason is the business case for these issues. They add a tremendous amount of expense to the care of these patients. Their hospital stays are prolonged and thus they consume additional resources. They may require aftercare services like home infusion therapy or nursing-home care. Historically in the United States we’ve had a misalignment of incentives related to these infections; there was an

expectation that almost all of these infections would occur during a hospitalization, so hospitals were paid more if such a complication occurred. If you’re paid more, there’s no real incentive to prevent them.

So, hospitals, physicians and payers were misaligned in the interest of the patient in these situations.”

With these undoubtedly being two of the major issues facing infection control in healthcare today, the University of Pennsylvania Health System – and the industry in general – is ensuring that they take the necessary steps to tackle these issues head on and with a sense of immediacy.

“I think the fi nancial challenge in the US is being addressed through better alignment of incentives,” says Brennan. “The Centers for Medicare and Medicaid Services in this country have identified hospital-acquired conditions for which institutions will no longer be paid additional revenue should those conditions occur. They include urinary tract infections and certain infections of surgical sites and catheter-related bloodstream infections. So, where in the past those conditions would result in billing and having additional codes added that would garner additional revenue; that is no longer the case.

“Instead, payers are adopting pay-forperformance mechanisms where they want to see hospitals address these issues and reduce their rates of these complications. If they are successful, they can receive additional incentive payments for better performance.

It’s enormously beneficial to patients if we can prevent some of these complications of care, and it’s enormously beneficial to the payers too because they’re not paying those additional bills to hospitals and physicians.”

The idea of better-implemented incentive schemes certainly enables a win-win situation fi nancially, but what is being done to address the infections themselves? “There are a number of initiatives that have occurred in the US,” continues Brennan. “One of the critical things that still needs to be done is to carry out additional research to better understand how these infections are acquired and how they can be prevented.

I think there is a myth that we know all we need to know in order to prevent these infections. We do know a lot, and we should act on that evidence. That will certainly go a long way, but by no means will our current state of knowledge prevent all infections.”

More specifically, the University of Pennsylvania is challenging these issues by dispersing accountability for quality and safety down to the unit level. They’ve already established goals based on the performance of the organization and created an infrastructure on each of their inpatient nursing units consisting of a team of leaders, from physicians and nurses to quality leaders, whose job it is to understand the organizational goals and implement strategies. Once this is realized, then performance is tracked against those strategies and reported back to the relevant leaderships.

“One of the critical things that still needs to be done is to carry out additional research to better understand how these infections are acquired and how they can be prevented”

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“Much of our focus in the University of Pennsylvania healthcare system has been around infections, and we’ve had tremendous success in preventing bloodstream infections. We’ve had months where two of our hospitals have had no bloodstream infections at all and in two consecutive years we’ve reduced ventilator-associated pneumonias by 30 percent in each year. In hospitals there are always lots of things going on.

“Nursing is changing products and changing practices, and physicians are introducing new practices. So, it’s hard to tease out exactly what all the contributors are, but we do know through an experiment that we’ve done that this unit leadership model had a profound impact, along with others that rightly deserve credit. That’s been our approach, to hold everybody in the organization accountable for quality and safety.”

And it seems to be working. Brennan has no qualms about employing the traditional approach of “plan, do, study, act” that many hospitals have taken on board. However, while others may be focusing more on Lean methodology and experimentation, Brennan admits to concentrating more on culture and accountability and remains relatively agnostic towards the remaining methods.

“We developed a strategic planning document that we call our Blueprint for Quality and Safety that established the organizational goals and four imperatives. The four imperatives are better accountability, better coordination, better transitions in care and fewer variations in practice and under the rubric of fewer variations in practice, we’ve attacked healthcare associated infections. So, we’ve tried to standardize our ap-

proach to the management of central venous catheters, for example, where the bloodstream infections occur.

“That has included standardization of the decisionmaking process of putting the lines in and site selection for the line insertion. Whether we’re using maximal sterile barrier precautions or not, we standardized the products we use, the dressings and the soaps and things that are used to decontaminate the skin.”

Nursing at the Pennsylvanian University has also standardized its practices around accessing catheters and changing dressings by limiting who can draw blood and insert into catheters, as research found that this played a significant role in the development of infections due to an overwhelming number of people accessing catheters who weren’t necessarily experts in the procedure. To date, the figures draw a pretty positive downward trend that has been sustained for well over a year. So, whilst they’ve been agnostic about the methods, they’ve certainly been persistent in trying to identify new practices to improve on.

However, the constant media attention focused on healthcare-acquired infections has had a dramatic impact on the industry, especially in relation to claims that half of all infection deaths are linked to hospital care. “I think the attention to this has had a galvanizing effect in healthcare,” admits Brennan.

“It’s changed the paradigm from one where these were events that were expected and unavoidable to one where we’ve begun to realize at least some of these can be eliminated or nearly eliminated; for example, bloodstream infections are the one best example of near elimination in some organizations. Both the public and media attention, as well as the legislative and regulatory attention, has given the industry a lot of impetus to work on this. It’s been an important factor, no question about it.”

Another important driving factor within the industry is the American Recovery and Reinvestment Act of 2009, which includes $50 million to support states in the prevention and reduction of healthcare-associated infections. “I think that it’s an important start,” affirms Brennan. “In the entire universe of funding, the Recovery Act is a relatively small amount, but it’s a large number of dollars for this area, and most states applied for it and are using it. The money goes to states, not to hospitals, and the states are using it to bolster their efforts and to come into compliance with the sort of practices recommended by the Centers for Disease Control and Prevention. I think it’s terrific that it was included.”

Even with a substantial amount of funding and declining numbers of healthcare-acquired infections, the industry as a whole still has an arduous uphill battle to fully understand, develop and implement plans and strategies that will effectively control, if not completely prevent, the future of healthcare-acquired infections. Until then, industry experts such as Patrick Brennan must continue to attack on all possible fronts to minimize the preventable.

Patrick Brennan is Chief Medical Officer and Vice President of the University of Pennsylvania Health System.

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EXECUTIVE INTERVIEW

The latest in hand-washing technology Yon Makino talks to EHM about why innovation matters even in a seemingly unassuming product like soap.

Is this the same popular retail Dial brand for soap products in the US? Yon Makino. Yes it is. The Dial brand has a strong heritage in trusted antibacterial protection, and launched the fi rst antibacterial liquid hand soap in 1989. And Dial hand soap continues to be the number one doctor-recommended brand. Our Healthcare Division ensures that healthcare professionals benefit from the latest developments in soap and sanitizer technology. Healthcare’s needs are very different from retail’s. For example, a hospital worker may wash or sanitize 20, 30, or more times a day, necessitating products that are not only effective against pathogenic organisms, but also mild enough to protect their skin under such demanding conditions.

®

How complicated can soap technology be?

Have there been any advances recently of note?

YM. Most people don’t think of soap as a hightech product. Certainly, all soaps with physical agitation can remove some germs. Adding an antimicrobial ingredient provides an additional measure of protection by killing germs on the skin that were not washed away. Our researchers found that while antimicrobial soaps were better than plain soaps in reducing germs, the germ-killing potential of the active ingredient was severely hindered by its tendency to bind to the surfactants.

When this happens, much of the active ingredient isn’t available to kill germs and just gets washed down the drain.

To counter this, we developed a new approach, called Activated Triclosan™ Technology, to free the active from binding to the surfactants, thus allowing the full germ-killing potential to be unleashed. The results were quite dramatic – achieving from a 100-fold to a 10,000-fold difference in germ kill vs. other soaps. And, by not requiring high levels of harsh surfactants to achieve a high germ kill, the formulation is extremely mild to the skin – as mild as water itself as demonstrated in our clinical testing. Th is technology can be found in our Dial Complete Antimicrobial Foaming Hand Soap, which outperforms other healthcare soaps containing Triclosan, PCMX or even CHG.

®

Can this new technology make a difference in a real-world healthcare setting?

YM. Absolutely. In an experiment, subjects’ hands were contaminated, washed with one of two selected test soaps, and then allowed to handle

cantaloupe balls to measure germ transfer from a washed hand on to food.

Bacterial enumeration was then performed on the cantaloupe balls. The result? There was over a log10 more bacteria recovered from the melon handled after washing with the ordinary soap than from the melon handled after washing with Dial Complete Antimicrobial Foaming Hand Soap. Based on previously published dose/response studies, we determined the likelihood of infection from ingesting the contaminated cantaloupe. The data suggests that washing with Dial Complete can help reduce disease by 50 percent compared to washing with an ordinary soap.

®

How important is hand washing now that the focus is on hand sanitizing?

YM. Alcohol hand sanitizers certainly play an important role in any healthcare hand hygiene program. They offer convenience, germ kill and some skin conditioning. The danger is when healthcare workers mistakenly believe hand sanitizing replaces hand washing. Soils such as dirt, blood, urine, feces, hand sanitizer residue buildup, powders, and perspiration tend to build up on the hands. Since sanitizers neither penetrate nor remove these from the hands, germs can survive, and the healthcare worker using just hand sanitizer may unwittingly contribute to the spread of disease. That’s why it’s so important to continue to wash with soap and water throughout the day and not rely on hand sanitizers alone.

What type of healthcare facilities would benefit from using Dial Complete?

YM. Any facility that is interested in the latest soap technology to help prevent disease transmission could benefit from using Dial Complete Antimicrobial Foaming Hand Soap. A number of respected healthcare facilities and systems are currently using this product, including MD Anderson Cancer Center in Texas, Intermountain Healthcare in Utah, Geisinger Health Systems in Pennsylvania, and Adventist Care Centers in Florida.

®

Fischler, G. E., J. L. Fuls, E. W. Dail, M. H. Duran, N. D. Rodgers, and A. L. Waggoner. 2007. Effect of hand wash agents on controlling the transmission of pathogenic bacteria from hands to food. Journal of Food Protection Vol. 70, 12: 2873-2877.

Yon Makino is Senior Brand Manager – Healthcare Division, Henkel Consumer Goods Inc. Prior to Henkel, he worked for Johnson & Johnson’s Ethicon Endo-Surgery, Inc., the US Peace Corps, and the Microbiology Department at the University of Wyoming. He holds a BS in Biology, an MS in Bioengineering, and is an MBA graduate from Northwestern University’s Kellogg School of Management.

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FEATURE INTERVIEW

STREAMLINING GOVERNMENT As the US government attempts to tighten its belt in the face of a worldwide recession, once again, public ofďŹ cials are trying to do more with less. Technology is being highlighted as the enabler of a Leaner and more agile system, both in government and its healthcare agencies.

Terry Mason, Commissioner for the Chicago Department of Public Health explains the importance of effective IT for a Lean organization.

T

he rapid pace of change in technology has no doubt empowered people, but it’s also made us more demanding of organizations, particularly organizations that are slightly slower to react, such as the government. However, this requires different agencies to work together and crucially, it needs funding.

Most famous for beginning his tenure by telling city hall to shape up, Terry Mason explains how at the time he came into the Chicago Department of Public Health (CDPH), it employed 1200 people, had around 45 different locations and involved at least 20 different services, but had not yet taken advantage of the technology to help manage both the day-today operations or to help drive the collection of data for performance metrics. As well as this, he talks of the need for the department to be more fi nancially responsible and transparent.

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“We embarked upon a journey when we came here in 2006 and said, ‘Well, let’s take a step back.’ I don’t come out of a public health background; I was in private practice as a urologist and had a very small business, so I was used to operating like a speedboat,” he says, discussing his background. “When I came over into government I understood that now I would have to operate more like a steamship; there’s tremendous institutional inertia one must overcome to do anything, and there are a number of reasons why that is.”

“Some of it’s good; some of it’s protective or at least gives the appearance of being protective, and some of it is just plain obstacles.

So we had a number of challenges, but in order to make sure we addressed it properly, I took a medical model.

“First, I took some time to learn the organization – I took a year to do that. We did our year of discovery, and then once we came out of that we decided as an executive team to do a year of education because we realized that one TERRY MASON of the biggest problems was that there was no investment in educating staff. So many people were still doing tasks the way they’d been doing them for the last 20 years, and the technology divide, which existed out in the city in general, was even more pronounced within the organization. Before you could even bring in any technology we needed to at least elevate the various and sundry levels of competencies that people had.

“The other thing was to talk about a vision of where the department was going, so we then completed our strategic plan to fi nd our priorities for the organization. Excellence in management was one of those seven strategic priorities that we identified, along with number one being to establish a real organizational focus in chronic disease, so once we got to that and understood what we had to do, we brought in speakers to educate the staff.”

Mason explains how meetings were established for staff to be educated all at once, and in doing so communication issues came to light; for instance, one of the problems highlighted was that of transmitting information down to every level. Once these issues had been highlighted, the organization then took on the strategy to become project-driven.

“We do a series of projects, whereby we get grants which start at this time and end at that time. It has a defi ned beginning, something you do in the middle and a defi ned end with a report out, and now we’re actually backing into that the national management system, which gives us, on top of that, a better way to organize a lot of those things.

“We felt that this would be a wonderful opportunity to take that along with looking at re-examining workflow; people here did a lot of things ‘because that’s the way we’ve always done it’. That’s the thing that we heard a lot of in this instance. We took that as our culture change, so we then exposed a lot of people to a different kind of learning in the

accelerated solution environment.”

He notes the benefits of having Carlo Govia in the department, Mason’s First Deputy Commissioner and Chief Financial Officer, who comes out of that industry and who helped to facilitate and understand how things were to be done most efficiently. Mason says that during that year, the department began to educate people and bring them on the journey in which it was headed.

“We looked at how could we then process map the entire organization, just for our current state, where we were, how we did it and so on, and we still have some issues that we need to continue to investigate. We understood the organization, how it was doing and what it was doing. We now have a methodology for thinking about transformation, and that’s what we need to do with our people,” he says.

Lean Streamlining the education of the people within the organization is just as important as streamlining the processes, and as a result directly impacts the residents of Chicago.

All of the organization’s staff, as residents, are taxpayers, and therefore have a fiduciary responsibility to the taxpayer to provide them with the best value for the dollar that they provide in tax revenues. Mason notes the importance in ensuring that people are as well trained as they could be – tools are provided in order to do a job most efficiently, and technology in its various forms is these tools.

He notes the power of technology in the organization’s transactions, in communicable disease investigations for outbreaks, such as swine flu, managing grants or getting contracts ready.

“When we were beginning to outsource our data center, for example, to a company that manages that and has a big installation on the east coast and one on the west coast, that’s far more robust than we could ever hope to do in the city of Chicago. The fact that rather than going with this big, behemoth kind of way, with a mainframe, code-writing mentality, we now have very powerful, singular applications.

“You have ways now to link these different applications so that you can create a quasi-enterprise resource managing system (ERP), to get the best in breed of these particular applications all working together to provide the kind of benefit that we need in order to give our people the tools they need to be as efficient as they can in a very Lean way and remove and strip off all of that maintenance cost that you need for these huge, behemoth, SAP-like systems.

“I don’t have to worry about that because the individual people have to maintain the best in breed of what they do. As long as they do that, we create the interfaces for them to work together, so that now all of our things are stored in a virtual space and we can move everybody from a

“If we want to look at what health is about, we need to look at the social determinants of health”

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box kind of thinking to a cloud kind of thinking, where you only need internet connectivity to get into your system. So you move the mentality of working on a computer to working in a system, and that is the big challenge and the big piece that we’re moving quite effectively.

“The President of the United States said a couple of things that really hit home with me, and those things, particularly since he’s from Chicago, make it critical that we do everything we can to be in lockstep with what the President says.

He said two things, number one, that it’s not about big government, it’s about effective government; on the IT question, he said that he would like to see government implement IT at the speed of the private sector, and those two things together said to me that we had to figure out a way to make that happen, so we could not constrain ourselves to the idea of big, expensive, one-system approaches to a problem,” says Mason.

He explains how the department then began to look at things that they identified as being core competencies and as having the ability to market, bringing those things together in a quasi-ERP to make government tools more effective and save costs. Most important was ensuring that such implementations could be done at a similar speed to the private sector, so the department opted for a multi-month strategy to address the issues of government.

up and continues to roll up so that you’re not scrambling, trying to go get data on a bunch of different Excel spreadsheets. Rather, if you start out with a project management tool and you set up the metrics in those project management tools with the red, yellow, green to let you know where you go, those roll up.

“The fi nance piece is tied to that roll-up, as is the service delivery piece. The idea is that when I turn around, on the back of my desk, I’ve got two or three monitors so that in five minutes or less I am able to see exactly what’s going on in the entire organization, based on looking at a series of metrics that roll up from the bottom all the way to the top. They give me those important indicators that I need so I can then focus my activity and energy on where it needs to be, and those things are transparent to everybody in the organization; then the system allows me to drill down to the lowest level of detail that gives me the answer that I need instantaneously. The business case is to be able to get that information faster – the quicker I do it the sooner I can make a decision, move or change some things that are impacting that in a way that I never could do before.”

Mason explains how IT has not only contributed to the department’s efficiency, but has also made him a better leader. “We used to be at a situation where it was always at the 11th hour that we were scrambling because we had unspent grant dollars and our systems were antiquated.

