By Lola Butcher
Providers are addressing alarm management with the following strategies:
What does too much information sound like?
Try 942 high-priority monitor alarms per day on a 15-bed unit. That is what The Johns Hopkins Hospital found when it sought to understand its alarm environment. "I call it a cacophony of sound because you have horns and beeps and buzzes and all kinds of noise," says Maria Cvach, MS, RN, assistant director of nursing of clinical standards at Johns Hopkins.
Johns Hopkins is by no means alone. During a 24-hour period at Boston Medical Center (BMC), patients and staff in a single unit heard 2,489 cardiac arrhythmia alarms. The vast majority-some 1,600-were clinically insignificant; 743 were "warning" alerts of a potential problem, and 70 were "crisis" alarms that called for immediate attention.
"It causes alarm fatigue," says Jim Piepenbrink, director of clinical engineering at BMC. "People get desensitized to alarms and they may overlook a crisis tone."
All that noise is not just annoying; it can be deadly. Alarm fatigue-along with malfunctioning or disconnected alarms and other alarm safety issues-contributed to more than 500 patient deaths between 2005 and 2008, according to a report by the Association for the Advancement of Medical Instrumentation.
Eliminating unnecessary noise is also important to patients' recovery and may influence hospital revenues. Through its value-based purchasing initiative, Medicare is evaluating each facility's scores on the HCAHPS patient satisfaction survey, which includes this question: "During this hospital stay, how often was the area around your room quiet at night?"
Addressing the problem of alarm safety is both simple and complex. Relatively easy, low-cost fixes can significantly reduce noise. However, to truly understand, manage, and address alarm safety issues, healthcare leaders need to adopt a C-suite-endorsed, systematic approach that enlists a great amount of time and effort from a wide group of stakeholders.
Ironically, problematic alarms are often attached to medical devices that are critical to saving patients' lives, such as telemetry monitors, ventilators, infusion pumps, and dialysis units. Hospital alarms associated with these devices top ECRI's report, Top 10 Health Technology Hazards for 2012.
While many hospitals are proactively working on alarm safety to prevent problems, many others are not doing anything about the cacophony, hoping they do not experience an adverse event. "There are many, many hospitals that are taking a reactive approach," says Kathryn Pelczarski, director of applied solutions at the ECRI Institute.
In its report, ECRI identified several specific alarm issues that endanger patients. In addition to becoming desensitized to the noise, nurses and other staff members sometimes adjust alarm limits outside the appropriate range-or turn the volume too low-to reduce noise stress on patients and family members. In addition, staff may not recognize urgent alarms or be able to tell which device is issuing an alarm because so many alarms are occurring in close proximity to each other. There is also the issue of whether alarms accurately notify the appropriate staff person via pager or wireless phone.
Access related sidebar: What Causes Alarm-Related Adverse Incidents?
The full scope of the problem is not yet known because hospitals do not currently report alarm data to any outside agency. But that eventually may change: The Food and Drug Administration and The Joint Commission announced last year that they are jointly working on a strategy to address alarm fatigue. This spring, The Joint Commission also conducted a survey of healthcare facilities to collect information about clinical alarm management, with the goal of identifying best approaches for addressing the issue. According to the survey introduction, "accreditation requirements" is one option under consideration.
Unlike many patient safety issues, the concept of "best practices" for alarm safety is not well-developed, although there are some common strategies that all hospitals can adapt as they determine the best way to improve alarm management in their organizations, says Pelczarski. "You really need to take an introspective look at the culture, infrastructure, practices, and technologies within your own organization-and within each patient care area-because making alarm management safer is really a very complex issue, she says.
Setting device parameters. Johns Hopkins began addressing alarm safety in 2006 through a quality improvement project on a medical progressive care unit. By conducting small tests of several interventions, the project team reduced the number of monitor alarms by 43 percent-and identified ways to make changes in other units throughout the hospital.
"The lessons we learned are that you need an infrastructure within your institution, support from administration, and an interdisciplinary approach," says Cvach.
