Asheville – Mission Hospital’s Plan of Correction (POC) is intriguing because it provides the general public with its first view of the Centers for Medicare and Medicaid Services (CMS) writeup that put the hospital in “immediate jeopardy” of losing funding. It is agonizing to read how patients suffering a hypertensive crisis, pain rated as a 10 on a scale of 1 to 10, or critically high blood glucose levels, had to wait sometimes seven hours in the hospital before any action was taken. The protracted episodes of pain and suffering have, in fact, buried the POC in mainstream news reports.
Regardless, the POC is substantive, going beyond one-size-fits-all corporate jargon. To address one of the most significant shortfalls evident in the accounts: staffing shortages, Mission is hiring not only nurses but also creating positions to better coordinate staffing and manage demand surges. It also instituted triggers for increased staffing that look not only at the number of patients a nurse serves but also at the acuity of those patients’ needs. To help right-size staff in response to the fluctuations in patient volume, it is monitoring demand for nurses on a four-hour cycle. It is also utilizing more rapid-travel nurses and paying a premium to nurses who want to “pick up in the ED above their current commitment.”
At no time in the narratives did staff appear to be disengaged or disinterested. They were just overwhelmed.
The hospital reorganized the emergency room to streamline workflow. It tried out a few patterns before settling on the current configuration with one-stop intake. Overflow patients in the halls continue to be a problem. For one thing, halls are not equipped with heart monitors, and IV or oxygen delivery can be awkward in a fast-paced emergency department. The CMS report included a story of a girl on the autistic spectrum leaving her room and violently pulling the hair of patients “on the wall.” To help, the hospital reopened a section that was going to undergo renovations and added 20 beds elsewhere. They also improved surveillance of “wall” patients.
At a fundamental level, in recent years, staff members have had to scurry around looking for items as basic as telemetry boxes, and then introduce more delays looking for leads. It was as if nobody understood the concept of a “place.” The report indicates the hospital has now organized and set up a Critical Supply Room and standardized its supply carts. Following an inventory and assessment, the hospital ordered four more portable heart monitors and three more vital sign machines. It even designated a place for discharge papers.
To address bottlenecks in phlebotomy specifically, the hospital “added new analyzer functionality” to all lab stations and expanded and reorganized the floorplan for better ergonomics. They even created a position for a sample bottle stocker. Changes were made to streamline and reduce errors in getting patients their medications as well.
These changes should help all patients. The cases in the CMS write-up, however, appear to pertain to patients falling through the cracks. Mission responded with several instances of education and training for staff. In addition, the hospital now requires vitals to be monitored at set intervals, and it even changed the visuals in care team software to make important data stand out. This will likely help patients more than supplying more data to busy professionals who don’t have the time or bandwidth to read what is already available.
Not to minimize each and every excruciatingly painful account, the copy of the report made public does not provide context. It would be important to have a better sense of mortality rates at Mission, adjusted for the complexity of patients’ needs, and how that compares to other hospitals.
According to Becker’s Hospital Review, HCA is the largest hospital system in the country. It has the financial and legal resources to acquire the best technology, so it should be able to attract the brightest and most-experienced physicians and support staff. If well managed, Mission should reap the statistical benefits that accrue from high-volume procedures.
Even so, the Journal of Patient Safety reports that, on average, 210,000 people die in US hospitals each year from preventable medical mistakes. Another 230,000 die from misdiagnosis or errors of omission. Approximately 1.2 million US hospital patients are harmed by medical errors. There are currently 6,129 hospitals in the country. It should go without saying that doctors are neither omniscient nor infallible, and the state of the medical art is still evolving and far from complete. It just doesn’t feel that way anytime somebody dies.