Now you’ve got 30 or 60 days to try to spend, redirect or figure out what you’re going to do with these grant dollars. The systems allow us to look at what’s going on with our grants and our burn rate; there were some other issues that we had that didn’t give us that visibility in a current enough way.”

He adds that now information can be assessed on a regular basis, ensuring that all of the annual grants are used sufficiently and adding further fi nancial support to the department’s projects, aligning the strategic priorities of the department and taking into account the needs of the funder and the requirements on the dollars. There are more questions being asked – is the right equipment being bought, could the money be spent differently – and more resources being used to manage realistic guidelines, goals and objectives.

He concludes with a return to healthcare: outlining its purpose and reasserting why the discussions of technology are important. “If you really want to get to what health is about, health is not what goes on in hospitals or what goes on in doctor’s offices or with medication,” he explains. “That’s medical care. If we want to look at what health is about, we need to look at the social determinants of health. Those things look huge because they’re things like poverty, housing, education and other social structures and social policies, but that’s where we need to be.

Other countries around the world have dealt with those things and have created more corporate benefit for their citizens. Other countries around the world spend half of what we do on so-called healthcare, and if we could divert some of the dollars we’re already spending through a health lens, we might be able to move the needle in on some of those problems that plague us.”

The department now has up to 60 days to try and spend or redirect grant dollars.

Compliance Pervious strategic plans of government agencies have often led to a complicated technology environment of infrastructures, systems and departments. In order to ensure that business needs drive the IT application requirements of CDPH, a number of requirements have been imposed on the department by federal and state grantors, and particularly since the stimulus package the government must now be more transparent both internally and externally. By operating on a project basis, CDPH can put together all of the contracting, procurement and fi nancials to

“Rather than going with a big, behemoth, code-writing mentality, we now have very powerful, singular applications” help maintain focus on the business of public health.

As well as this, Mason explains how the department is attempting to become more streamlined through integration of the various arms of the department, be it clinical operations, shared services, strategic affairs or personal health. “We had a situation where we had an organization that was a bunch of castles trying to exist in one kingdom, and each castle had its own siloed operation and it duplicated a lot of those things at each of those organizations,” he explains.

“What government now has to do is figure out how it’s going to make all of that transparent. You need the systems in place to capture that data on an ongoing basis and that precludes having a structure and the technology and a methodology by which the work is done automatically, rolls

Terry Mason is Commissioner for the Chicago Department of Public Health.

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TECHNOLOGY

Balancing g actt Why juggling g the need to leverage people people, processes and technology is IT’s greatest challenge, according to Scott Dresen.

I

ntegration, alignment, security and compliance are all top of mind for IT and operations executives in the current environment, with one of the biggest challenges being juggling all these varying areas, as Scott Dresen, VP of Enterprise Technology Services for Spectrum Health, explains: “If you think about the role of IT as being to leverage people, processes and technology to drive business value, one of the biggest challenges we have is just trying to balance all these competing drivers.

“The changing regulatory landscape; customer alignment engagement; integrating systems technologies; trying to keep our costs in alignment: the list continues. Going on, our challenge is fi nding that

point of balance that allows us to operate in the most efficient way, while at the same time addressing these competing priorities.

“There is as much art in this as there is science. One of the key learnings that we’re fi nding is that transparency with the business is a very important factor; establishing trust of your IT group with your customers, so you can have those hard dialogues and prioritize these initiatives.”

Dresen also points to the impact of regulatory and compliance requirements on the organization: how to best serve and meet their needs, while at the same time helping to continue driving business value and making service delivery as efficient as possible, so that the organization is focused on these customer-facing, value-providing activities.

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Service management is also becoming a key focus within IT: “With that posit that IT has to leverage people, process, and technology to drive business value,” Dresen says, “We need to be as close to the business as we can, and operate in as efficient a manner as possible.

A lot of service management is about resource alignment, so we want to reduce unplanned, reactive work, in favor of planned and proactive work.

“Service management, for us, is all about reducing the inefficiencies in our service delivery model, so that we can maximize our engagement with the business on those customer-facing, value providing activities – the requirements of the business driving the goals of IT process and operations, as opposed to IT driving the business.”

The right tools In terms of the tools needed to achieve these goals, Dresen says it’s the proverbial people process, and technology. “We think in those three branches. About two years ago we developed, from an infrastructure and operations perspective, a strategy we call our service excellence strategy, but it really is about service management.

“This involves looking at the culture of infrastructure and operations to be more service-oriented, in terms of service delivery, and not thinking in the technology silos, which we’ve historically done. Establishing that culture. Training for the employees. Using and leveraging best practices from a process maturity perspective, to help provide those reference frameworks from which we can draw, to improve and mature our processes. Then implementing and delivering tools that can support all that work, to help us integrate more efficiently and effectively than not having a strong tool base to do.”

Dresen points out that Spectrum IT has had a strong focus on businesscentric processes for some time. “We’ve tried to align with the business in a way that supports their initiatives,” he says. “We don’t have a separate strategic plan for IT. Our strategic plan is the organization’s strategic plan; because we provide IT value based on a business requirement that’s being articulated from the organization, our application of information technology is to support, ultimately, the delivery of a business value the organization hopes to realize.

“Leveraging our service organization has allowed us to change over the years. Because as the organization has changed and matured, we’ve also had to change and mature, to demonstrate that the service delivery can meet the needs of the organization. So we have the impact of customer expectations changing. We have the impact of consumerization of technology driving

expectations. We have industry driving expectations with our business.

And all that has pushed IT to be much closer with the business, to make sure that we’re providing that business value where they need us to.”

The development of silos – the notion of people within an organization dividing themselves up into small groups based on their own speciality areas – is a danger in any industry, and healthcare is not exempt. Dresen cites as a particular challenge the decisions around how to leverage available integration technologies to provide access and visibility to data from disparate systems in a way that facilitates and improves decision-making.

“We’ve done a lot of work in terms of aggregating data from multiple systems into common repositories, where we can layer decision support systems on top of those data stores, to help interpret the data and present it in a way that will allow us to make better decisions moving forward.

“We were able to leverage solutions that follow the business transaction. We can then provide better, more accurate data that are relevant to the business. We have a product called Novo, which was bought by a company called Medicity. It’s a grid solution that allows us to follow the clinical process for patients, between the physicians and the hospital, to provide access to that patient data where it’s needed. It does this in a way that is consistent with the clinical care delivery process, so that the data presentation is appropriate for the context that they are being viewed in, and instead of being just a mass of data that we have to sift through to find value.

“It serves as a transaction broker. We can place an agent out in a private physician’s office, from a physician who has very little technology maturity and predominantly operates through faxes, to a larger group that has a fully deployed electronic medical record. The solution allows for a variety of different technology profiles that we might find in a physician group.

“It also provides the ability to more seamlessly interact with the hospital, in terms of exchange of data, as well as ordering of labs and other types of procedural engagements, and then the subsequent return of information back to the provider, relevant to that patient. It stays patient-focused and in patient context, in a way that was much more difficult in the past.”

Dresen explains that the main idea is to bridge the chasm between large systems, such as Spectrum’s, and private provider groups with a lot of the patient interaction that in the past would have been information-starved.

Integration Dresen points out that Spectrum Health is a fully integrated delivery network, with a hospital arm, a physician group arm, and an insurance arm. The system encompasses access into the healthcare system all the way through the delivery of the healthcare system, whether it be in an outpatient or inpatient setting. “We have an ability to impact the efficiency of the process,” he says. “We can maximize the efficiency and streamline the process, for both providers and patients, but also leverage the value of the system to improve the clinical care experience.

“As an example, we had some studies done between our health insurance company and our hospital group in spine service cost reduction, where we had an increase over the national norm of spine surgeries.

“In the review of that aggregate information from both the insurance company as well as the clinical side of our organization, we were able to reduce the overall cost of that service, while at the same time improving the quality outcome for our patients, because we were able to data mine the information across the entirety of our system. In an organization that

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wasn’t as integrated as we are, that would have been a much more difficult, if not impossible, task to even contemplate accomplishing.”

Technology will be essential to reinvigorating America’s beleaguered healthcare system. Dresen says the current situation helps the power of information technology to drive business value. “If you have appropriate alignment with the business, you’re leveraging tools in a way that delivers, ultimately, in business value,” he points out.

Proving return on investment for tech solutions is particularly critical, given today’s tight operating environment. What can CIOs and IT directors do to ensure they’re getting the most out of their technology investments? In answer to this question, Dresen is working with his team to change the orientation of the organization’s culture, thinking in the context of how the technology that they’re implementing is delivering business value.

“Every time we ask that question, if we can answer it and understand the context within which we’re offering that solution, that will help us best position ourselves to maximize the opportunity that we have with the various solutions that we’re trying to leverage,” he says.

“We always need to challenge our status quo. We need to look at maximizing the investment of technology to deliver the business value for those investments that we make. And to do that, we really have to understand the nature of the business, to ensure that we’re answering the right questions that are being asked of us.

“In some respects, this means helping the business ask questions that they weren’t anticipating, but that they need to, in order to better deliver on the business challenges that are being presented to us. With all the competing priorities we have and the opportunities we have to leverage our various economic resources, we can’t afford to make poor decisions.

“We can’t afford not to take full advantage of the technologies we choose to invest in. That means driving the business value from an infrastructure and operations perspective and creating that service-oriented culture, to make sure we’re delivering, in the most efficient way possible, the highest quality of service. It also means applying those best practice frameworks that minimize inefficiency and waste, so we can focus on customer-facing, value providing activities.”

“Using and leveraging best practices from a process maturity perspective helps provide those reference frameworks from which we can draw to improve and mature our processes”

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Scott Dresen is VP of Enterprise Technology Services for Spectrum Health.

23/3/10 09:36:51

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RELAY HEALTH_mar10 23/03/2010 10:00 Page 78

EXECUTIVE INTERVIEW

Health information exchange: To be sustainable, solve a business problem Jim Bodenbender offers advice on how to develop and maintain a sustainable health information exchange system.

About 31 percent of “meaningful use” guidelines relate to healthcare information exchange (HIE). With the calendar marching forward toward deadlines, why are so many health information organizations (HIO) failing?

Jim Bodenbender. Not all are failing. Some that have failed were developed solely with grants and weren’t able to find the business model to keep going. Others have not only been able to sustain operations, but have actually expanded in terms of constituents, content, and geography. A recent study published in the Journal of the American Medical Informatics Association suggested that those who exhibit viability share some characteristics, including financial support from participants and a wide variety of participants sharing a narrow set of data.

Additionally, there is evidence that collaborative healthcare communities that start by first trying to solve a business problem can find they have done so by creating a vibrant health information exchange.

What do you mean by “solve a business problem?”

JB. An example is Saint Luke’s Health System in Kansas City. In 2007, CIO Deborah ‘Debe’ Gash had a problem to solve. The organization’s affiliated physicians complained about the amount of paper and phone calls their practices had to deal with from the hospital. Debe was looking for solutions in an area where few physicians were adopting technological tools.

Debe turned to RelayHealth SaaS-based tools to solve her problem, and branded the solution as Saint Luke’s CareLink. They started with messaging tools that allowed physicians to securely communicate with their patients.

Later, they implemented results management tools that allowed them to share clinical information electronically. This information includes hospital reports (radiology, H&P, Discharge Summary, and many other reports) and lab results. Debe’s business problem was solved. Her hospitals are able to share information with their community physicians electronically, even with those who do not use electronic health records.

Jump forward a couple of years to the release of the draft meaningful use guidelines. Debe found that in solving her business problem, she had created a de facto health information exchange. Saint Luke’s and their affiliated physicians are well positioned for meeting meaningful use guidelines. Additionally, she is reaching out to other health systems in her market to formalize an HIO.

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The RelayHealth solution is well suited for competitors to share patient information across organizations.

Why is RelayHealth advantageous for competing health systems to use?

JB. Some non-adopting hospitals have expressed concerns that their competitors would be able to analyze global information and determine, for example, that a competitor is currently focusing on their cardiac service line. With the RelayHealth security model, patient information is only made available on a need-to-know basis and only if the patient has given access permission. So if John Smith is visiting Dr. Jones, the doctor can see all of John’s information – but no aggregate data.

This solves the problem of making available to all healthcare providers a complete picture of a patient’s care, but without the concerns that competitive information will be released in the process.

How does this relate to a more expansive healthcare information organization?

JB. We’re finding that early adopters of RelayHealth tools are acting as HIO champions in their communities, encouraging competitors and other health systems to participate, and formally adopting an HIO structure.

Can you give me an example of this?

JB. Sure. Linda Reed is the CIO of Atlantic Health in New Jersey. Her hospitals and community physicians began sharing data through RelayHealth in 2007. Linda then reached out to other healthcare systems in the area. They recently applied for – and received – grant funding to form a formal regional health information organization (RHIO) called Jersey Health Connect. Again, a visionary CIO was solving a business problem – in this case, helping her hospitals and affiliated physicians to automate processes in pursuit of efficiencies and improved care. The result is a formal group that’s connected from central to northern New Jersey and well positioned for inclusion in the National Health Information Network. n Jim Bodenbender serves as President for RelayHealth Connectivity Solutions. He joined McKesson in 2004 as Vice President of Business Performance Solutions before assuming his current role in 2006. Bodenbender has more than 25 years of experience in information systems and services with both start-up and large public companies and has an extensive background in domestic and international sales, marketing, M&A, operations, and finance.

He holds an accounting degree from Bowling Green State University.

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DATA SECURITY

Staying safe James Koenig tells Marie Shields about the role played by single sign-on in identity access management for healthcare IT.

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here are challenges within the hospital IT environment: legacy applications may not support modern authentication controls; there is a need to share access to equipment and patient care areas, across multiple users who require access to medication records; the open nature of hospital floors causes problems of physical security; and regulatory compliance requirements are increasing.

If that’s not bad enough, there is the additional, often underestimated, risk of improper access and even medical identity theft by knowledgeable insiders, as James Koenig, Practice Leader, Privacy & Identity Theft, and Practice Leader, HIT Privacy & Security, for PricewaterhouseCoopers, explains: “Knowledgeable insiders have surpassed outsiders and hackers as the leading cause for identity theft within companies. Within hospitals, the main areas that have been vulnerable have been within collections, within patient enrollment, with physical security, with IT and even the janitorial crew. There are a lot of risks within the environment to electronic health records.

“There are many reasons for which information is improperly accessed. Some of the more notable ones have been when healthcare providers and staff have accessed the medical records of celebrities; that’s one type of improper access that is still relatively common. The other type is for gaining information that can be used for medical identity theft, to get a health insurance ID number or other information that could allow someone else to access medical care, or to even obtain prescription drugs that are commodities that can be used on the street.

“That’s one of the new major underestimated risks within an environment, and within hospitals you have so much change, so much vulnerability, so many people, that this is naturally starting to grow.”

Hospital IT departments are also now faced with the challenges of complying with the requirements of HITECH, which has expanded on those originally set out by HIPPA. Koenig recommends that healthcare providers focus on the changes to HIPPA under HITECH, specifically on the protected health information breach notification requirement.

“The return on investment depends on the profile of your workforce and how many logins they average in a given day”

A number of requirements were added under HITECH, which was part of the stimulus bill. One of these is to create in the US a federal breach notification provision if protected health information becomes improperly accessed or compromised. Hospitals must notify the individual whose information has been compromised, whether the information is in electronic form or paper form. They must also notify Health and Human Services, who will list the breaches on a website; the state attorney generals if there are more than 500 people in a particular state that have been compromised; and the local media.

“Th is new notification provision is stronger than any state requirement,” Koenig points out. “Providers are quickly focusing on this for three reasons. One, most of the state breach notification laws that existed before didn’t include health information; now health information under HITECH is included.

“Second, providers had a strong program around HIPPA but HIPPA security only applied to electronic protected health information.

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Single sign-on Despite the rising concerns about security and the need to comply with increased regulatory requirements, the adoption of single sign-on in healthcare has been slower versus other industries, often due to the inability of older specialized medical equipment to talk and to accommodate some of the new identity management and single sign-on tools.

According to Koenig, this is becoming less of an issue as technology matures and hospitals continue to upgrade their systems, especially around electronic health records. “Vendor consolidation has reduced the number of tools in the market’” he says. “It has also consolidated some of the developer talent, and the remaining tools tend to be a little more consistent so that there’s no longer a reducing number of platforms and standards and options that healthcare can focus around. They’re probably behind other industries, but it’s maturing and getting better.”

What is clear is that the use of single sign-on does confer a number of benefits, including fewer passwords to remember, lower support costs, more ability to push secure authentication standards and controls across the enterprise at one time, centralized support, centralized logging and monitoring, and fewer accounts to maintain each year.

In general, Koenig says, organizations using single sign-on will spend less time looking into many different types of applications; instead, they can track it across the single sign-on. “The return on investment depends on the profi le of your workforce and how many log-ins they average in a given day, and with this reduced time and cost of the people entering in passwords repetitively it allows more time to focus on healthcare delivery.