The hospital's Alarm and Monitor Subcommittee-which includes physicians, nurses, respiratory therapy staff, clinical engineers, IT staff, and human factors engineers-is a standing committee that reports to the Critical Care Committee. The group wrote a cardiac and physiologic monitor policy, which is updated regularly, and works to standardize the operation of alarms and monitors throughout the hospital. For example, cardiac monitor software has been standardized throughout the hospital and acceptable secondary alarm notification systems have been defined.
Beyond that, Cvach worked with two physician leaders-the vice president of medical affairs and the chair of the Critical Care Committee-to create an Alarm Management Committee that examined the default parameters for alarms on every monitored unit in the hospital.
Manufacturers of devices and monitors often provide dozens or even hundreds of parameters that can be set to determine when an alarm sounds. "Unit managers are supposed to figure out the parameters if they don't want to use the manufacturer's defaults. The problem is that most people don't have enough information to make an informed decision about what parameters to choose," says Cvach.
The physician-led Alarm Management Committee revised these parameters so that nurses would only be alerted to actionable alarms. "In other words, when you hear an alarm, you're going to do something about it," she says. "You're not going to ignore it. That's what our focus was."
The same committee also developed criteria for which patients should have continuous versus intermittent physiological monitoring, and it is currently working on recommendations for when those monitors should be discontinued.
Despite the work to standardize alarm management, Johns Hopkins leaders recognize that alarm safety cannot be accomplished by forcing a one-size-fits-all approach. That's why the hospital's Alarm Management Committee provides a list of options. For example, when the hospital opened a new patient care building, unit nursing leaders were given three notification choices, using an alarm escalation scheme:
Given the choices, various units are using different strategies. For example, on the new 40-bed pediatric ICU, unit leaders chose to have designated nurses receive secondary alarm pages. "Nurses are going to receive primary alarm notifications from the bedside monitors. However, if an alarm is not addressed in a set timeframe, designated nurses will receive zone alarms through a pager," says Cvach.
Meanwhile, the nurse leaders on the cardiac progressive care unit chose a unit-based monitor watch approach because of the high-risk patients being treated for cardiac abnormalities. Trained technicians will observe patient monitors 24 hours a day and inform nurses via wireless phone of arrhythmias or technical issues requiring attention.
Focusing on arrhythmia patients. At Boston Medical Center (BMC), Piepenbrink's clinical engineering staff first spotted the variance in alarm defaults when it started assembling a database of all the hospital's medical devices and their default settings. A task force of physicians and nurses was recruited to identify where the variance presented a patient safety issue, and arrhythmia alarms topped the list.
"The group ran with that, and we identified the best strategy for ensuring that all arrhythmia devices are standardized," says Piepenbrink. "We changed the alarm defaults to make them uniform and, in concert with that, we provided staff education on why we were making the change."
In addition to reducing noise, BMC is working to ensure that bedside nurses know when telemetry patients need help. Typically, at BMC, alarm notifications are sent to the central nursing station. But nurses are often away from the station, taking care of patients. So they may not know that a particular patient's alarm went off. To curtail that problem, flat panel displays that show and sound alarm activity are being installed in locations throughout each telemetry unit.
"Staff will be able to hear alarms better but also, instead of walking all the way to the central station, they will be able to go to substations to have a look and see what the alarm is about," says Piepenbrink.
The flat panel displays are expected to improve the care of monitored patients at a nominal expense. "The caution I have for those who tackle the alarm issue is this: Be careful about what you throw at this in terms of capital investments," says Piepenbrink. "There are a lot of solutions out there for alert management and distribution, but if the process of alarm management is broken, additional technology will magnify the problems."
Although patient safety is its first goal, BMC leaders also are focused on patient satisfaction. Piepenbrink's holy grail is to methodically and safely eliminate clinically insignificant alarms so that patients can rest during hospital stays. "We know that this is not going to happen overnight," he says. "It is a gradual thing, and the reason is that we don't necessarily know what is a good alarm versus a bad alarm because every patient is a little different."
BMC's task force is now systematically reviewing monitors throughout the hospital to look for alarm settings that can be safely changed. The hospital is comparing alarm data from its monitor manufacturers with its own patient data to analyze false positive alarms and identify opportunities for improvement.
