Legal briefs.

This column provides executive summaries of developments in legal and regulatory issues related to healthcare, lists a bibliography of pertinent healthcare law-related articles, and discusses interesting health law court decisions.

Healthcare reform after the Supreme Court ruling: implications for nurse executives.

On June 28, 2012, the US Supreme Court upheld the provisions of the Patient Protection and Affordable Care Act of 2010, as amended by the Healthcare and Education Reconciliation Act of 2010, with the exception that the Department of Health and Human Services may not withhold existing Medicaid funding from states that refuse to adopt the Medicaid expansion, but rather only new Medicaid funding associated with the expansion. This article will review the impact of this ruling on healthcare providers with a focus on the practice of the nurse executive.

Reducing Employee Injury Rates with a Hospital-wide Employee Safety Program.

Introduction: Despite the well-known dangers of working in the healthcare industry, healthcare organizations have historically accepted workplace injuries as business as usual. In 2017, Children's National Hospital began our Employee and Staff Safety program to drive down the employee injury rate and address this disturbing industry trend. Methods: With guidance and support from executive leadership, we created an Employee and Staff Safety program that aligned employee safety work with existing patient safety and quality improvement efforts. Team leads collected and analyzed baseline employee injury data and identified areas of highest injuries. Dedicated subcommittees focused on five specific areas: slips, trips, and falls; sharps injuries; blood and body fluid exposures; verbal and physical violence; and overexertion injuries. Subcommittees established aims, identified key drivers, and brainstormed interventions for tests of change. Results: Because the inception of the Employee and Staff Safety program, Children's National has seen significant reductions in our Days Away Restricted or Transfer (DART) rate. The DART rate shows a sustained 37% reduction since the baseline period of FY16-FY17 (1.48 injuries/200,000 h worked to 0.93 injuries/200,000 h worked). The regression trend shows a significant decrease (38.3%) in DART injuries, from 1.544 to 0.952 over 56 months; P = 0.016. Conclusions: Active leadership support and analyzing data on specific employee harm areas coupled with targeted interventions, helped improve Children's National's DART rate. The Employee and Staff Safety program's success in utilizing patient safety and quality improvement tools creates a generalizable framework for other hospitals to advance their high-reliability journey.

Children's Hospital Ambulatory Response to the 2019 Novel Coronavirus Disease (COVID-19) Pandemic.

The 2019 novel coronavirus disease (COVID-19) pandemic produced an abrupt and near shutdown of nonemergent patient care. Children's National Hospital (CNH) mounted a multidisciplinary, coordinated ambulatory response that included supply chain management, human resources, risk management, infection control, and information technology. To ensure patient access, CNH expanded telemedicine and instituted operational innovations for outpatient procedures. While monthly in-person ambulatory subspecialty visits decreased from 25 889 pre-COVID-19 to 4484 at nadir of the COVID-19 pandemic, telemedicine visits increased from 70 to 13 539. Further studies are needed to assess the impact of innovations in health care delivery and operations that the crisis prompted.

A review of basic patient rights in psychiatric care.

Although patient rights is a concept that all nurse managers need to be aware of, this concept often becomes confusing when applied to patients undergoing psychiatric treatment. It is important for the nurse manager to understand the basic rights that psychiatric patients are entitled to, to best be able to help staff nurses under his/her supervision to protect these rights. The nurse manager on a psychiatric unit often serves as a reference for staff nurses, and even for physicians, when questions regarding patient rights present themselves. The nurse manager should be certain to discuss these issues with the facility's legal and risk management team to be aware of particulars of the law of the state in which the facility is located, as state laws may differ somewhat in their treatment of psychiatric patients.

Criminal prosecution for nursing errors.

Headlines describing nurses being prosecuted for crimes related to nursing errors raise numerous questions for nurses and their managers. Nurse managers need to be aware of situations in which nurses may be subject to criminal prosecution to assist staff in educating themselves and acting to minimize risk. After reading this article, the reader should be able to (a) identify the legal basis for criminal charges for nursing errors, (b) list 3 errors likely to result in criminal prosecution, and (c) discuss licensure implications of criminal charges for nursing errors.