“Resetting of passwords will fall if you have fewer passwords to remember. You will also fi nd people writing them down less, and writing passwords down is what makes them insecure; this is how some of the security incidents at hospitals have occurred. Also, because of the new technology, many payers HITECH now includes paper-based proare upgrading their electronic health records tected health information, which providand related systems and architecture in James Koenig is Practice Leader, ers may not have focused on before. preparation for certification to get stimulus Privacy & Identity Theft, and Practice “And third, HITECH now requires funds for the meaningful use of electronic Leader, HIT Privacy & Security, for that all business associates comply health records.”

PricewaterhouseCoopers. completely with the HIPPA privacy and As part of this overall update of the syssecurity rules. Previously they only had tems and investment in the infrastructure at to agree to provide adequate safeguards in a contract. Now, when enhospitals, single sign-on will also be accompanied by self-service resets trusting protected health information to a third party – which could be as opposed to a manual call to a help desk. These new systems often have a lab or another vendor – the focus around protected health information features that allow users to go to an intranet site and through self-service is growing.” and answering a couple of challenge questions, they can reset the passKoenig says that the types of information that can be compromised, word themselves. not just healthcare information, but employee information and the The benefits can be summarized as: reduced cost for the enterprise, requirements under other privacy laws, including the state breach noquicker response time for people who need to get their passwords, fewer tification laws, have changed the environment and made it much more instances of these passwords because people remember a single sign-on complicated for healthcare providers to comply. better, and less need to write passwords down.

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Glossary Single sign-on (SSO) is a property of access control of multiple, related, but independent software systems.

With this property, a user logs in once and gains access to all systems without being prompted to log in again at each of them.

Identity access management (IAM) encapsulates people, processes and products to identify and manage the data used in an information system to authenticate users and grant or deny access rights to data and system resources. The goal of IAM is to provide appropriate access to enterprise resources.

Strong authentication centers around the strength of the information need to access a system, such as the type of password and how difficult it is to crack.

Multi-factor authentication brings other information into the equation, based on questions related to ‘something you have’ or ‘something you are’. Federal Financial Institutions Examination Council guidelines state that true multi-factor authentication requires the use of solutions from two or more of the three categories of factors.

Implementation As with any new technology implementation, there are challenges involved in bringing single sign-on into a hospital or healthcare setting.

Koenig believes the main challenge is cost. “Return on investment is based upon building a core framework and then adding additional applications over time. Part of the challenge is adding that to our legacy applications that aren’t quickly compatible. You can always build them in, you can always address it, but the question is, at what cost?

“The second challenge is that by having a single sign-on, people will potentially have access to a wider group of systems, applications and information with each sign-on across this system of single sign-on applications.

Th is means it will be more difficult for providers to make sure that access control rights and authorizations given to employees, doctors and staff are limited to the areas that they need for legitimate business and healthcare purposes.

“For example, there may be a staff person who used to have a log-on for the practice management application, which would do scheduling and billing for patients. There was another application for the electronic health records that needed a different sign-on. There’s another sign-on for the laboratory, and for the blood work. There’s another sign-on for radiology data.

“Four different sign-ons, just in this one example. If they’re all part of a single sign-on, hospitals have the challenge to make sure that the right person can only go into where they need to. If there’s a staff member who doesn’t need radiology data, maybe they’re improperly looking at a patient’s data or multiple patients’ data in radiology.”

Koenig says the challenge will be to limit controls and adjust them when people get promoted or terminated, or at a minimum review term each year. “With single sign-on, you can do a lot more and seamlessly move across areas. That’s great unless you haven’t checked to make sure that the areas are appropriate.

“Right now the management is done because there isn’t single signon, it’s all manual. When somebody says, ‘I need another sign-on,’ you ask, ‘Is it appropriate for that person?’ Now, when you’ve seen them all together someone may have too much access to information that they don’t need.”

Authentication Another method of ensuring only the right people are allowed access to the correct areas is authentication. Strong authentication centers around one type of authentication, such as a password: how many characters are there, are they letters and numbers? Do you need a special character like an asterisk or an exclamation point? How hard is the password to crack? Multi-factor authentication involves the number of questions you need to answer to get in. For example, single-factor authentication could be just a user ID. If someone had a user ID 123, and someone else knew that ID number, they would be able to access that system.

Two-factor or multi-factor authentication adds other information to the equation, related to ‘something you have’ or ‘something you are’.

“When you’re logging in to your bank or calling up, they may ask you challenge questions about your mother’s maiden name or other things, that’s multi-factor,” says Koenig. “It goes beyond the simple stuff.

“How does single sign-on work with two-factor authentication?

Strong authentication or strong passwords should always be part of the equation. Two-factor authentication, using a name plus a password, is currently industry common practice. The fi nancial services industry addressed this issue several years ago, requiring it for online fi nancial information.

“Since then, fi nancial institutions and frankly most large and medium-sized organizations have used two-factor authentication to allow access to any system. That would be a sub-requirement for a single signon. Sometimes, for example, if you’re going from a simple access into the radiology system, where a limited number of people have access, you might just have someone’s user ID number and not necessarily a password, and maybe the password requirements aren’t that hard.

“But when you’re going to a single sign-on environment, you want to make sure that the person who is entering, who now has access to a lot more information, actually is that person. It’s very common, when you’re moving from a smaller environment that may not have these controls to single sign-on, that people will need to have more complex passwords in addition to what might previously have just been a user ID. “Part of that goes to the success of the single sign-on. People need to be trained and they need to get used to the fact that instead of having multiple IDs to remember, they may now have only one, but a more complicated one that would truly make sure that it’s them.”

Identity management Koenig points out that typically, single sign-on is part of an organization’s identity management program, or it could be thought of as

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a component or a benefit of some of these identity management tools.

Organizations’ websites will very often already have single sign-on and some of these identity management access control solutions built in, but other areas are not so secure.

“Very often it’s the internal intranet connections between the laboratory, radiology, billing and the practice management system’s electronic health records that aren’t connected,” Koenig says. “That’s the area where there needs to be work and often a separate investment focusing on extending what might be an existing identity management approach, which covers certain applications to some of these older legacy systems and applications.

“For example, many organizations have a wide variety of applications that leverage what’s called an active directory, which is like a single vault of ID. Every time someone enters the system, they check against this active directory. But typically right now, it’s only covering email and a couple of other applications. It doesn’t always get out to those separate ancillary, important healthcare delivery applications. Extending identity management beyond the existing areas that are covered – email, web and some basic applications – will take a separate investment.

“It’s part of regular authentication of controls, but when people buy these systems in these different departments, they don’t always integrate them with the existing identity management controls and functionality that already exists elsewhere. Th at’s the connection that needs to be done now.”

Koenig’s forecast for the use of SSO and identity access management tools in the healthcare sector is bright: continued deployment in the industry will occur as providers mature their systems and applications in to prepare for certification to get the stimulus funds for the meaningful use. There will be increased purchasing and use of some of these single sign-on and identity management tools to help grow secure access from beyond the areas in which it now exists.

“Return on investment is based upon building a core framework and then adding additional applications over time” “A big stimulus or driver for that will be the stimulus funds and the meaningful use of certifications over the next couple of years,” he concludes. “It’s a great opportunity to use those funds and those existing efforts around enhancing your technology, plus the need to certify around privacy and security when you apply for the meaningful use funds. That’s an important part that a lot of people who are just focusing on the technology are potentially missing.”

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ASK THE EXPERT

Business security Tim Alsop defines single sign-on and explains its goals, benefits and challenges.

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any people consider the primary goal of single sign-on (SSO) to be a way to give users a single log on, so that they only have to remember one password, which is important from the user’s perspective, but is not the SSO goal for the business. If a user only has to log on once, the number and cost of password resets is reduced, but security can be weaker, especially when users leave their workstations unattended after they log on. The primary goal of SSO for the business is actually to manage authentication and improve security when users log on to IT resources and applications, and do so as efficiently and cost effectively as possible.

If you remember this goal when selecting SSO vendor solutions for your company, you will reduce the challenges you are faced with and avoid security issues and problems. The wrong SSO solution can increase infrastructure and administration costs, provide weaker security and increase technological challenges for the IT organization.

There are a number of technical approaches to SSO. The first approach involves capturing a user’s current ID and password when they log on to an application, then every time the user logs on to the application the stored user ID and password is inserted into the application log on screen. You’ve eliminated prompts, but somebody or something has to manage the real user IDs and passwords being used. Another approach is where passwords are synchronized across multiple applications so that the user has to enter the same password for each log on. With both of these approaches, you haven’t eliminated the passwords which need to be managed, or improved the security, and you’ve shifted the costs from the shoulders of the end-user to the IT organization, which has to buy the product, pay the maintenance and manage and support the product.

A third approach is to try to implement a common user ID and password repository, such as an LDAP directory. You need to make every application use this common repository when checking a user’s password.

There will be one copy of the password, which needs to be managed, but it’s costly and often not possible to change the user ID and password repository used by an application, and it doesn’t improve security.

A fourth approach is to use a common authentication protocol, which will provide the authentication

services required by critical applications, and won’t rely on a pre-exchange of passwords between the user and the application you are logging on to. One example is the Kerberos protocol, which is especially interesting because any user who logs on to a Windows active directory domain is already using the Kerberos protocol, so application SSO is relatively easy to accomplish. You can completely eliminate the prompt for a user ID and password, and the application network security is improved because passwords are never transmitted or stored, and cryptographic session keys can be used to encrypt network communications and check data integrity.

A successful SSO deployment can be achieved when the critical business applications are implemented fi rst, then the big benefits can be achieved and cost savings realized quickly. Sometimes the users get reduced sign-on (RSO) instead of SSO. Do you actually need SSO or will RSO be sufficient and beneficial to your business?

In summary, you should make sure you look at SSO from the business perspective, not from the user’s perspective. You should consider the Kerberos protocol SSO approach fi rst, since Kerberos is rapidly becoming the defacto standard for SSO in modern networks. If your critical business applications are based on SAP, and you want to achieve the goal of SSO, you should consider the TrustBroker products from CyberSafe, which allow you to take advantage of Kerberos authentication, implement common authentication and reduced or single sign-on for the users of these applications.

“The wrong SSO solution can increase infrastructure and administration costs, provide weaker security and increase technological challenges for the IT organization”

Tim Alsop is a Director of CyberSafe Limited, the leading SAP and Active Directory integrated authentication solution vendor. The CyberSafe TrustBroker products provide improved network and system security, and provide common authentication and secure SSO for SAP applications.

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WIRELESS NETWORKING

A wireless word The Wi-Fi Alliance’s Sarah Morris looks at the expanding use of Wi-Fi in the hospital setting.

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10-year-old trade association, the Wi-Fi Alliance has 350 member companies that span the whole ecosystem from service providers to equipment makers, chip, silicon IC vendors and software.

Its goal is to ensure that Wi-Fi has full access to markets. Much of this is achieved through members coming together to design certification programs around the needs of particular markets.

As Sarah Morris, Senior Marketing Manger for the Wi-Fi Alliance, explains, most people associate Wi-Fi with wireless area networks (WLANs), but the diversity of uses for Wi-Fi has grown exponentially in the past few years. “In a traditional wired setting, a local-area network is a series of devices that are interconnected so that they are networked together,” Morris

explains. “So from a wireless standpoint, obviously that connection could be happening over Wi-Fi. “And then there are the broader places that Wi-Fi is being embedded into; a lot more electronics devices as well as into mobile handsets, and Smart Phones in particular, are integrating Wi-Fi. What it then becomes is something a bit more pervasive where a single device may be using several different kinds of connections. But from the end-user’s standpoint, you’re just connected.

“It’s still pretty common for people to associate Wi-Fi with internet connections, that’s one of the kind of core uses of Wi-Fi. But again, Wi-Fi is certainly broader than that. There are Wi-Fi technologies that are about wide-area networking, otherwise known as mesh networking, that are used for public-area networks and municipal networking.

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“When we talk about Wi-Fi security, we’re talking about two things: authenticating devices that connect to the network, guaranteeing that appropriate devices connect; and encrypting the transmission from that device to the access point.

“In those two regards, Wi-Fi is top notch. The Wi-Fi Alliance has a program called WPA2, Wi-Fi Protected Access 2, and it has a sophisticated Hospitals and robust security that includes government grade encryption.

Within the hospital setting, Wi-Fi is very well established as a com“Questions about network security shouldn’t make anyone munication tool for a wide range of data functions. Voice over IP conhesitate to install Wi-Fi. That’s not to say that IT managnections, for example, are a big deployment practice forr Wi-Fi, ers don’t as are mobile computing carts. This appears to be borne out do have other layers of security concerns, but the Wi-Fi by an estimate from ABI Research that Wi-Fi revenue forr Wi- piece certainly is a strong player. I wouldn’t say anything other than a thumbs-up on that.” healthcare in 2013 will equal $5 billion. an It is estimated that Wi-Fi can also look forward to a strong future Morris says uptake of wireless among US hospiWi-Fi revenue for in tals varies geographically in terms of what infrastruci the healthcare sector. Morris sees a lot of mohealthcare in 2013 mentum, with hospitals seeing the benefits of a ture is already in place and where it makes sense. “If m robust, secure, wireless connection for their data you look at hospitals as similar to typical enterprise will be equal applications.

“That’s happening right now, and it networks, it’s as if you have an existing building and a $5 billion will wi continue to be the case, and penetrate further your alternative is putting in Wi-Fi access points versus and further into that market. running new cabling,” she explains.

“The next growing edge, the next opportunity for IT “It also lets you be flexible as you grow. You don’t have managers and pacity to a hospital administrators, will be where Wi-Fi to pre-wire everything at the start, and you can add capacity can add value in the monitoring, and into patient services, for home the network as it goes on. It’s very flexible and cost-efficient in that way. healthcare as well as hospitals. They’re distinct needs, but they’re both Depending on the individual circumstances, I think Wi-Fi is becoming a places where Wi-Fi can be a real valuable part of the solution. no-brainer choice for a lot of applications. And hospitals are in a similar “The key is for hospital administrators to be thoughtful about what place with regard to data.” their needs are. Remote monitoring and dispensing is one example. We have members who are active in that area, where they are developing devices that might be a wireless blood pressure cuff, or something that could take vital information and report it over the network.

“That’s the early edge, and there are more developments to be made, but we certainly have members who are active and successful in those markets.”

“There’s also a move within Wi-Fi right now to connect individual devices together without an access point. That’s a technology that was developed in the Wi-Fi Alliance, called Wi-Fi peer-to-peer. It will be coming out under the tradename Wi-Fi Direct.”

“Questions about network security shouldn’t make anyone hesitate to install Wi-Fi”

Sarah Morris is Senior Marketing Manager for the Wi-Fi Alliance.

Morris points out that when we talk about hospitals as a single entity, IT managers are comfortable and familiar with Wi-Fi and data networking and the voice applications, and the next horizon that they have in terms of understanding, is not so much Wi-Fi’s limitations as the particular needs they have.

However, as these needs begin to encompass things like medical sensing applications, which are more about data and the monitoring of patients, it will become even more important for IT administrators to understand the needs they have in their specific environments.

“Wi-Fi is a robust, proven, reliable technology,” Morris says. “The focus for a successful deployment for IT managers is to understand the environment they’re in as well as the requirements they have for the network.”

Security There are always security concerns around any kind of patient data, and perhaps even more so when it comes to electronic storage and transmission. Morris underlines the importance of putting Wi-Fi security in the context of the security of the whole network.

The Wi-Fi Alliance’s mission is to: • Deliver the best user experience by certifying products enabled with Wi-Fi technology.

• Grow the Wi-Fi market across market segments and geographies, on a variety of devices.

• Develop market-enabling programs.

• Support industry-agreed standards and specifications.

What is Wi-Fi? Wireless fidelity (Wi-Fi) is a trademark of the Wi-Fi Alliance that may be used with certified products that belong to a class of wireless local area network (WLAN) devices based on the IEEE 802.11 standards. Because of the close relationship with its underlying standard, the term Wi-Fi is often used as a synonym for IEEE 802.11 technology

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ASK THE EXPERT

this by injecting test traffic into the network, sending real packets over the airwaves and then through the backend network infrastructure. By behaving like a real client, the monitoring system gets a real client’s eye view of the network. And just like patient monitoring, if the level falls below an acceptable limit, an alarm is sent.

“The capacity given to each user has to be stable so that nurses and clinicians know their applications will work every time”

The world of wireless LANs

Fortunately, the traditional approach of IT staff having to walk around with laptops and running applications from every corner of the hospiWith wireless networks playing an important role in tal no longer scales: technicians can’t be hospitals and health centers, Vaduvur Bharghavan, everywhere at once and they don’t want to work 24/7. A better approach is to create a virtual client founder and CTO of Meru Networks, explains how on each access point. That virtual client can then wireless LANs will be able to provide the levels of service connect to other nearby access points in exactly required by tomorrow’s healthcare applications. the same way as a real client, going through the ireless LANs improve patient vide an acceptable level of performance. That same airlink, the same controllers and the same care with applications like modoesn’t just mean making sure that a signal is authentication servers. bile nurse call; reduce errors available; it means monitoring The virtual client can inthrough EMR systems; and inall the network’s vital signs to ject test traffic that measures crease utilization of limited resources by tracking ensure that the IT infrastructure every performance metric, so equipment like IV pumps, wheelchairs and defibremains healthy and up to specinetwork administrators can rillators. As dependency on the network increasfication. see exactly how real clients es, wireless LAN technology must evolve to The capacity given to each perform – anywhere and at ensure availability and application predictability. user has to be stable so that nursany time.