Meanwhile, Johns Hopkins discovered one easy way to reduce meaningless alarms: Change the ECG lead electrodes attached to patients every day. While many monitor manufacturers recommend a daily electrode change, it is not generally practiced. When Johns Hopkins tried it on one unit and saw the number of daily alarms drop by 48 percent, Cvach was incredulous.
"We didn't believe it, so we decided to repeat it on a different unit with different staff," she says. "This time, we saw almost a 50 percent reduction in alarms-just by changing electrodes."
Cvach says the effect may stem from several factors, including better skin prep, fresh electrodes that deliver high-quality tracings, or better skin-electrode contact. "Regardless, the benefit of changing electrodes daily in reducing nuisance alarms outweighs the pennies it costs to replace electrodes," she says. Thus, Johns Hopkins is rewriting its policy to require daily electrode changes for all adult patients.
Another simple fix: Asking clinicians to think about whether a patient needs a monitor. At BMC, the computerized order entry system is embedded with decision support regarding the appropriate use of telemetry. "This helps ensure that patients are using telemetry for an appropriate period of time instead of just keeping them on for no apparent reason other than convenience," says Piepenbrink.
Those examples show that alarm safety can be improved in some ways without major expense. In some cases, hospitals may need to hire people specifically to monitor alarms or invest in an alarm integration system that directs all or a subset of alarms to a clinician's wireless device, but those high-cost solutions are not always the right choice.
"A lot of the simple strategies for improving alarm management are really process issues," says ECRI's Pelczarski. "There are many things you can do to improve alarm management that are not cost intensive."
Lola Butcher is a freelance writer and editor based in Missouri.
Interviewed for this article (in order of appearance): Maria Cvach, MS, RN, is assistant director of nursing, clinical standards, The Johns Hopkins Hospital, Baltimore (email@example.com). Jim Piepenbrink is director of clinical engineering, Boston Medical Center, Boston (Jim.Piepenbrink@bmc.org). Kathryn Pelczarski is director, applied solutions, ECRI Institute, Plymouth Meeting, Pa. (firstname.lastname@example.org).
The Claro Group: Partnering for Performance Improvement
In this Business Profile, Larry Volkmar, a managing director in the performance improvement
practice at The Claro Group, discusses key strategies for improving
clinical and financial performance.
Deloitte: Taking Data Analytics to the Next Level
In this Business Profile, Christine Santos, chief of strategic business analytics for
Providence Health Services and Chris DeBeer, principal at Deloitte
Consulting LLP explain the value of enterprise data analytics.
PatientMatters: A Patient-Centered Financial Experience
In this Business Profile, Sheila Schweitzer, founder and CEO of PatientMatters, offers insights
on ways hospitals and healthcare systems can address rising patient
Cerner RevWorks: Helping Providers Boost their Bottom Line
In this business profile, Jason Rawlings, vice president ambulatory
and revenue cycle for Cerner talks about leveraging third-party
management services to improve revenue cycle health.
The Claro Group: Transforming Clinical Documentation Improvement
In this business profile, Tim Marshall, managing director at The
Claro Group, discusses the value of rethinking and retooling clinical
Ontario Systems: Maximizing Self Pay Collections
6 Patient Revenue Cycle Metrics You Should Be Tracking (and How to Improve Your Results)
Patient financial engagement is more challenging than ever – and more critical. With patient responsibility as a percentage of revenue on the rise, providers have seen their billing-related costs and accounts receivable levels increase. If increasing collection yield and reducing costs are a priority for your organization, the metrics outlined in this presentation will provide the framework you need to understand what’s working and what’s not, in order to guide your overall patient financial engagement initiatives and optimize results.
10 Ways to Reduce Patient Statement Volume (and Reduce Costs)
No two patients are the same. Each has a very personal healthcare experience, and each has distinct financial needs and preferences that have an impact on how, when and if they chose to pay their healthcare bill. It’s no longer effective to apply static billing techniques to solve the complex challenge of collecting balances from patients. The need to tailor financial conversations and payment options to individual needs and preferences is critical. This presentation provides 10 recommendations that will not only help you improve payment performance through a more tailored approach, but take control of rising collection costs.