10,000 Good Catches: Increasing Safety Event Reporting In A Pediatric Health Care System.

BACKGROUND: In 2014, Children's National Health System's executive leadership team challenged the organization to double the number of voluntary safety event reports submitted over a 3-year period; the intent was to increase reliability and promote our safety culture by hardwiring employee event reporting. METHODS: Following a Donabedian quality improvement framework of structure, process, and outcomes, a multidisciplinary team was formed and areas for improvement were identified. The multidisciplinary team focused on 3 major areas: the perceived ease of reporting (ie, how difficult is it to report an event?); the perceived safety of reporting (ie, will I get in trouble for reporting?); and the perceived impact of reporting (ie, does my report make a difference?) technology, making it safe to report, and how reporting makes a difference. The team developed a key driver diagram and implemented interventions designed to impact the key drivers and to increase reporting. RESULTS: Children's National increased the number of safety event reports from 4,668 in fiscal year 2014 to 10,971 safety event reports in fiscal year 2017. Median event report submission time was decreased by nearly 30%, anonymous reporting decreased by 69%, the number of submitting departments increased by 94%, and the number of reports submitted as "other" decreased from a baseline of 6% to 2%. CONCLUSIONS: Children's National Health System's focus on increasing safety event reporting resulted in increased organizational engagement and attention. This initiative served as a tangible step to improve organizational reliability and the culture of safety and is readily generalizable to other hospitals.

Operating room fires: the CRNA and the deposition.

Although the reported incidence of surgical fires indicates they are rare occurrences, any Certified Registered Nurse Anesthetist (CRNA) who is involved in one will most likely end up in court defending a malpractice suit. This column discusses one such case with an emphasis on the CRNA's deposition testimony and its impact on the need to settle the case. The column also will discuss how surgical fires can be prevented and provide sources of further information on this important risk management issue for CRNAs.

Is the "July Effect" Real? Pediatric Trainee Reported Medical Errors and Adverse Events.

INTRODUCTION: The "July Effect" suggests an increase in patient adverse events in July compared with other months due to the introduction of new providers throughout the training continuum. The aim of this initiative was to analyze reported pediatric trainee medical errors from May through September 2015 at a tertiary care free-standing academic children's hospital to determine if there were more reported medical errors and more adverse events from those errors in July. METHODS: An error surveillance system is used to report and track near misses, adverse events, and medical errors. Three of the authors reviewed each report, which was electronically collected in the institution during the time period of interest. The reported medical error incidence per 1,000 trainee-days was compared against those in July for a significant difference. RESULTS: There are a total of 282 trainees (86 pediatric residents, 81 nonpediatric residents, and 115 fellows) who are clinically active in the hospital at any given month. Pediatric residents had more reported medical errors in July (31) compared with May (16; P = 0.015), June (16; P = 0.019), and August (19; P = 0.046). There was no significant difference in the number of adverse events from reported medical errors by trainees in July (7) compared with May (5), June (8), August (4), or September (8; P > 0.2). CONCLUSION: In this single-center evaluation, there is an increase in reported medical errors involving pediatric residents in July compared with the months surrounding July. However, there is no difference in numbers of adverse events from those errors between these months.

Our journey to zero: reducing serious safety events by over 70% through high-reliability techniques and workforce engagement.

The techniques and best practices used to achieve a successful safety culture transformation and drive down the incidence of serious safety events are described. The Safety Transformation Initiative at Children's National resulted in national and local recognition, a financial savings of an imputed $35 million, and a greater than 70% decrease in the serious safety event rate over a 3-year period (July 1, 2008-June 30, 2011). The results were achieved during a time of significant financial constraints and with limited resources. A blueprint detailing specifics of the implementation is presented to assist others in achieving similar results. Our safety transformation was initiated in our fiscal year 2009 as part of a 3-year corporate goal. The work is continuing and we aspire to virtually eliminate serious safety events by 2016.