Once wireless LANs are deployed, various rees and clinicians know their apIt can support and assure quirements still remain to ensure high levels of perplications will work every time. the availability of any applicaformance. Because healthcare is a 24/7 operation, The round-trip latency has to be tion, but it’s particularly usenetwork access has to be available 24/7 too. Changes predictable too, to prevent downful for applications that don’t within a healthcare environment such as new equiptime in voice and other real-time tolerate poor connectivity. ment and physical modifications will affect network applications. And this assurance Many EMR applications eat performance. As well as tracking users, devices and has to extend beyond the wireless a lot of bandwidth, so proacapplications, the network management system part of the network. Users need tive monitoring will verify Dr. Vaduvur Bharghavan, cofounder of Meru Networks, is a needs to be aware of changes in the physical enviacceptable performance from all that the capacity they need is credited innovator in wireless ronment and new, non-WLAN devices that can incomponents working together – always available for them. networking, specifically wireless medium access protocols and terfere with the network. The system must verify if application servers, security inIt’s critical for the phones QOS architectures. He holds MS and PhD degrees in Computer the coverage and performance levels are maintained, frastructure and backend wired and communicator badges Science from UC Berkeley and a BTech Degree in Computer ensuring that the network is available and operating links too. used by nurses and other Science from the Indian Institute at the appropriate service level.

Just like patient monitorstaff too. Although these are of Technology at Madras.

Assuring application performance is the ing, we need to be proactive in fairly low bandwidth, they most significant challenge facing IT when manassuring users that the network need constant connectivity aging wireless LANs in healthcare organizations. is healthy by continuously and low latency because Healthcare staff need to trust the wireless network checking the network’s vital signs to make sure even a few microseconds delay can be noticewill be there when they need it and that it will prothat everything is running smoothly. We can do able in conversation or lead to dropped calls. n

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SOCIAL MEDIA

Making connections EHM talks to Matthew Lees, Consultant and Vice President at the Patricia Seybold Group, about the opportunities that the use of social media can bring to the healthcare sector.

What are the benefits of implementing a customer-centric approach and social media within the healthcare industry?

Matthew Lees. Healthcare tends to have particular challenges around privacy and the seriousness of the conversations. In healthcare, if you are creating an environment for people to communicate and share their stories with each other – things that have worked for them, things that haven’t worked for them, ways of getting information you need or getting results that you need – whoever is sponsoring those conversations needs to be particularly careful.

Part of it is ensuring a safe environment. It’s part moderation and policing to make sure it’s a comfortable environment and that the community is a friendly and productive place.

Are there any approaches that have worked particularly well in the healthcare sector regarding for the implementation of social media or social networking in a community-centered task?

ML. An example that’s often given, from the physician perspective, is the Sermo site, where physicians can communicate with each other. It’s password protected and anybody can join, though you need to be a physician to do so.

The site uses a lot of social and engagement approaches to helping physicians, not only with medical work, diagnostic work and reading between the lines on different products and medications and drugs, but also on the processes that physicians have to deal with.

From a patient perspective, what many people find helpful is sharing their stories and reading the stories of others, people who have been in similar situations and are dealing with the issues, whether it’s helping support an elderly parent or children with medical conditions.

Regulation must be a key challenge for any healthcare organization looking to get started on a crowd sourcing social media type initiative. What challenges do healthcare institutions face in terms of regulation around things like HIPAA? ML. HIPAA underscores the importance of involving your legal team in the early stages in the design of whatever customer-facing program you’re setting up. There’s not a lot of case law around online communities and legal aspects, whether it’s intellectual property or privacy of information.

There haven’t been that many cases, and so there’s always some uncertainty there. But for any of these kinds of programs, you want to make sure that your organization is receptive to what you’re hearing and that you determine your business goals and your success. What would constitute success of the program ahead of time?

You figure out what technology resources you’ll need, what people resources you’ll need, and you need to think about risk. And you’ll want to involve your corporate communications and your legal team in those conversations early on.

You mentioned technology requirements. What kind of considerations should healthcare organizations keep in mind when selecting a technology solution for their social networking initiative?

ML. One requirement relates to security and HIPAA. There’s a huge trend towards soft ware as a service and putting technology in the cloud. So one question to be asked early on is, are we going to host the data? Are we going to host the community, the crowdsourcing program? Is that going to be done internally on our own servers in our own datacenter, or are we using a vendor, a provider that hosts everything in the cloud?

There are soft ware-as-a-service companies that run stuff out of their own servers, which can meet any security constraints that there are. At first, healthcare wasn’t using these companies so much. They wanted to run them themselves, but as these datacenters improve their security and their compliance, these are stronger options.

Integration and extensibility are becoming important these days, and these applications, less and less, are living by themselves as islands.

Everything is starting to connect with everything else. For example, there’s the social web: maybe there’s a crowd-sourcing application or a community that you’re running on a platform, but other people in the community are also on Facebook. Maybe some people are using Twitter.

It’s becoming an incresingly important technology requirement that these applications can integrate with other systems such as Facebook, such as Twitter, such as a CRM system with customer information. You want these applications to be able to talk to each other.

Matthew Lees is a Consultant and Vice President at the Patricia Seybold Group.

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TECHNOLOGY

Playing

to your strengths

Adam Lynch tells EHM how the Regence Group stays ahead of the game in today’s challenging healthcare IT environment.

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dam Lynch, Assistant Director for Web Applications for the Regence Group, has a lot on his mind. He explains that his institution is in the throes of a consolidating the various claim and membership systems that power its insurance operations, as well as transforming and investing in its external web properties.

“We’ve got a lot of moving parts going on right now,” he says. “The greatest concern I have in the midst of all that is that I’m able to support both the internal needs and the external needs at the same time. I need to make sure all the deliveries are happening as they need to happen and that we’re making our dates and hitting our schedules and delivering the value that we need to be.”

Lynch explains that Regence is investing in its web properties so they can be used to communicate its vision for transformation, as part of its efforts to take on a leadership role during these turbulent times for the US healthcare system. “We’re doing a lot of either custom development or integrations around all of our constituent websites,” he points out. “Our member portal is a resource not just for transactional information, but is also a call for our members to engage in healthy lifestyles and therefore has content focused on health, nutrition and fitness, including a community

“When companies are looking to make that transition they need to focus in on what it is they want to be good at and how that will help them in three to five years” for members to engage one another and programs that encourage exercise and following a healthier diet.

“All of this is being shaped in our member portal as a go-to resource for people to be aware of what’s going on, and as a call to action for them. We’re doing a lot of custom development in that space and the business sees the value of investing in that way. We’ve been doing it in an iterative fashion over the last several years and we continue

to be successful, and so we continue to make changes and add more functionality and grow more presence.”

This is not true only for the member site: Regence is doing the same thing with its provider and employer portals, and most recently it has completely overhauled the e-commerce site that sells directly to consumers who aren’t insured by a group. “We’ve been doing a lot in that space,” he emphasizes, “and our business community sees that those tools are going to be important to us in the future and understands the role they will play in communicating and positioning us in the transformation.”

Challenging times The US healthcare industry is going through a period of tremendous upheaval, and Lynch points to cost transparency as one area that is ripe for change. “Regence has stayed pretty clear on some of the things that need to change around cost transparency. Everybody needs to be much more aware and educated and make different choices around the real cost of delivering some of these services, which is why we’ve added a lot of relevant information to our sites in terms of tools and data, and ways for them to act on it.

“We also believe that the members, the healthcare users, the individuals – you and I – need to become more engaged and a more active part of the process as opposed to the process just washing over us. If what comes out of the reform relates to cost transparency, cost overall, and becoming more consumer-oriented in terms of the whole system, then we’re already going in that direction, and those are the things we’re trying to advocate for. We’re also paying close attention to what’s happening in the individual space and that’s partly why we have started to overhaul our direct-to-consumer experience.”

Proving the return on investment for technology solutions is also critical, given today’s tight operating environment. What can CIOs and IT directors do to ensure they’re getting the most out of their technology investments? Lynch believes the answer lies in not biting off more than you can chew; but instead choosing wisely and being careful not to overwhelm teams with competing initiatives.

“Don’t try and do too much at once,” he advises. “Th is is something that’s pretty common: I’ve seen many situations in the past where there are so many great things we could do that we try to do too much. We need to get better at doing fewer things, know how to measure our success before we start, and continually use our leadership to reinforce those priorities.

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“If you’re doing all those things then your message won’t get lost in the noise. If you’ve got too much going on, your teams will struggle to understand priority 1 from 1A from 1B. You can’t have that many important priorities.”

Back to basics In order to address this issue, over the past few years Regence has made an effort to streamline its IT priorities: “We may have started with 10 objectives for the year and the next year we would realize that 10 was too many and we would cut that down to seven, and then five,” Lynch says. “We’ve narrowed that funnel a little bit and we’ve become more successful because we’re focusing on the right things and getting them done. That may sound like a platitude and it may sound basic, but it does matter.”

Getting back to basics is the approach Lynch would recommend to other companies looking to make an IT transition or improve their IT operation. “You can’t do everything and you can’t be great at everything,” he says. “You need to pick your battles and decide where you’re going to invest for a competitive advantage and where you’re not.

“What we’re going through is a transition around realizing that the web will give us a competitive advantage, and so most of our IT growth and our IT development is taking place there. We’re trying to normalize and rationalize on a common internal platform because there’s no competitive advantage for us to get super good at running the payroll

system or running the HR system, but there is a competitive advantage in having an amazing web presence.

“When companies are looking to make that transition they need to focus in on what it is they want to be good at and how that will help them in three to five years, and go there.”

As well as dealing with current issues, Lynch and the rest of IT also have their eyes firmly on the horizon. Regence’s first priority is to complete and realize the benefits of the internal system consolidation – moving the multiple claims and membership systems over to one. After that, he says

“Healthcare users need to become more engaged and more active, as opposed to the process just washing over us” it’s a matter of leveraging the web to ride the wave: “It’s surfing the sea of change that will come over the next 12-24 months around what happens in healthcare. We’re trying to do whatever we can to get our internal house in order and lay the right foundations in our portals so that we are nimble enough to do what we need to do as the market changes.”

Adam Lynch is Assistant Director for Web Applications for the Regence Group, the largest health insurer in the Northwest/Intermountain Region, serving 2.5 million members in Idaho, Oregon, Utah and Washington.

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INDUSTRY INSIGHT

Optimizing healthcare processes Bill Nordgren explains how healthcare has gone Master Black Belt.

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y defi nition a Master Black Belt (MBB) has been trained as a Six Sigma Black Belt and demonstrated proficiency in statistical tools and expertise in leading and teaching others. Within healthcare organizations, the MBB trains Black Belts and Green Belts, helping to select, scope and mentor projects. MBBs also guide the organization in addressing quality from a strategic business perspective and focusing statistical problem-solving efforts to drive results. In short the MBB is charged with optimizing healthcare processes to insure quality and cost reduction. The MBB is proficient in implementing Lean process techniques to improve the efficiency and cost of processes and activities. If your hospital or hospital group does not have an MBB, it will. And when it does, get ready for change.

Change is good right? Well not always, especially if change is not for the better. Someone who does not completely understand why a current process is followed and what the impacts of that change will be makes the worse kind of change. On paper many changes look exceptional. In reality they fail miserably. Many changes increase the workload of healthcare workers to the point that patient care suffers. Staffi ng issues such as too many patients per nurse, not enough housekeeping personnel and overtime policies all affect the patient length of stay and directly increase costs. Waiting time for patients in emergency departments has historically been hours. How does a hospital solve these kinds of problems? Can a simple change to the process help?

Can reducing waste (time, money) through a kaizen event produce the desired outcome? How will it affect patient care? How can you be sure the decisions and plans made will work?

The answer to these questions is simple and it’s called simulation. Simulation allows you to model before and aft er scenarios to prove that process changes will work. Not only will a simulation model determine if they work, but it will show the extent of the improvement. Healthcare simulation has made dramatic improvements in the last two years to allow those who understand the healthcare process to effectively model real-life scenarios in 3D and determine the benefits of proposed changes. Every healthcare professional has

seen the aft ermath of a poor decision that was implemented without a full understanding of the effect of the change. Simulation can not only prevent bad ideas, but it can prove the good ideas and maximize the benefit, optimizing processes and procedures. The cost of implementing bad policies and procedures can be astronomical. The cost savings resulting from simulation and proving the value of good change is significant.

Simulation soft ware, like Flexsim HC that has been specifically designed from the ground up to model complex healthcare processes, is a significant benefit. Until recently, if you wanted to simulate a healthcare process you were forced to use manufacturing simulation soft ware. Manufacturing simulation soft ware does not handle the complexities of the healthcare environment. At best manufacturing tools could only handle 20-40 percent of the problems in healthcare. The fact is healthcare processes are not like manufacturing problems and need to be treated differently. Flexsim HC knows healthcare.

So the question now is, ‘Will you gamble on change or will you prove your changes before you implement them?’ Simulation is the only tool that can verify if a proposed change is good or bad before you implement it. Give your MBB the tool they need to prove change is good before implementation. Face it: change is here.

Validate and verify before unwanted changes plague your hospital with excessive costs and lower patient care.

“Staffing issues such as too many patients per nurse, not enough housekeeping personnel and overtime policies all affect the patient length of stay and directly increase costs”

Bill Nordgren founded Flexsim Software Products, Inc.Nordgren has authored several papers dealing with simulation project management, queuing theory, and has taught hundreds of classes in the use of simulation software. He received a Bachelor of Science and a Master of Science from Brigham Young University.

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TECHNOLOGY

Healthy profits To build a smarter system, healthcare solutions need to be instrumented, interconnected and intelligent. IBM believes it has the answer. By Ben Thompson

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e live in an unpredictable world. You know it when you get caught in an unforecast storm on a sunny summer’s day; you know it when the stock market tanks and your previously rocksolid investments are reduced to worthless junk; you know it when you hit unexpected gridlock on the way to that all-important business meeting. What you don’t always know are the hows, whys and wherefores – the myriad combination of variables that fell into place in order for those events to unfold.

But what if you did? Given better intelligence, is it possible to predict how such permutations might play out in future – thus avoiding the storm, selling high and dodging the worst of the traffic? Can a better understanding of the way systems work help solve some of the challenges we face as a global society? And what implications could this have for that most complex system of all: human health?

IBM Chief Executive Sam Palmisano doesn’t claim to have the all the answers – but he’s working on it. From financial crises to climate disruption, energy geopolitics to food supply hazards, Palmisano believes solving the global challenges of today and tomorrow will be about the smarter use of information, and has spent more than $50 billion on acquisitions and R&D in preparation for the seismic shift in thinking such a move will require.

“The first decade of the 21st century has been a series of wake-up calls with a single subject: the reality of global integration,” he explains. “In business, global integration has changed the corporate model and the nature of work itself. In the last few years, our eyes have been opened to global climate change, and to the environmental and geopolitical issues surrounding energy. We have been made aware of the vulnerabilities of global supply chains for food and medicine. We entered the new century with the shock to our sense

“The financial crisis has highlighted the burden that healthcare costs are placing on our society, prompting a very engaging debate about what to do about it”

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of security delivered by the attacks on 9/11. And, of course, we experienced the lower end of the spectrum – despite the fact that it is a very technology inthe recent global financial crisis. These collective realizations have reminded tensive and information intensive sector,” says Hogan. “But IT can help make us that we are all now connected – economically, technically and socially.” the administrative process smarter and more efficient; it can enable health inAnd as the world continues to get flatter, smaller and more interconformation to be shared between care providers and eliminate redundant procenected, IBM is banking on something happening that holds even greater podures; and it can better support the process of care so that physicians have the tential: the prospect of our planet becoming smarter. “This isn’t just a right information available to support the decisions they need to make.” metaphor,” asserts Palmisano. “New intelligence is being infused into the way For instance, Sainte-Justine, a research hospital in Quebec, is automatthe world literally works – the systems and processes that enable physical ing the gathering, managing and updating of critical research data, which is goods to be developed, manufactured, bought and sold; services to be delivoften spread across different departments. With the help of IBM technoloered; everything from people and money to oil, water and electrons to move; gy, the center is applying analytics to speed childhood cancer research and and billions of people to work and live. The future now beckoning us is one improve patient care while drastically lowering the cost of data acquisition of enormous promise.” and enhancing data quality. Another example is Geisinger Health Systems, His confidence is based on three key developments. Firstly, the world is which is integrating clinical, financial, operational, claims, genomic and becoming instrumented. IBM claims that by 2010 there will be a billion tranother information into an integrated environment of medical intelligence sistors per human, each one costing one ten-millionth of a cent, while sensors that helps doctors deliver more personalized care. This enables them to are being embedded into everything from cars, appliances, cameras, roads and make smarter decisions and deliver higher quality care, all because they can pipelines to medicine and livestock. Secondly, with over a trillion networked easily turn information into actionable knowledge. devices, the world is also becoming more interconnected, producing risHealthcare systems like these hold promise beyond their particular ing volumes of data each year. Finally, things are becoming more communities, patients and diseases. “The smart ideas from one can intelligent. Algorithms and powerful systems can analyze and be replicated across an increasingly efficient, interconnected and IBM has turn those mountains of data into actual decisions and acintelligent system,” says Hogan. “This should result in lower spent more than tions that make the world work better. Real insight, in costs, better-quality care and healthier people and commureal time, is now a real possibility. nities. In other words, we’ll have a true healthcare sys“With so much technology and networking availtem with the focus where it belongs – on the patient.” on acquisitions and able at such low cost, what wouldn’t you enhance?” he In fact, much of smarter healthcare is not focused R&D to prepare for asks. “What wouldn’t you connect? What information on the next big breakthrough in medical research. the smarter use of wouldn’t you mine for insight? What service wouldn’t you Smarter healthcare solutions start with the individual. information provide a customer, a citizen, a student or a patient?”