Reduce Patient Balances Sent to Collection Agencies: Approaching New Problems with New Approaches
This white paper, written by Apex Vice President of Solutions and Services, Carrie Romandine, discusses the importance of patient segmentation and messaging specifically related to the patient revenue cycle. Applying strategic messaging that is tailored to each patient type will not only better educate consumers on payment options specific to their billing needs, but it will maximize the amount collected before sending to collections. Further, targeted messaging should be applied across all points of patient interaction (i.e. point of service, customer service, patient statements) and analyzed regularly for maximized results.
The Future of Online Patient Billing Portals
This white paper, written by Apex President Patrick Maurer, discusses methods to increase patient adoption of online payments. Providers are now seeking ways to incrementally collect more payments due from patients as well as speeding up the rate of collections. This white paper shows why patient-centric approaches to online payment portals are important complements to traditional provider-centric approaches.
Payment Portals Can Improve Self-Pay Collections and Support Meaningful Use
Increased electronic engagement between healthcare providers and patients provides significant opportunities for improving revenue cycle metrics and encouraging patients to access EHRs. This article, written by Apex Founder and CEO Brian Kueppers, explores a number of strategies to create synergy between patient billing, online payment portals and electronic health record (EHR) software to realize a high ROI in speed to payment, patient satisfaction and portal adoption for meaningful use.
Large Health System Drives 10% UP (Patient Payments) and 10% DOWN (Billing-related Costs)
Faced with a rising tide of bad debt, a large Southeastern healthcare system was seeing a sharp decline in net patient revenues. The need to improve collections was dire. By integrating critical tools and processes, the health system was able to increase online payments and improve its financial position. Taking a holistic approach increased overall collection yield by 10% while costs came down because the number of statements sent to patients fell by 10%, which equated to a $1.3M annualized improvement in patient cash over a six-month period. This case study explains how.
ICD-10: Managing Performance
With the ICD10 deadline quickly approaching and daily responsibilities not slowing down, final preparations for October 1 require strategic prioritization and laser focus.
Clarity Drives Collections
Read how Gwinnett Medical Center provides clear connections to financial information, offers multiple payment options for patients, and gives onsite staff the ability to collect payments at multiple points throughout the care process.
Orlando Health Gains Insight into Denials, Reduces A/R Days with RelayAnalytics Acuity
Read how Orlando Health was able to perform deeper dives into claims data to help the health system see claim rejections more quickly–even on the front end–and reduce A/R days.
Revenue Cycle Payment Clarity
To maintain fiscal fitness and boost patient satisfaction and loyalty, healthcare providers need visibility into when and how much they will be paid–by whom–and the ability to better navigate obstacles to payment. They need payment clarity. This whitepaper illuminates this concept that is winning fans at forward-thinking hospitals.
Streamlining the Patient Billing Process
Financial services staff are always looking for ways to improve the verification, billing and collections processes, and Munson Healthcare is no different. Read about how they streamlined the billing process to produce cleaner bills on the front end and helped financial services staff collect more than $1 million in additional upfront annual revenue in one year.
Wallace Thomson Hospital Automates to Maximize Limited Resources
Effective revenue cycle management can be a challenge for any hospital, but for smaller providers it is even tougher. Read how Wallace Thomson identified unreimbursed procedures, streamlined claims management, and improved its ability to determine charity eligibility.
7 Steps for Building and Funding Sustainability Projects
Before launching an energy-efficiency initiative, it’s important to build a solid business case and understand the funding options and potential incentives that are available. Healthcare leaders should consider taking the steps outlined in the whitepaper to ease the process of gaining approval, piloting, implementing, and supporting sustainability projects. You will find that investing in sustainability and energy efficiency helps hospitals add cash to their bottom line. Discover how hospitals and health systems have various options for funding energy-efficient and renewable-energy initiatives, depending on their current financial structure and strategy.
Key Capital Considerations for Mergers and Acquisitions
Health care is a dynamic mergers and acquisitions market with numerous hospitals and health systems contemplating or pursuing formal arrangements with other entities. These relationships often pose a strategic benefit, such as enhancing competencies across the continuum, facilitating economies of scale, or giving the participants a competitive advantage in a crowded market. Underpinning any profitable acquisition is a robust capital planning strategy that ensures an organization reserves sufficient funds and efficiently onboards partners that advance the enterprise mission and values.