Take the medical home model, for example, where priHealthcare is one such sector set to benefit. “Our current mary care physicians act as ‘coaches’, leading a team that approach to healthcare is just not sustainable,” says Sean Hogan, manages a patient’s wellness, preventive and chronic care needs.

IBM’s VP for Healthcare Delivery Systems. “However, the financial crisis The doctor spends more time with each person, is available via email and ?????????????????????? has highlighted the burden that healthcare costs are placing on our sociphone for consultation, offers expanded hours and coordinates care ety, and as such is prompting a very engaging debate about what to do across the individual’s entire care team. Interest in the medical home is about it. And the conclusion is that if we are going to address the issues of building in the US and has caught on globally as well. Physicians, healthaccess, cost and healthcare quality, we have to have better information care leaders, insurers, legislators, large companies and other stakeholdtechnology to support that.” ers are focused on the fact that the medical home model of care improves Rising costs, limited access, high error rates, lack of coverage, poor requality and patient satisfaction and contributes to lower overall healthsponse to chronic disease and the lengthy development cycle for new medicare costs. cines – Hogan explains how most of these could be improved if we could link But while medical homes can be a cornerstone of transformation, diagnosis to drug discovery to healthcare providers to insurers to employers they are not what Hogan calls “a silver bullet”. They hold a great deal of to patients and communities. Today, these components, processes and parpromise, but many more supportive measures need to be undertaken to ticipants that comprise the vast healthcare system aren’t connected. fully realise the benefits. For example, steps needed for full implementaDuplication and handoffs are rampant. Deep wells of lifesaving information tion include improved access to patient information and clinical knowlare inaccessible. edge to improve prevention, diagnosis and treatment; changes on the part IBM believes that a smarter healthcare system starts with better connecof other stakeholders (consumers, other physicians, hospitals, health tions, better data, and faster and more detailed analysis. It means integrating plans, employers, governments and such life sciences as pharmaceuticals); data and centering it on the patient, so each person ‘owns’ his or her inforand a robust infrastructure to support comprehensive, coordinated care. mation and has access to a networked team of collaborative care. It means Nevertheless, he believes the strides being made by IBM in terms of moving away from paper records, in order to reduce medical errors and imharnessing the power of technology for better healthcare solutions are prove efficiencies. And it means applying advanced analytics to vast amounts significant. “We are taking advantage of the fact that our society is much of data, to improve outcomes. more instrumented, connecting that information and using intelligence “If you had a map of all industries and plotted the sophistication of the to take actions that create benefits,” he concludes. “It’s a very exciting use of information technology within those industries, healthcare would be on area.” n

$50 billion

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DIGITAL IMAGING

With the requirement for digital data to be archived for up to seven years in some states, the need for efficient picture archiving and communications systems has never been greater. Frost & Sullivan’s Nadim Daher fills Marie Shields in on the current state of the PACS market.

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icture archiving and communications systems (PACS) have become important tools in a hospital’s digital data management arsenal. According to Nadim Daher, Senior Industry Analyst for Frost & Sullivan’s North American Healthcare Practice, one of the challenges is managing data throughout its lifecycle, while also minimizing the incredibly high cost of using expensive storage media.

“Today PACS is also a lot about the distribution of images to other stakeholders in the imaging enterprise,” he says. “This is often outside the radiology reading room and into certain physicians’ office spaces and sometimes to other hospitals or to the electronic library of patient records.”

Daher explains that the advantages of PACS are those of a digital environment when it’s working well. There are challenges pertaining to the transition to digital, which has been going on in radiology for about two decades in the more advanced countries. This has taken place progressively, but Daher says there are still many places that are lagging behind and still largely printing out films.

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“There is also a challenge regarding the investment that needs to be made into it,” he continues, “both from a clinical standpoint where you get a high resistance to change, especially among the older generation of radiologists and other users, and also financially. You have an important financial investment in those systems, which have typically been acquired as a capital purchase. For an average 200- or 300-bed hospital with an average volume of 100,000 procedures annually, it can easily cost up to $1 million to install PACS. “Because PACS has an important hardware component, it requires a lot of equipment in the IT room, from servers and storage and networking, as well as probably the most expensive element, the software license.

Then you have all the services, both to put it in and to support it, because most of these systems are supported through maintenance contracts, typically over five years, and usually throughout the lifecycle of the systems.”

Investment One of the first considerations for hospitals considering a major capital

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outlay is return on investment. As Daher points out, for those facilities that have never used PACS before, the ROI model is pretty straightforward, because they’re going to be replacing film, which costs about a few dollars per sheet, with digital. “Once they have the system in place it’s going to cost less per procedure to manage study data,” he says, “unlike the film-based model where every study is going to cost tens of dollars for printouts on high quality silver-plated film.

“Various case studies that have shown that PACS pays for itself in anywhere from two or three years to six or seven years, depending on the case.

But, replacing film would be the main ROI item for first-time PACS users.”

However, market penetration is already high, with the majority of US hospitals – as many as 60 or 70 percent – already having PACS in place.

Daher believes the bigger question today centers on the users of first-generation PACS who are looking to replace their systems. “The replacement PACS market is what’s attracting the attention of the entire PACS industry,” he explains. “This tends to leave the few remaining first PACS opportunities out there to the smaller companies, who are happy to take on a contract for a 60-bed hospital or a rural community hospital that doesn’t have PACS. That represents a small contract value.

“The big players are all focused on the replacement PACS market and on being selected as a replacement vendor to put the next generation system in place and get that new $2 million or $3 million deal for the large hospitals and hospital chains.”

With the next generation of PACS, the return on investment on all models is much less certain. There are a number of benefits, but according to Daher they’re not easily quantifiable the way replacing film is: “They are not very quantifiable because they would be something like reducing the turnaround time from study to report from two hours with the current PACS, to 1.6 hours with the new PACS, for instance. While a business case can be made for that 0.4 hours when you look at the productivity of the radiologists, what they’re being paid and what they could be doing if they saved time on their current workload, it’s not as obvious as that for installing a first PACS.” Nevertheless, Daher believes there is a place for the next generation of PACS, to help improve workflow, make the imaging enterprise more productive and open up better communication with referring physicians. “At the end of the day, as an imaging enterprise, your customers are those referring physicians who send you patients to get images done. It’s important to have efficient IT solutions and to make it work better for them.

“On the clinical side, a better PACS infrastructure can help physicians make better decisions, because they have greater access to imaging over time, comparing priors to new, comparing with other patients, when you start doing things like data mining. It’s mainly clinical benefits, but also with a strong business component.”

PACS has been around for 10 or 15 years, so the first few academic centers that implemented the digital PACS that we know today are now at their third generation of the technology. Another large chunk of the marketplace is coming up to its second generation PACS, and Daher’s view is that this is probably the main thing that’s still driving the market forward.

“Although the uptake has slowed down in the last two years, it’s a con-

tinual process. Technology has to be upgraded at some point. You can’t keep 10-year-old servers running in your IT department.”

External pressures have also exerted an influence, resulting in the last two-and-a-half years being very challenging for the American PACS market.

“The macro-economic pressures that occurred in 2008 did not spare the PACS market,” Daher says. “Traditionally it has been more immune to outside market conditions, but this time it was hit pretty badly. The IT projects hospitals were doing were put on hold, if they weren’t cancelled.

“The fact that the reimbursement pressure is so heavy on imaging in general makes the ROI model for PACS less and less solid, because individual procedures are getting left without reimbursement. Some of it is offset by the fact that procedure volumes continue to grow at a single digit of five or six percent a year. When you have to do more for the same amount of money, IT is a solution for that, but at the same time you can’t spend the required money on it. That has been the deadlock for the PACS market during the last two years.”

“When you have to do more for the same amount of money, IT is a solution for that, but at the same time you can’t spend the required money on it. That has been the deadlock for the PACS market during the last two years”

International Comparing the US market to parts of the world like Canada, the UK and Scandinavia, Daher sees the major difference being that the US has a mostly privately operated healthcare system, and Canada, the UK and Scandinavia have a publicly managed system.

This has had a direct impact on the way that technology has been implemented throughout the years. It has been more of a grass roots movement in the US, of individual hospitals getting PACS and wanting to be competitive with respect to the technology and the neighboring facilities. On the other hand, in Canada, the UK and Scandinavia, PACS adoption has been planned more from the top down; province-wide or state-wide agencies have planned, to put on PACS in several hundred facilities at once.

“Places like Scandinavia,” Daher says, “have been able to reach 100-percent penetration. They’ve been able to do it much more cost-effectively than in the US. The national program for IT in the UK was also one of those top-down forces that has planned for PACS. They have had some big failures and some important challenges, but they have been able to put in more PACS technology in more remote places and do it more cost-effectively than in the US. “They’re also able to get the systems to better talk to one another, because the first phase when you look at it over a long period of time is to have digital data everywhere. And the next phase, which is the major debate in US healthcare IT today, is interconnecting all of these individual healthcare facilities into something more widespread, so you can track diseases, track trends, track everything nationwide.”

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Daher underlines that in the US, vendors have not been forced to comply to industry standards and have not been prevented from using proprietary technology, which has created a very challenging situation. “It’s very hard to get the legacy systems to talk with each other. In the legacy systems there is a lot of proprietary technology; it’s almost like secret recipes the vendors are using, and when it comes to replacing the system, providers find that they’re not able to read them.

PACS: a definition In medical imaging, a picture archiving and communication systems (PACS) is a combination of hardware and software dedicated to the short and long term storage, retrieval, management, distribution and presentation of images.

Electronic images and reports are transmitted digitally via PACS; this eliminates the need to manually file, retrieve or transport film jackets.

PACS consists of four major components: the imaging modalities such as CT and MRI, a secured network for the transmission of patient information, workstations for interpreting and reviewing images, and archives for the storage and retrieval of images and reports.

Combined with available and emerging web technology, PACS has the ability to deliver timely and efficient access to images, interpretations and related data. PACS breaks down the physical and time barriers associated with traditional film-based image retrieval, distribution and display.

“You don’t see this kind of thing much in the other countries I mentioned, where the vendors are more forced to align themselves and the way they do things. There was more in the long-term planning that one day these systems will talk to each other, we will interconnect them. And you’re starting to see that in Canada, Scandinavia and the UK.”

Looking ahead Looking to the future, Daher says systems will be better integrated with each other and there will also be better integration with electronic medical records, where PACS will become the imaging element of the EMR. “The EMR has a lot of components, an important one of which is images, and PACS is likely to be the underlying system that handles this component.

“Also, we have what we call enterprise PACS, and there are two sides to this. One is enterprise, meaning multi-departmental, so going beyond radiology and having a single system, or again, multiple systems, but that talk nicely to each other; one for radiology, one for cardiology, for orthopedics. All the imaging is done in the departments outside radiology that are also producers or users of images, so that you can have an effective way of managing those images throughout the multiple departments.

“And the other side of it is by enterprise, which can mean also multisite. When you have a hospital organization that has two or three hospitals in different locations, with imaging centers at each, they can bring together these geographically dispersed locations through an enterprise PACS system. That’s probably the biggest market shift in those larger scale systems.”n Nadim Daher is Senior Industry Analyst for Frost & Sullivan’s North American Healthcare Practice.

When you have a hospital organization that has two or three hospitals in different locations, with imaging centers at each, they can bring together these geographically dispersed locations through an enterprise PACS system.

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ASK THE EXPERT

system, such as Q-nomy’s Q-Flow soft ware, can automatically handle all common cases by applying business rules, which on one hand assign a priority to each case, and on the other hand set clear limits for maximum waiting that

“Specific clinics often have other particular types of cases with unique behavior” prevent lower priority cases from being overtaken again and again and never getting called.

Such a system would also allow very particular algorithms to be rapidly programmed to support the requirements of any site – such as the ophthalmologist’s clinic. Specialized systems like Q-Flow also provide appropriate presentation tools, which can be used to provide patients with clear indication of their priority and Sid Mandel explains the importance of patient management when they are going to be called. for an efficient and happy waiting room.

The basic tool would be LCD screen displays (these replace the old LED signs which linic queues present unique instance, patients visiting an ophthalmologist can only present the ‘next in line’ number). challenges to any person, might be asked to wait 20 minutes for dilation LCD displays provide enough room to show a system or method attempting to to take effect, and then be called to the doctors number of different queues (such as appointmanage them properly. A simple according to their original order of arrival. ments; walk-in; returning patients and so on) service like co-payment cashiers can rely on The challenge in all these cases is double. and to show more than one patient per queue. the simplest form of ‘take a number’ device to The fi rst is creating a system that handles All patients can see where they are on the arrange customers in a fi rst-in-fi rst-out line. all these cases, and can decide at any given display, and be relaxed knowing that there’s a But patient flow in the doctor’s waiting room moment who – of all waiting consistent method at work. behaves less like an orderly queue and more patients – should be called For patients who are like a cloud, from which patients need to be next, weighing in all the difabout to experience a long called according to complex logic. ferent priorities and factors. wait, more advanced options Th is cloud is made up of different types Secondly, making the complex can be offered – for instance, of cases, which may include: random visitors logic transparent to patients to go wait at a nearby cafadmitted based on fi rst-come-fi rst-served; so that each patient feels he or eteria and be notified using patients with appointments who take priority she is treated fairly and proSMS when they need to get over random visitors, assuming they arrived vided good care. To tackle this back to the waiting room. on time; patients who are too late for their apchallenge a simple numbering The bottom line is, clinic pointment (and whose priority might somesystem is not enough, and any patient flow is one complex how still precede random walk-ins); patients attempt to force such a system challenge where good autowho walk in and got prioritized based on into complex scenarios would mated technology can actuSid Mandel is the Director for level of urgency (possibly by a triage nurse); usually result in angry paally make people (patients Qnomy Inc. in North America. He patients who previously visited the doctor, tients, frustrated doctors and and doctors alike) more is responsible for sales, marketing, operations and oversight of got sent to a series of lab tests, and now come total disorder. happy and relaxed than any Qnomy’s existing clients and distributers. Mandel brings over back with results; and so on.

Instead, a specialized pahuman intervention – as 25 years of experience working Specific clinics often have other particutient flow management needs well intended as it may be – with software solutions for the healthcare industry. lar types of cases with unique behavior. For to be implemented. A suitable ever could.

Service with a smile

C

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WASTE MANAGEMENT

T O N T N A W M Millions of tons in waste are dumped by hospitals annually, with potentially disastrous consequences for the environment. Diana Milne meets Anna Gilmore Hall, Executive Director of Health Care Without Harm, to find out what can be done to stem the flow.

edical waste management has become a key priority for public and private health organizations, which are increasingly looking beyond incineration for safer and less environmentally harmful disposal solutions. As Executive Director of the lobbying body, Health Care Without Harm, Anna Gilmore Hall is campaigning hard for hospitals to consider the effects of toxic waste on the environment and to invest in alternative solutions. Describing the scale of the problem, she says: “Hospitals generate millions of tons of waste each year. When you think about all of the materials that we use in a hospital, the toxic materials, the chemicals, and that fact that in the past, many hospitals just dumped all their waste streams together, from the pizza boxes in the cafeteria to the trash in the reception area to operating room waste, and burned it in incinerators.”

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Feeling the burn

The use of incinerators is Gilmore Hall's biggest concern. She is particularly keen to raise awareness of the effects of using incinerators to dispose of instruments concerning mercury, such as thermometers, which she says release environmentally harmful dioxin fumes: “Medical waste incineration is the leading source of dioxin. When we started, there was a lot of mercury in the healthcare sector. We’ve been influential, I think, and very successful in getting mercury thermometers out of the healthcare sector in the US. You cannot go out and buy a mercury thermometer any longer, but there are still other sources of mercury that occur in the healthcare sector and even in our own homes, such as things like batteries and switches.

“When you put all of these things into the medical waste incinerator, the fumes from the incinerators release dioxin, mercury, lead and other dangerous pollutants that threaten human health and the environment. The prob-

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lem is we haven’t done enough research to know what the impact is of putting pharmaceuticals into incinerators and burning them. We certainly don’t want mercury going into the incinerators because we know that’s really harmful to the environment. It gets into the rain, the rain falls into the earth, the earth grows plants that are eaten by animals that are eaten by us. And so we have this vicious cycle of how harmful chemicals we put into the atmosphere end up back in our own bodies.”