Key Capital Considerations for Mergers and Acquisitions
The success of healthcare mergers, acquisitions, and other affiliations is predicated in part on available capital, and the need for and sources of funding are considerations present throughout the partnering process, from choosing a partner to evaluating an arrangement’s capital needs to selecting an integration model to finding the right money source to finance the deal. This whitepaper offers several strategies that health system leaders have used to assess and manage capital needs for their growing networks.
Trend Watch: Providers adapt as value-based care moves from hype to reality
Announcements from several commercial payers and the Centers for Medicare and Medicaid Services (CMS) early in 2015 around increased efforts to form value-based contracts with providers seemed to point to an impending rise in risk-based contracting. Rather than wait for disruption from the outside in, health care providers are now making inroads on collaborating with payers on various risk-based contracting models to increase the value of health care from within.
Yuma Regional Medical Center case study
Yuma Regional Medical Center (YRMC) is a not-for-profit hospital serving a population of roughly 200,000 in Yuma and the surrounding communities.
Before becoming a ZirMed client, Yuma was attempting to manually monitor hundreds of thousands of charges which led to significant charge capture leakage. Learn how Yuma & ZirMed worked together to address underlying collections issues at the front end, thus increasing Yuma’s overall bottom line.
Reforming with a New 50-Bed Acute Care Facility
Kindred Hospital Rehabilitation Services works with partners to audit the market and the facility’s role in that market to identify opportunities for improvement. This approach leads to successes; Kindred’s clinical rehab and management expertise complements our partners’ strengths. Every facility and challenge is unique, and requires a full objective analysis.
5-Minute Briefing on Revenue Integrity Through HIM WhitePaper Hospitals FS
As the critical link between patient care and reimbursement, health information enables more complete and accurate revenue capture. This 5-Minute White Paper Briefing shares how to achieve cost-effective revenue integrity by your optimizing HIM systems.
5-Minute Briefing on Accelerating Cash Flow Through HIM WhitePaper Hospitals FS
Speedier cash flow starts with better CDI and coding. This 5-Minute White Paper Briefing explains how providers can improve vital measures of technical and business performance to accelerate cash flow.
5-Minute Briefing on Reducing the Cost of RCM WhitePaper Hospitals FS
Qualified coders are getting harder to come by, and even the most seasoned professional can struggle with the complexity of ICD-10. This 5-Minute White Paper Briefing explains how partnerships can help improve coding and other key RCM operations potentially at a cost savings.
Providers Focus Too Much On Revenue Cycle Management
The point of managing your revenue cycle isn’t just to improve revenue and cash flow. It’s to do those things effectively by consistently following best practices— while spending as little time, money, and energy on them as possible.
Lucille Packard Children’s Hospital Stanford Case Study
How Lucile Packard Children’s Hospital Stanford increased payments received within 45 days by 20% and reduced paper submission claims by 70% by using ZirMed solutions.
Using Predictive Modeling To Detect Meaningful Correlations Across Claims Denials Data
The reasons claims are denied are so varied that managing denials can feel like chasing a thousand different tails. This situation is not surprising given that a hypothetical denial rate of just 5 percent translates to tens of thousands of denied claims per year for large hospitals—where real‐world denial rates often range from 12 to 22 percent. Read about how predictive modeling can detect meaningful correlations across claims denials data.
ZOLL and Emergency Mobile Health Care Case Study
Emergency Mobile Health Care (EMHC) was founded to be and remains an exclusively locally owned and operated emergency medical service organization; today EMHC serves a population of more than a million people in and around Memphis, answering 75,000 calls each year.
Maximizing Medicare Reimbursements White Paper
Since the Physician Quality Reporting Initiative (PQRI) introduction, CMS has paid more than $100 million in bonus payments to participants. However, these bonuses ended in 2015; providers who successfully meet the reporting requirements in 2016 will avoid the 2% negative payment adjustment in 2018, so now is the time to act! Included in this whitepaper are implications of increasing patient responsibility, collections best practices, and collections and internal control solutions.