Despite these obvious dangers, she says, in the past governments promoted the use of incineration as a waste disposal method – a situation her organization worked hard to change through research into alternative no-burn waste management systems. “There were a lot of governments and even public health association agencies that were continuing to promote incineration because they thought that was the best technology available for waste management solutions.

Fortunately, there are safer no-burn technologies that are currently available to the healthcare sector that effectively treat and disinfect medical waste, and we are working with many systems around the US and internationally to look at some of these alternatives to medical waste incineration.”

There are four basic no-burn processes used in medical waste treatments: thermal, chemical, radiation and biological. All of these processes rely on heat to destroy the pathogens or the disease-causing microorganisms. Gilmore Hall explains that the low-heat thermal process utilizes moist heat, steam and dry heat; and then there are high-heat processes involved with major chemical and physical changes that result in the total destruction of waste. There are chemical processes that employ disinfectants to destroy pathogens or chemicals that react to the waste.

Radiation involves ionization radiation to destroy microorganisms and biological processes use enzymes to decompose organic matter. Although each method has its merits, Gilmore Hall explains that there is no one perfect solution for the healthcare sector: “These are all fairly complicated and no one process takes care of everything. That’s one of the challenges that we have in the healthcare sector.”

An alternative solution to the latter four more scientific processes is to simply compact and treat medical waste so that it can then be disposed of in a landfill site, explains Gilmore Hall: “There are medical or mechanical processes that are shredders and that act and compact. It’s a bit like your old trash compacter; it can be a supplementary process to render the waste unrecognizable so that you can treat, put it through a rotoclave or an autoclave disinfectant, then you shred it and then it can just go into a landfill.”

She adds however that the drawback of this method is that it could potentially lead to the leaking of toxic medical waste into surrounding water sources and it would add to the already critical problem of overuse of landfill sites by industries generally. “One reason to avoid putting things in a landfill, is that the landfill is very big and you want to make sure that nothing you put in there is going to leech out into the surrounding water.

We generate so much waste in the healthcare sector that we want to make sure that we’re not adding to the landfill problem any more than absolutely necessary.”

Although each method has its merits, Gilmore Hall explains that there is no one perfect solution for the healthcare sector: “These are all fairly complicated and no one process takes care of everything.” And while no-burn waste management solutions address concerns over dioxide production, government regulations concerning chemicals disposal mean that there is often no alternative to using incineration methods.

“If there’s hazardous waste material that you’re dealing with and pharmaceuticals, you have to make sure that you’re in compliance with all of the regulatory requirements that hospitals have to deal with. And unfortunately, in some instances right now, incineration is still the better of all the bad alternatives for waste management, particularly around pharmaceuticals.”

She goes on to describe the complications that arise from the government regulations governing the disposal of chemical waste – particularly as these often differ across state lines: “There’s hazardous waste, biological waste and pharmaceutical waste; all have significant regulations that surround them. So for instance, biological waste – items that have blood or body fluids on them, or body parts, – has to be treated differently in addition to segregating it from other kinds of waste. It does have to be maintained in the hospital and then disposed of in certain ways that are appropriate to the state regulations where the facility is.

“It’s a bit of a tricky problem, because we don’t have federal regulations that take care of all of these things. It’s done state by state and that’s a bit confusing sometimes for hospitals and hospital systems that cross state lines. The basic idea is to make sure the hospital understands what its state regulations are and make sure it is complying with those regulations.”

“When you put all of these things into the medical waste incinerator, the fumes release dangerous pollutants that threaten human health and the environment” To further complicate the situation, figures on how many waste disposal sites are used by hospitals are sketchy, due to the amount of waste that is taken to different areas to be disposed of. This makes it difficult to monitor, says Gilmore Hall, whether government regulations are being observed and to ascertain the full scale of the waste disposal problem: “When Health Care Without Harm started 14 years ago, there were about 3000 medical waste incinerators in the country. There are now less than 80 onsite medical waste incinerators.

“What happens now, particularly for hazardous waste, is hospitals have haulers come collect the waste and they are sent to offsite incinerators.

Sometimes they’re municipal incinerators or sometimes they’re sent across state lines into other states for disposal. We don’t have a good indication, frankly, of how much that’s occurring or what the tonnage is. Even though we know that hospitals are huge producers of waste, how much is actually being transported across state lines for disposal in other communities is not exactly clear.”

The root of the problem There is, however, a solution that avoids hospitals having to make any decision about how to dispose of waste and that is to tackle the root of the problem – procurement. Gilmore Hall believes one of the most effective ways her organization can help to reduce medical waste is to encourage

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Waste management action plan Anna Gilmore Hall’s guidelines on establishing a waste management action plan within hospitals Establish a green team: Convene a task force of administrators, housekeepers, nurses, the people who are involved in managing the waste, and say, “We need to come together and agree on a plan on how we’re going to address this issue in our facility.” Any program that deals with waste needs to involve the nurses as they come into contact with 90 percent of most waste in hospitals. So nurses need to be involved in these green teams and in order to be successful, everyone has to take this seriously. Everyone has to realize this is part of their job. This group should strategize about the appropriate courses of action for that particular facility with input from all of the responsible sectors in the system.

Conduct a waste audit: The first thing that the green team should do is conduct a waste audit. One of the things that happens is people don’t really understand the amount and volume of the waste. They don’t understand the cost of the waste and so most hospitals have to have a better handle on that. For instance, the cost to dispose of a normal bag of waste is around $8. To dispose of red bag waste, which is where the hazardous waste goes, costs about $15. When people realize the difference, they understand the importance of segregating their waste. About 85 percent of the waste that exits the hospital is non-infectious waste similar to the waste you’d find in a hotel or an office building. You don’t want to be paying all that money for that 85 percent of the waste when really you should be paying the higher rate for only 15 percent.

Educate staff: Education is really important, particularly teaching nurses and housekeeping staff the proper way to segregate waste and training people about the environmental consequences of medical waste incineration, perhaps posting signs where waste is sorted so that people understand this is something that they need to take seriously as part of their practice. A lot of people recycle at home. There are lots of things that you can recycle at the hospital and we recycle cardboard, glass, paper, newspapers, magazines, soda cans, all those sorts of things. This can be done in a very cost-effective way.

Improve purchasing practices: Purchasing practices are key to pursuing an aggressive waste management program.

Working with the purchasing team to select reusable rather than disposable products is important. Have your product selection team examine the environmental impact and safety of materials coming in to the hospital and work with your risk manager to choose products that don’t have a negative impact on worker and patient health and safety. Implement a purchasing program that favors products made of recycled paper that hasn’t been bleached with chlorine.

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hospitals to reduce the amount of waste they generate in the first place by making smarter purchasing decisions: “We can do a lot by making smarter purchasing decisions and working with manufacturers and others as far upstream as we can to make sure that we are only buying products that are as green as possible, that have the least amount of packaging as possible. And when we have all of these products in the systems, than we are properly segregating and recycling as much waste as possible.”

One way to cut down on waste, she explains, is for companies to liaise with their suppliers regarding the amount of packaging used in their products: “There’s a lot that you can do with packaging.

We’ve been very pleased to have hospitals work with manufacturers and producers to say we want you to reduce that amount of packaging. It saves money for the hospitals and it also saves money for the manufacturers, and it certainly reduces the amount of waste we have to deal with afterwards.”

In terms of procurement, she goes on to say that hospitals are being encouraged to invest in products that contain the least amount of chemicals, particularly neurotoxins that are known to cause cancer.” A lot of persistent bio-accumulative toxins are chemicals that are used in many products from medical equipment to the desks that we use and the carpeting that’s on our floors, and the paint on the walls. There’s a lot that we can do in demanding safer alternative products upstream, which is one of the most important things we can do around medical waste.”

Encouraging hospitals to recycle is another approach used by Health Care Without Harm to reduce the amount of material that finds its way into waste disposal sites or incinerators. “We encourage hospitals to introduce waste minimization techniques and segregation, using recycling as an opportunity to save money and reduce the amount of waste that we have to take care of in the end,” says Gilmore Hall.

At the cutting edge Many products used daily by hospitals cannot, however, be recycled or subjected to smarter procurement decisions. Among the most complex and potentially harmful products to public health when it comes to waste disposal are needles. Gilmore Hall says that major progress has been made with regards to safe sharps disposal, including devices with retractable needles and education of employees to ensure proper precautions are followed.

“Hospitals have done a very good job of trying to reduce needle stick injuries to nurses and other

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healthcare workers, particularly the people who are managing the waste in the trash. There are a lot of new devices out there in the world that have retractable needles and actually reduce the opportunity to have a needle stick because of the way that the device is designed and manufactured, and that’s one of the best things that you can do to reduce that hazard from the very beginning. This includes putting needle stick boxes and containers in a patient’s room so that whoever is using needles or sharps, there’s an immediate place for disposal. There should be properly trained employees in the hospitals that know how to manage those boxes.”

The disposal of these sharps boxes usually involves either incineration or grinding using autoclaves or rotoclaves then disinfection before disposal, she goes on to explain.

Equal care is needed for the disposal of electronic equipment, which in hospitals can range from laptops to MRI scanners and X-ray machines.

Systems are in place that allow hospitals to return disused equipment to manufacturers rather than disposing of it themselves. The drawback of this is that hospitals cannot guarantee that the manufacturers will then safely dispose of products containing chemicals.

Indeed, one worrying trend is that this used electrical equipment can be dumped in third-world countries. “We see hospitals start to negotiate takeback programs with the electronic manufacturers so that we are not disposing of those electronic pieces of equipment,” says Gilmore Hall. “They’re not going into a landfill but they’re actually going back to the manufacturer for

Anna Gilmore Hall is Executive Director of Health Care Without Harm, an international coalition of healthcare providers, healthcare systems and NGOs interested in healthcare and sustainability, with 500 members in 52 countries.

proper disassemblement, making sure that the hazardous chemicals that are in them are properly taken care of and disposed of and even in some instances, can be recycled for use in other products.

“The unfortunate thing that sometimes happens, however, is that some of these recycling programs end up dumping this electronic waste into thirdworld countries and we’ve seen child laborers and other people who don’t have any kind of safety training sorting through these electronic pieces of equipment and computers and trying to pull out the mercury and pull out the lead, the cadmium and other chemicals. So I think the safest thing for us as the healthcare sector to do is to negotiate a strong take-back program with the manufacturers and then make sure that those manufacturers are properly taking care of those electronics when they’re returned.”

Concern about both the effects of waste disposal on thirdworld populations and the waste disposal methods practiced there are key priorities for Health Care Without Harm and it has worked closely with the World Health Organization to help reduce the use mercury in the world health industry: “We have been involved with the World Health Organization in getting mercury out of the healthcare sector around the world,” Gilmore Hill explains.

“We’re hoping that within the next 10 years, mercury everywhere is out of the healthcare sector.

“The fact that we can’t use mercury thermometers here in the US but other people are being exposed to mercury on a daily basis seems ridiculous to us and so we’re very pleased that our international mercury program is taking off. It’s doing such a fabulous job of getting mercury out of the healthcare sector and we’re trying to encourage manufacturers to provide cost-effective alternatives to mercury in these other countries. Gilmore Hall says the organization is also particularly concerned about the inappropriate use of incineration in third world countries, which often situate incineration facilities close to residential areas or within easy reach of local communities.

“A lot of hospitals in third-world countries are continuing to use incinerators and the issues for them are the same as the issues for us. They’re releasing dioxin and lead and mercury into the environment. They’re doing it in communities oftentimes right beside the hospital or right beside a residential area and so they’re inadvertently releasing toxic chemicals and materials into a community where, again, they should be trying to keep them healthy, not make them sick.”

Ensuring medical waste management doesn’t cause the very conditions hospitals exist to treat is the key aim of Health Care Without Harm. And as it succeeds in getting the message across to increasing numbers of healthcare organizations about the dangers of incineration and mercury usage, the industry can expect to see a significant cut in unnecessary medical waste filling landfill sites or polluting the atmosphere. n

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ASK THE EXPERT

SUPERIOR DESIGN To the large majority, all hospital textile products are one and the same. For Geoff Mayo, however, there are a few products being introduced to the market that stand out from the crowd.

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would have to say that our new ECT Patient Gown is exceptional in its ability to help caregivers achieve superior patient outcomes. There has never been a gown with so many user-friendly features designed from the perspective of both patients and nurses. Many times a textile product looks good on the drawing board, but fails in use because it does not withstand institutional laundering or day-in, day-out use in the clinical setting.

Sometimes the textile item interferes with dressings and devices used to treat the patients acute conditions, or makes it more difficult for nursing staff to administer care.

The ECT Patient Gown has overcome all of these hurdles and actually works with medical devices and caregivers to help produce better patient outcomes, and helps provide greater comfort to patients in the process.

fortable in many ways: It has a generous overlap in the back, so the posterior is modestly covered without having to use two gowns. With other gowns, drains are either pinned to the outside, or hang by their tubes from the point of insertion, which causes pain and discomfort and may cause dressings to come lose. The ECT gown has two front pockets for drains or other medical devices that help to minimize this strain on insertion sites. These pockets lessen patient pain and discomfort, and help keep dressings in place to provide a barrier, again keeping patients more comfortable and minimizing the potential for infection.

The gown also has additional features including a pocket for a telemetry unit, snap sleeves to accommodate IV lines and a fenestration placed in the abdominal area that allows a PEG tube to remain visible and outside the

“There has never been a gown with so many user-friendly features designed from the perspective of both patients and nurses”

One factor that makes this particular product so important right now is the high rate of hospital-acquired infections (HAIs). Any medical device, including a textile product that can help to lower the incidence of HAIs has its ‘heart’ in the right place. The ECT gown has patented features that allow the unused lumens of multi-port central lines to remain outside the gown, separated from the skin, and in plain view of nurses. The design of the gown actually helps keep the lumens from making contact with potential causes of infection, and makes it easier for nurses to follow infection control protocols when they swab the unused lumens.

The ECT gown also helps to make the patient more com-

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gown for administering flushes or other procedures.

Most importantly, the gown helps to encourage early ambulation. Patient pain and discomfort is minimized, and because the gown’s pockets carry devices it is easier for the staff to get the patient up and out of bed. The importance of post-op ambulation in staving off complications is well known, and the ECT Gown’s design helps to accomplish this as well. n Geoff Mayo is Divisional Director for Healthcare at American Dawn Inc. Mayo has over 25 years’ of senior management experience in the manufacturing and distribution of reusable textiles for the acute, longterm care, and commercial laundry healthcare markets. He is a graduate of the Carlson School of Management, University of Minnesota.

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ROUNDTABLE

A safe input Intravascular catheters are a staple in the modern-day medical world. EHM talks to two industry experts on the potential challenges and emerging solutions facing catheter-related infections.

Preventing the transmission of infectious agents in healthcare settings has always been a key concern for healthcare practitioners. What are the key challenges for healthcare professionals and facilities alike in terms of implementing effective infection control?

Mark Hunter Mark Hunter is Associate Director in Clinical Development for Baxter, working with product development and educational programs in infusion therapy. He has over 20 years of experience as a registered nurse, is certified in infusion nursing, has been involved with the Infusion Nursing Society at the local and national levels and contributed to the INS Standards of Practice.

Kerry Edgar is the Vice President of Marketing and Clinical Affairs for Medegen Inc., developer of the Maximus line of IV therapy products. She has worked in the healthcare industry for 22 years, in marketing, clinical, and sales capacities. For the past five years, Edgar has directed the marketing and clinical affairs for Medegen Inc.

Mark Hunter. The key challenges for healthcare professionals and facilities in implementing effective infection control are the increased resistance of today’s microorganisms and the lack of knowledge related to their transmission. The super bugs of today are much more difficult to treat, requiring stronger anti-infective medications and longer treatment, often requiring a central line catheter (another risk factor for infection). As far as education, we need to ensure that not only clinicians but patients, family members and friends understand the seriousness of infections and the steps to prevent the spread. We need to hold each other accountable when we see key steps, such as hand washing or donning personal protective equipment for isolation ignored, which could potentially spread infectious agents.

Kerry Edgar. The challenges facilities face in implementing effective infection control are a lack of administrative resources to implement and manage infection prevention programs, and a lack of fi nancial resources to employ new technologies. Implementing an infection prevention program requires staff to manage and monitor the program, assuring adherence to the program guidelines, collection of data and outcome measurement. Effective programs require buy-in from all participating staff, along

with evidenced-based best practices and new product technologies. Consistent education and compliance monitoring on use of evidencebased practices, such as hand hygiene and the IHI bundle, are required for success. Effective programs often require a change of culture at the hospital through use of a multi-department team approach. Oftentimes the patient to nurse ratio is very high, limiting the amount of time a HCW has to perform best practices, and this may result in sub-optimal practices.

As manufacturers, we are developing better products to help enhance the performance of best practices and further educate clinicians on the need to perform these practices at the most optimal level.

“Effective programs require buy-in from all participating staff, along with evidenced-based best practices and new product technologies” - Kerry Edgar Intravascular catheters are indispensable in modern-day medical practice, yet their use can put patients at risk of local and systemic infectious complications. What new solutions are emerging to help mitigate such risks?

KE. Many new interventions are being utilized to help facilities reduce catheter-associated bloodstream infections. These interventions

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include devices designed to prevent migration of pathogens into the bloodstream from both extraluminal and intraluminal pathways. New technologies that assist in preventing intraluminal pathogen transmission feature antimicrobial protection, specifically catheters, needleless connectors, and lock solutions. In laboratory studies, antimicrobial additives in needleless connectors have been shown to greatly reduce the growth of pathogens associated with bloodstream infections. The MaxGuard Advanced

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Luer Activated Device from Maximus has been shown to kill greater than 99.999 percent of the most common pathogens associated with catheter associated infections. Published clinical studies also support the use of antimicrobial catheters, which provide an additional layer of protection especially relevant to a facility’s most immuno-compromised patient population. Antimicrobial protection does not negate the need for proper nursing practices; these new technologies must be accompanied by best clinical practices in order to realize a significant, sustained reduction in catheter associated bloodstream infection rates.

MH. There are multiple antimicrobial technologies in the emerging market. These include central line catheters, skin prep, needleless IV access devices, as well as preps/cleaners, sutures, dressings and lock solutions. Equally as important are new educational programs designed to improve utilization of vascular access devices with early vascular access assessment, and ensuring that the right catheter is placed and removed appropriately.

Is a purely technological/scientific response required? Or is it just as much about improving processes and raising awareness as to the issues involved? How have you been involved in terms of increased user education?

MH. Infusion therapy has become a part of day-to-day life within a hospital, whether it is for a diagnostic procedure or medication.

It is important to understand that infusion therapy, including intravenous catheters and the care of catheters, is only a small part of the clinician’s formal training, and a lot is on-the-job training. Th is is where it becomes extremely important to have strong policies and procedures and educators to facilitate the training of new staff.

Advanced techniques and technology need to be utilized together to reduce the risk and help prevent catheter-related bloodstream infections (CR-BSIs). Clinicians have made great strides in the reduction of infections, but CRBSIs still remain. Technology advances can aid clinicians in their quest by improving the techniques already in place. A great example is the use of silver in catheters and needleless IV access devices to further reduce the risk of contamination along with the use of the catheter insertion bundle. Healthcare and industry

a valuable service to the often overwhelmed infection prevention and risk management departments.

As the pace of medical innovation increases, do you anticipate new challenges on the horizon with regard to the prevention and management of infectious complications resulting from the use of intravascular catheters?

MH. I predict that we will have challenges with regard to the prevention and management of

“It is important to understand that infusion therapy, including intravenous catheters and the care of catheters, is only a small part of the clinician’s formal training, and a lot is on-thejob training” - Mark Hunter need to work together, combining their efforts to one day completely eliminate the risk of bloodstream infections.

KE. With infusion therapy a purely technological or scientific response will not solve the infection problem. Devices for infusion therapy need to be simple, intuitive and designed to enhance clinical best practices. Just as CHG enhances skin antisepsis, needleless connectors should enhance the process of disinfecting, flushing and maintaining patency. Needleless access connectors should feature a flat, tightly sealed surface to promote complete disinfection during pre-access swabbing, clear housing to permit complete visualization of the fluid path – enabling proper flushing of the connector and catheter, and positive displacement to assist in maintaining catheter patency.

Both MaxPlus Clear and MaxGuard from Maximus are designed with these risk reducing features. Maximus is active in providing continuing education programs, training services and support for the bedside clinician; we also offer a comprehensive CLABSI prevention program that can be customized to the needs of any facility and assist hospitals in meeting the Joint Commission National Patient Safety Goals. Th is program can be easily implemented in a hospital and provides

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infections resulting from intravascular catheters. However, I do feel that it will continue to decrease and believe that this could become a complication of the past within my lifetime. A caveat to this is that both the medical field and industry must work together with the common goal to improve patient outcomes. I think Dr. Allan Fromme said it best: “People have been known to achieve more as a result of working with others than against them.”

KE. Yes. New innovations designed to help prevent transmission of infection-causing pathogens may lead clinicians to believe that best practices are not as important or do not need to be performed as well. This is a challenge for manufacturers of antimicrobial devices and other technologies designed to reduce the risk of infection. As manufacturers, it is important that we stress that the use of new technologies will never replace the need to perform best practices. Best practices such as hand hygiene, skin antisepsis, scrubbing/disinfecting the hub of the needleless access connector and completely flushing the catheter and connector are key to successful CLABSI prevention. Maximus strives to design devices and educational programs that support and sustain best nursing practices, because these must be maintained and sustained in order for hospitals to reach the goal of zero nosocomial infections.

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PATIENT CARE

PREVENTION

IS THE CURE Dennis Maki tells Nick Pryke about the magnitude of intravascular catheter-related infections and what is being done to aid prevention.

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ospitals by their very nature are breeding grounds for bacteria; they concern themselves with – and trade in – precisely that. For those in need of significant medical attention, entering through those double-glassed, automatic doors into a world of hectic clinical sterility may seem like a sanctuary free from infection. But as levels of home and aftercare increase, alongside rocketing hospital populations and staffing demands, what is being done to ensure the progression of infection prevention, especially in intravascular catheter insertions?

Dealing with already vulnerable people can mask the true susceptibility to and causes of patient infection, something Dennis Maki, Professor of Medicine and Head of the Section of Infectious Disease at the University of Wisconsin-Madison Medical School, is all too aware of: “If one looks at preventable complications of hospitalization, healthcare-

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associated infections are by far the 800-pound gorilla. It’s important to understand that just because there’s a hospital-acquired infection doesn’t automatically mean somebody did something wrong. People in hospitals are sick. They’re very vulnerable and very susceptible to infection, so many of them get serious infections in their home setting totally unrelated to being in a hospital or in a healthcare system.”

Indeed, it would be naïve to presume that hospitals aren’t prone to human error – drug and anesthetic mistakes, incorrect insertions sites, and electrical injuries are all very real risks – but hospital infections result in more extended hospitalizations and deaths than any other hospital-associated complication. To be more specific, they result in roughly $10 billion to $20 billion per year in healthcare costs, and it’s estimated at least 100,000 people a year die as a consequence of a hospital infection.

Focusing on the potential for intravascular catheter-specific infections, Maki explains the importance of correct vascular access to minimize such potential complications: “To be able to give intravenous fluids to people who are in shock or to give them intravenous drugs, which is by far the most common route of administration of potent drugs of all types today – and for hemodynamic monitoring, measuring pressure and cardiac output in the critically ill – stable vascular access is absolutely fundamental to modern day healthcare,” he says.

Outpatients “There’s a tremendous amount of vascular access now in the outpatient setting, where there was virtually none 30 years ago. Now probably three million to five million patients per year go home with long-term intravascular devices for access for cancer chemotherapy or nutrition – from home IV antibiotic therapy and for a whole range of applications – because one of the more important trends in healthcare in the last 100 years has been the move to manage more healthcare in the outpatient setting that was previously managed in the hospital.”

Managing healthcare in the outpatient setting certainly has its advantages. Firstly, patients can return to their homes, making it significantly less expensive. Secondly, the luxury of long-term devices in a patient’s bloodstream to aid stable vascular access – which didn’t exist a generation ago – is now widely used as all hospitals have patients who are getting home IV therapy of varying degrees. As such, hundreds of companies have emerged specializing in home IV therapy and providing stable vascular access, monitoring the patients and teaching them to ensure that vascular access is done as safely as possible. However, in order for these advantages to become fully viable, a stable and sophisticated infrastructure needs to be built to take care of patients and defend against diseases that prevail in the home, which had been previously taken care of in hospitals.

With an estimated 40 million patients hospitalized in acute care hospitals in the US every year, and a further five million in extended care facilities such as chronic disease hospitals and nursing homes, somewhere in the range of three million hospital-acquired infections occur every year. The dilemma stems from the fact that when you have very sick, very vulnerable patients who are immuno-compromised or have any long-term vascular access issues, invasive procedures can’t be taken care of without taking on further risks.

“Hospital infection control deals with understanding that risk – un-

derstanding exactly what the factors are that allow infection to occur and understanding the pathogenesis of each of these types of infection.

Whether we’re talking about vascular catheter-related bloodstream infection, ventilator-associated pneumonia, surgical site infection, antibiotic associated colitis or understanding the pathogenesis of infection and its epidemiology; how these invasive organisms get to the patient, and what the factors are that allow infection to occur, is fundamental to developing strategies that could prevent infection.”

Maki admits that when he entered this field over 40 years ago, there were very few control programs in place: “They were very primitive, and the whole world’s literature on hospital infections could be carried in a little manila fi le.” Compare that with the 300,000 to 500,000 published studies, research papers and reviews in medical literature today, and it is clear that the field has exploded with interest. Moreover, the overwhelming amount of evidence in the past 25 years depicts a significant decline in the incidents that cause such infections.

“Have we prevented all infections?” asks Maki. “Not by a long shot.

But we’ve reduced the risk enormously, and if we had done nothing, we’d

“There’s a tremendous amount of vascular access now in the outpatient setting, where there was virtually none 30 years ago” probably have 10 million to 15 million infections a year instead of two million to three million. So, infection control strategies that are based on an understanding of pathogenesis and good science have had a huge impact. I think that I will live to see the day where we will have a zero risk in virtually all hospitals, but it’s going to require continued effort to apply what we know in terms of behavioral modification and management of devices plus technology. Technology has a huge promise towards making the fi nal step of getting to zero.”

Technology will, undoubtedly, become essential in carving out a path approaching towards the ‘zero-risk’ of infection. Indeed, there’s already plenty of technology out there that’s proved itself to be useful and cost-effective. The challenge confronting industry experts such as Maki is now to convince hospitals and infection control groups to embrace this technology. It’s been a slow process, but what is obvious to all is that applications of simple technologies have contributed substantially to the progress that has already been made.

Trend setting Given this progression, what strategies and trends are hospitals starting to apply in helping to prevent infections from happening? Well, considering the vast spectrum of hospital-acquired infections, there are specific strategies available for each different type. Keeping it specific to catheter related bloodstream infection, Maki has highlighted four simple factors that he believes will make a big difference.

“One is clear guidelines for when different types of devices are placed, using the right devices for the specific indication. Secondly, maximize precautions when they’re inserted – particularly for central catheters of

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all types, which are the largest proportion of high-risk catheters. Central venous catheters need to be put in by individuals who have operating room sterility.

“Number three is using chlorhexidine for prepping the skin for disinfection of the skin insertion site. Finally, developing strategies to assure that patients who have catheters are scrutinized on whether they need it for further days. If they don’t, it should come out that day and not be forgotten – because a forgotten catheter is a catheter that can cause a

“Research and the relevant scientific studies have already proven three of these factors, which have had a massive impact”

still in the range of two to four bloodstream infections per catheter day.

“They’re not at zero or one,” admits Maki. “Two to four isn’t bad.

It was excellent compared with 10-15 years ago. Two to four is too high today, and with using coated catheters, antiseptic-impregnated dressings for catheters, and possibly by giving patients a total body sponge bath in chlorhexidine once a day, have all been shown to substantially reduce the risk of infection beyond the good infection control practices just discussed. Those are examples of technologies that clearly work.”

And the impact technology has had on long-term devices is just as prevalent. Using an antiseptic or antimicrobial lock solution – when a long-term central or hemodialysis catheter is not in use – allows for a locking of the lumen with a solution that has the antimicrobial activity to kill any organisms that may have gained access and would otherwise multiply and cause invasive bloodstream infections.

Insert here totally preventable, unnecessary bloodstream infection.”

Research and the relevant scientific studies have already proven three of these factors, which have had a massive impact. Achieving a high level of compliance with these simple measures has seen national rates of infection drop by 50-60 percent in many hospitals. One would presume that would be enough to reach the zero mark – but that’s still a long way off. It won’t get you to zero consistently, and looking at national figures published by the CDC in the last two years, 50 percent of US hospitals are

However, irrelevant of long-term or short-term devices, there remains a level of contention between preferred insertion sites in order to keep infections to a minimum – especially in relation to peripheral and central catheters. Fundamentally, catheters below the femoral vein should be avoided at all costs, but realistically there are times when it’s appropriate and desirable to do precisely that. Contrastingly, studies suggest that subclavian insertion sites are a little safer. “While it may be more challenging to gain access there, if people are well trained and we

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have the advantage of using sonography for insertions, it’s possible to put in subclavian catheters with a very low risk of mechanical complications.

It tends to be a more stable device and has a lower risk of infection than an internal jugular catheter.”

The use of needleless access devices remains extremely complex in the current world of infection control. After the AIDS epidemic in the 1990s, there was a shift towards developing engineered controls to reduce the risk of accidental sharps injuries to healthcare workers. One of the biggest potential risks came when connecting IV bags to a patient’s central catheters with a needle that passed through a membrane in the hub of the catheter. As Maki explains, “Needles could become contaminated by blood that refluxed back and result, if they stuck themselves accidentally, in becoming HIV or Hepatitis B or C contaminated – causing a serious infection in the healthcare worker.”

Ironically, Maki’s research on needleless connections discovered that the valvedluer-activated connectors developed to protect healthcare workers may in fact be putting patients at an increased risk of bloodstream infection. “These valved systems have complex internal workings, and research that we and others have done has shown that they readily become contaminated with the biofi lm – microorganisms that get access into the fluid stream, through the catheter and its valve and can contaminate the entire valve apparatus – shedding organisms and causing a bacterium.”

As such, connectors from different manufacturers have been implicated. “It’s many different brands, and it appears to be a potential generic problem,” admits Maki. “There’s urgent need for better research, as there are promising technologies where it’s possible to coat the internal surfaces of the connector with a powerful antiseptic coating that can prevent biofi lm formation. The bottom line is that we don’t have as good a grasp on the magnitude of the problem as we would like to have, and because of the fear there’s recently been a recommendation from ACDC suggesting the abandonment of valve connectors.”

What remains unclear from the recommendation is whether or not to return to the old split septum connectors, as there’s a strong possibility that they could also be problematic. “We just don’t know that with certainty because it’s not been adequately studied. So, the use of needleless connectors is sort of a conundrum. We don’t have as good a grasp on the magnitude of the problem or especially what circumstances of use in a hospital allow contamination and bloodstream infections to occur, which is a very important area for future research.”

“The research that’s needed to develop those that have not been adequately studied to better understand how effective they are – or are not – and to provide adequate data that, if effective, will convince the practicing medical community that it’s time to embrace these technologies.”

The evidence would indeed suggest that coating catheters with a reliable antiseptic is one way forward, with at least two different catheter types showing a risk reduction of over 50 percent. Yet fewer than 10 percent of central catheter patients in the US are offered coated catheters.

“These technologies have been out there for 10-15 years, and to me it’s been frustratingly slow.

“A good example in another field would be patients who have an anterior myocardial infarction. Studies were done 25 years ago showing that if you could re-establish flow with a thrombolytic such as streptokinase or TPA to break up the clot, you improve survival in patients who had anterior myocardial infarction. This technology has been out there since the early to mid-1980s, yet for the first 10 years far less than half the patients who came into the big MI had this technology used in their care. It took 10-15 years until it really started to get embraced and practiced widely.

“Today, it’s part and parcel of a patient coming in with an acute anterior myocardial infarction that they’re going to either have an angioplasty or thrombolytic, unless they’re in a remote area where they can’t get to anything resembling modern day secondary tertiary healthcare, or unless there are compelling contra-indications, because it’s so clear it’s beneficial.”

Maki clearly feels that infection control technologies need to reach that same stage, as he continues by stating that during his time as a critical care physician, not to mention as Head of Infection Control, he has witnessed an inexorable increase in the survival of patients with critical illnesses over the last 30 years as a result of applying these modern technologies.

However, in order for a measurable and sustainable improvement in healthcare through technology to prevail, there are three simple challenges Maki is keen to highlight. “One is the need to devise it and have a good idea. Two: you need to show it works. It reduces disease and it’s cost effective. Even though it’s a premium cause for it, you’re going to save money in the long run because you save lives and reduce complications.

“Thirdly, you need to get it adopted widely. We’re at this transition between steps two and three in infection control. We’ve got a long way to go before we can have the wholesale option of proven technologies to really make a big difference. I hope I live to see that day.”

It is clear that the future of infection control, and the steps needed to be taken towards the zero mark both in the US and worldwide, will stem from the ability of industry thinkers like Dennis Maki to push the envelope and combine dedicated research, innate understanding and adaptable technology to combat the unnecessary number of patient deaths attributed to preventable infections. Until that time, continuing to battle standards of infection control proactively and transparently remains the only way forward. Simplicity, in this context, truly is the best medicine.

3 million to 5 million patients per year go home with long-term intravascular devices

Future research Leaning on the time-honored adage of always looking ahead, future research will be pivotal if reaching a zero rate of infection is to become anywhere near a reality. Almost any way of modifying the design of an intravascular device or how it’s used whether in relation to a sterile, antiseptic dressing, a disinfectant for prepping the skin, coating the catheter or talking about a lock solution – all of these intuitively conceived strategies have already been studied and shown to work.