Denials Deconstructed: Getting Your Claims Paid
Getting paid what your physician deserves—that’s the goal of every biller. Yet even for the best billers, achieving that success can be elusive when denials stand in the way of success, presenting challenges at every turn. Denials aren’t going away, but you can learn techniques to manage and even prevent them.Join practice management expert Elizabeth W. Woodcock, MBA, FACMPE, CPC, to: Discover methods to translate denial data into business intelligence to improve your bottom line, determine staff productivity benchmarks for billers, and recognize common mistakes in denial management.
Automation and Operational Improvement Drive Sustainable Results
Physician practices must improve organizational efficiency to compete in this era of reduced reimbursement and escalating administrative costs.
Revenue Cycle Management Resolves Migration Implementation Issues
Many healthcare organizations are pursuing next-generation health information systems solutions. Learn more about Navigant's work with University of Michigan Health System.
Partnering For Success – Provider Achieves Strength in Stability
The proper implementation of healthcare information technology systems is crucial to an organization’s financial health.
Building a Clinically-Integrated Network
As value-based payment models evolve, providers are challenged to maintain superior clinical outcomes while controlling costs.
Winning in the Post-Acute Marketplace
Read more about factors contributing to the changes in the post-acute marketplace and what it means for manufacturers, physicians, clinicians, patients, and post-acute facilities as they anticipate the transition to the second curve.
Building A Common Vision with Employed Physicians
HSG helped the physicians and executives of St. Claire Regional in Morehead, Kentucky, define their shared vision for how the group would evolve over the next decade. As well as, develop the strategic and operational priorities which refocused and accelerated the group’s evolution.
Practice Performance Improvement
The client was a nine-hospital health system with 14 clinics serving communities in a multi-state market with very limited access to care, poor economic conditions, high unemployment, and a heavy Medicare/Medicaid/uninsured payer mix. In most of these communities, the system was the sole source of care.
Though the clinics were of substantial size (they employed 98 physicians) and comprised of multiple specialists, the physicians functioned as individuals and the practices lacked any real group culture.
Clinical Integration Without Spending a Fortune
Clinical integration can be expensive, but it doesn’t have to be, as this four-step road map for developing a CIN proves. Does it have to cost millions to initiate a clinical integration strategy?
Contrary to popular belief, we have clients who have generated substantial shared savings and a significant ROI over time, without massive investments. Yes, some financial capital is required for resources the CIN providers can’t bring to the table themselves. But the size of that investment can be miniscule relative to the value it produces: improved outcomes and documentation for payers.
Adding Value to Physician Compensation
Today’s concerns about physician compensation are the result of the changing healthcare environment. The transition to value is slow, but finally becoming a reality. Proactive hospitals want to ensure that provider incentives are properly aligned with ever-increasing value-based demands.
This report focuses on the three big questions HSG receives about adding value to physician compensation; Why are organizations redesigning their provider compensation plans? What elements and parameters must be part of successful compensation plans? How are organizations implementing compensation changes?
Effective Revenue Cycle Management in Your Network
Revenue Cycle Management has become an even more complex issue with declining reimbursements, implementation of Electronic Health Records, evolving local carrier determinations (LCD), and payer credentialing [The emphasis on healthcare fraud, abuse and compliance has increased the importance of accuracy of data reporting and claims filing).
The efficiency of a medical practice’s billing operations has critical impact on the financial performance. In many cases, patient billings are the primary revenue source that pays staff salaries, provider compensation and overhead operating cost. Inefficiencies or inaccurate billing will contribute to operating losses.
Succeeding in Value-Based Care
This publication identifies and outlines the necessary characteristics of a fully-functioning clinically integrated network (CIN). What it doesn’t do is detail how hospitals and providers can participate in the value-based care environment during the development process.
One common misconception is that the CIN can’t do anything significant until it has obtained the FTC’s “clinically integrated” stamp of approval. While the network must satisfy the FTC’s definition of clinical integration before single signature contracting for FFS rates and contracts can legally start, hospitals and providers can enjoy three key benefits during the development process.
Therapy: Benefits at All Levels of Care
Nearly half of all Medicare beneficiaries treated in the hospital will need post-acute care services after discharge. For these patients, a stay in an inpatient rehabilitation facility, skilled nursing facility or other post-acute care setting comes between hospital and home.