Dennis Maki, MD, is a Professor of Medicine and Head of the Section of Infectious Disease at the University of Wisconsin-Madison Medical School.

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COMMENT

Making positive change last longer Richard Karl on why implementing a cultural transformation around patient safety requires more than just a few training programs.

A

t least two major university hospitals in the United States have invested in a form of crew resource management (CRM) training in the hopes of improving patient safety only to be frustrated by modest results of uncertain permanence. Why? Why is it so hard to change culture in the fi rst instance and even more difficult to sustain any positive change for long? Psychologists and industrial engineers will know far more about the reasons than I, a cancer surgeon and pilot, do, but I’ve got a suspicion that those of us interested in safety are seeing only a small part of the safety challenge and, as a result, our attempts are too narrowly focused and our effort is exerted over too short a period of time.

If one polls students immediately aft er CRM training in surgical settings, most nurses, residents, technicians, surgeons and anesthesia providers get the essence of the message. Their awareness of human factors, red fl ags signifying times of increased risk, methods of communication and cultural and hierarchal effects is relatively good. A year later, with some exceptions, most places have returned to business as usual. If the institution is unlucky, an administrative or fi scal officer will conclude the CRM training is of no value and any further efforts at improving patient safety will be shelved until the next patient gets the wrong side of the brain opened. Then there will be a great deal of effort expended on managing the public relations horror show that ensues.

Much like a good anti-cancer drug that is abandoned for lack of efficacy after a phase ı trial in a small number of moribund patients, CRM might never get the chance to make a contribution in healthcare, as opposed to other industries where it has. Very likely, little introspection or interest in looking to other high reliability industries for helpful guidance will be expended.

If one were to look to commercial aviation, for instance, a wide variety of tools and techniques are routinely employed to create, promote, manage and sustain a culture of safety. Airlines start by looking at emotional intelligence as well as traditional skills in

their pilot applicants. Pilot training is constantly reinforcing the need and expectation for safety. Recurrent training every six months back at headquarters provides another opportunity for practicing and emphasizing CRM skills. Checklists, minimum equipment lists, dispatch calculations, and lots of other tools, both obvious and subtle, continue to ring home a message of safety.

“If one polls students immediately after CRM training in surgical settings, most nurses, residents, technicians, surgeons and anesthesia providers get the essence of the message” The recent worldwide medical excitement over a positive study demonstrating that the use of checklists in operating rooms can improve communication between nursing, surgery, and anesthesia and save lives bears great promise. But it is also possible that the excitement will die down, that the use of checklists will enjoy a momentary popularity only to slide back down the slope of chaos that surrounds most surgical operations, leaving us right back we started.

The fact is it isn’t just a checklist and it isn’t just CRM; it is all that and more, including routine line assessments as to how these skills and tools are being used day in day out by the people who have sharp objects in their hands. It is only by doing it all will we become safer and fi nally honor the responsibility that each of us, whether we be an administrator, an accountant, a nurse, or a surgeon, bears towards the patients who have entrusted us with their lives.

Richard Karl is Founder and Chairman of the Surgical Safety Institute.

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Paulk Ed_16 nov 23/03/2010 09:54 Page 120

RECRUITMENT

PROMOTING FROM WITHIN Pamela Paulk offers her expertise on the advantages of promoting internally and her perspective on the potential future transparency of employers.

By Nick Pryke

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W

ith the phrase ‘current economic climate’ becoming a staple in almost every industry’s vocabulary, recruitment and HR divisions have had to tackle severe financial and employment issues. In addition, with more graduates returning to academic study to cushion the blow of such a poor job market, employers are finding it difficult to re-establish the balance between bringing in new blood and developing staff internally; nowhere does this feature more prominently than in the healthcare and clinical industries.

Combine this with the battle for the recent US healthcare reform bill, and it becomes clear that something has to give. Pamela Paulk, Vice President for HR at Johns Hopkins Hospital, believes precisely that. “There is now and continues to be a real shortage of skilled care,” expands Paulk.

“We’re going to have many more people who are going to be appropriately accessing the healthcare system. And it’s a healthcare system that’s already facing shortages and already facing often long wait times, so it’s just going to exacerbate that problem.

“What the current economy has done, I think, is to make things worse because it’s a temporary blimp. People who were going to retire have decided to stay in the field a little bit longer and people who were part-time have added to their hours. And to some extent, there are people not doing elective surgeries and things like that. So for right now, we feel like we have a pretty good balance. Our vacancy rates are low. Our turnover rates are low. But I think that that’s temporary.

“What’s happening now is that because it’s that way, people are going to say, ‘Well, maybe I won’t go into healthcare. It’s not as guaranteed as I thought it was.’ And we’re going to wake-up two to three years from now and we’re not going to have the number of graduates that we need. I keep telling my colleagues that we have to continue to be vigilant about this. We have to continue to train and advance the professions because it’s going to be worse for us in a few years.”

Indeed, with many companies and HR specialists considering the situation to be better than originally forecast, people seem to be taking a metaphorical breather and overestimating their current workforce numbers; but as Paulk correctly points out, it’s in the long-term that the real problems will start to emerge. To combat this, Johns Hopkins – alongside other institutions – attempts to nurture potential and develop staff internally wherever possible.

“I’m a real believer in developing your staff internally if you possibly can. The reason for that is most turnovers occur in the first year and often that’s because of poor fit. It may be fit with the culture; it may be fit with the supervisor; it may be fit with the particular job. It may be any number of things.

“If you have an employee who’s already worked with you for a number of years, you know that they fit the organization; they fit the culture of the organization. They know who their supervisor’s going to be. To me, it’s such a better investment to take somebody who is already loyal to your institution and train them to stay with the institution, versus bringing someone in from the outside, when you don’t know if they’re going to even make it past that first year or not.

Conversely, many other institutions will argue that there are plenty of skilled people out on the market with vast amounts of potential who deserve the opportunity. And that’s absolutely true, but Paulk maintains that this perspective sends out the wrong message. “We send the message that outside is better than helping our employees who are already here. And, again, it goes back to the loyalty factor.

“What I do think, is that it would be physically unsound to continue to spend all this money to train people internally when there are great people on the outside to bring in. What you do instead is cut back somewhat. If every year we were taking 20 of our employees and training them, giving them time to an Hum for t iden Pamela Paulk is Vice Pres kins Hospital. become nurses; maybe we just cut back to five or 10 for a couple of years and Resources at Johns Hop then go back to the 20 in later years. But I don’t think you can stop it. If you stop it all together then it’s very hard to put back in place. And I think you’re sending the wrong message to your staff.”

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So what about those who are lucky enough to be offered such positions?

With the ratio of applicants to job positions being extraordinarily high, it has left a silver lining in the cloud of recruitment for employers, allowing them to be far more selective with a higher concentration of quality candidates in the job market.

“We used to get 8000 applications a month. Now we’re getting close to 10,000. So, you think about it and say, we had plenty of applicants before. We have plenty of applicants now. The difference is that we’re getting really great people.

In some, the selection is harder because before, maybe you had 10 really great people to choose from, now you have 20 great people to choose from.

“It’s a good place to be. We’re happy about that. But again, it goes back to loyalty. Those folk who are out on the job market right now who are highly qualified; they’re coming to us, but they may not be the people who stay, because as soon as the job market picks up they may choose to go back to something they were doing before. In some cases, they’re really well qualified because they’re accepting jobs that might be less than what they really want. As soon as the economy picks up, they’re going to go back to those jobs. I’m not saying everybody, but some people might. Whereas, the loyal worker that you trained up is not going to do that.”

“We feel very, very strongly that that is our business and so you can’t sacrifice one for the other. Hopkins is an almost 125-year institution, built on a culture of innovation and giving; it’s philanthropy. The minute we stop caring for people and taking care of the people who take care of people then we don’t have a business any more.”

Inspiration This notion of ensuring the people who care are cared for on the most fundamental level is more than just part of the culture of Johns Hopkins. In June of 2009, Paulk became part of a 16-patient ‘domino donor’ kidney transplant system and helped donate a kidney to a colleague and friend. While she is keen to highlight that she did it for personal reasons, it has certainly left an inspirational footprint on the hospital and its staff.

“I’ll tell you where I think it has made a difference,” offers Paulk. “I think people know beyond a shadow of a doubt that I genuinely care about them. It doesn’t matter who you are in the institution. Where that helps me is when I have to give somebody bad news or talk to somebody about their behavior, they know it’s coming from an absolute place of sincerity and authenticity.”

Low risk The loyal worker seems to become the logical and safe choice for many HR departments. But considering a candidate for internal development training is no simple task; in order for the risk for failure to remain as low as possible, the intangible assets of a member of staff need to be just as strong as their technical capabilities.

“We want someone who not only meets all the check boxes of being technically qualified, but who also fits the values and culture of the organization. That might be a little harder to get to, but we’ve trained our managers in what to look for. For every employee we have here, 30 percent of their job description – which means at least 30 percent of their evaluation – is customer service. So they can be technically the best person around, but if they’re rude, if they’re not friendly – then they don’t fit our culture and we wouldn’t want to hire them.

“If we have an employee who we know doesn’t have those intangible things, we’re not going to invest in them. So before we put you into our training program we have a series of assessments that you have to go through. A lot of the assessments have to do with not only your aptitude and your skill, but your attitude, what you really want to do, what you really enjoy. We won’t train someone for something that they’re not a very good match for.

“We also have a pre-employment screen that looks at the intangibles such as if they are team players; if they are customer service-orientated; if they are flexible and adaptable. Every applicant has to fill out that survey, and then we get the ratings on them as to where they stack up, where their strengths and weaknesses are.

And, again, managers use that.”

However, Paulk isn’t for a second suggesting that Johns Hopkins has a ‘cutoff’ point in terms of scoring below a certain amount. Instead, the assessment serves as a guideline for managers to look at and gage whether or not a candidate is likely to fit into their culture; a combination of their intangibles and what Paulk refers to as their ‘working attitude’. Indeed, the Johns Hopkins motto of “People…caring for people…caring for people…one person at a time” speaks volumes for their HR department.

“Those folk who are out on the job market right now are highly qualified, but as soon as the market picks up they may choose to go back to something they were doing before”

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Even with such a compassionate force driving the HR routes of Johns Hopkins Hospital, more aggressive tactics are predicted for the future in order to embrace the emergence of technology and social media; the more traditional approaches of past generations will undoubtedly not be enough to compete with potential employees expecting more transparency from potential employers.

“I believe that social networking will be huge. Part of the reason for me doing the blog and Twitter for my kidney donation was because I had been talking to our PR people about how we would use it in HR. So, it was a good way for me to try it out and get a sense of it. And I am absolutely amazed by the power of that medium. We’ve bought flip cameras that plug right into our computers, so we’re playing with that at the moment to make our recruitment more friendly.

“When somebody clicks on a job, instead of just seeing the job description, they’ll get a video of someone who does the job. We haven’t totally mastered that yet, but that’s just some of the media that we could use. We’re finalizing guidelines on the use of social media by employees because it’s ripe with problems of violations of confidentiality. I thought it was important to encourage that because we know it’s coming and we may as well figure out how to use it.

“The traditional forms of recruitment are going to get less and less important, which means we’re going to have to learn new skills. Traditionally, you go to colleges, job fairs or put ads in to professional magazines; all that stuff is going to become passé in time and it’s going to be based more on social media. I’m an absolute believer that the demographics are going to cause far more demand; the supply is going to begin to critically diminish over the next decade or so, so I think you’re going to have to try and reach people in very unusual ways.” n

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REGIONAL FOCUS 124

FIGHTING A NEW

COLD WAR The battle to provide good healthcare in post-Soviet Russia continues.

T

he Russian Federation encompasses 83 federal subjects. At 6,592,800 sq miles, Russia is by far the largest country in the world, covering more than a ninth of the Earth’s land area. Russia is also the ninth most populous nation in the world with 142 million people.

Pre-1990s Soviet Russia had a totally socialist model of health care; a centralized, integrated, hierarchically organized system with the government providing free health care to all citizens. Despite weaknesses, the integrated model achieved considerable success in dealing with infectious diseases such as tuberculosis, typhoid fever and typhus.

The new Russia has changed to a mixed model of healthcare with private fi nancing and provision running alongside state fi nancing and provision. Article 41 of the 1993 constitution confi rmed a citizen's right to healthcare and medical assistance free of charge,

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REGIONAL FOCUS 125

achieved through compulsory medical insurance rather than just tax funding. Th is and the introduction of new free market providers were intended to promote both efficiency and patient choice.

Unfortunately, none of this has worked out as planned, and the reforms have in many respects made the system worse. Despite the fact that Russia has more physicians, hospitals and healthcare workers than any other country in the world, the health of the population has significantly declined since the collapse of the Soviet Union.

In contrast to the wealth and prosperity of those who live in cities such as Moscow and St. Petersburg, life in the rest of the country remains harsh and short. Life expectancy for males is 61.5 years, which is considerably lower than the fi figures gures for the European Union. The reason for thiss is thought to lie mainly in the high mortalityy Male life rate of working-age males, who succumb expectancy to preventable conditions such as alcohol poisoning, stress and smoking.

Russia is Heart disease accounts for 56.7 percent of total deaths, with approximately 30 percent involving people still of working age. oAbout 16 million Russians suffer from cardion the vascular diseases, placing Russia second in

Moscow Moscow is Russia’s capital and is the largest city in the country. It is also the largest metropolitan area in Europe and ranks among the largest urban areas in the world. Moscow plays home to a large number of the world’s billionaires; the emergence of a market economy has produced an explosion of Western-style retailing, architecture and lifestyle. It is rich in culture, most notable is the Tretyakov Gallery, The Bolshoi Theatre and Moscow International House of Music. It also encompasses 96 parks, the world-renowned Saint Basil’s Cathedral and the park Tsytsin main Botanical Garden of Academy of Sciences.

Tsyt

in

61.5 years

world, after Ukraine, in this respect. HIV/AIDS, which was virtually non-existent in the Soviet era, rapidly spread following the collapse, mainly through the explosive growth of intravenous drug use, and cases of and deaths from tuberculosis have also increased.

Pharmaceuticals The Russian government’s drug reimbursement program encouraged an increase in drug consumption and medicine sales and this trend is expected to continue in 2010, according to a report from Frost & Sullivan. The healthcare industry will also benefit from the country’s aging population as well as an increase in disposable income, consumer spending, demand for healthcare products, and government funding for drugs through a new health insurance system.

As imports account for nearly 60 percent of the total volume of the Russian pharmaceuticals market, the government has been trying to lower the reliance on western drugs by giving an impetus to the local production, mostly of generic drugs, which is a market with tremendous potential.

The government is also actively encouraging the biotechnology sector, as part of the country’s economic modernization plan.

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EVENTS_EHM_FEB10 23/03/2010 09:34 Page 126

INTERNATIONAL EVENTS 126

A roundup of upcoming conferences and events across the globe.

Munich

Dallas

Seoul

11th European Symposium on Controlled Drug Delivery April 7 – 9, 2010

Global Healthcare & Medical Tourism Conference 2010 April 13 – 16, 2010

Strategies Against Counterfeit Medicines April 26 – 28, 2010

Hotel Zuiderduin Egmond aan Zee, The Netherlands www.escdd.eu

Coex Intercontinental Seoul Seoul, South Korea www.asiamedicaltourismcongress.com/in dex.php

Maritim Hotel Wurzburg Wurzburg, Germany www.counterfeit-conference.org

ADMET Europe April 8 – 9, 2010

Next Generation Pharmaceutical Summit April 26 – 28, 2010

Armada Speciality Pharmacy Summit May 4 – 7, 2010

The Boulders Resort Scottsdale, AZ www.ngpsummit.com

The Wynn Hotel Las Vegas, NV www.armadasummit.com

Holiday Inn, Munich City Centre Munich, Germany www.selectbiosciences.com/conferences/A DMET2010

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INTERNATIONAL EVENTS 127

London

St. Petersberg

Las Vegas

Dubai

RNAi & miRNA World Congress May 5 – 7, 2010,

Russian Pharmaceutical Forum May 19 – 21, 2010

APS - FIP Vaccines 2010 June 8 – 9, 2010

Boston Park Plaza Hotel and Towers Boston, MA www.selectbiosciences.com/conferences/R NAiWC2010

Corinthian Nevsky Palace St. Petersburg, Russia www.adamsmithconferences.com

Royal Pharmaceutical Society of Great Britain London, UK www.apsgb.co.uk/Events/20100608/defau lt.asp

Next Generation Healthcare Summit 2010 May 17 – 19, 2010 The Four Seasons Resort & Club Dallas, TX www.nghealthcaresummit.com/

Hospital Build Congress June 1 – 3 June, 2010 Dubai International Convention and Exhibition Centre Dubai, United Arab Emirates www.hospitalbuildme.com/Exhibition/Datesandvenue/

Population Health Management June 21 – 22, 2010 Royal on the Park Brisbane, Australia www.populationhealth.com.au

PHOTO FINISH 128 An Indian woman lifts a container for drinking water in Mumbai on World Water Day, March 22, 2010. The UN has kept clean water for a healthy world as its theme this year.

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