Patient safety surveillance: keeping watch in hospitals, from sinks to surgery
■ Maryland gets federal stimulus funds for "secret shoppers" to monitor health professionals' hand hygiene. A Rhode Island hospital will videotape surgeries. Some worry about Big Brother.
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Doctors in Maryland hospitals soon may find themselves the targets of covert surveillance.
That stranger in the corridor reading Newsweek or texting on his iPhone actually may be taking notes on whether physicians and other health care workers wash their hands after leaving patients' rooms.
In early November, the state launched a safety initiative using $100,000 in American Recovery and Reinvestment Act -- popularly known as the federal stimulus package -- funds to help hospitals train "secret shoppers" to monitor health workers' hand hygiene. Forty-five of the state's 47 acute care hospitals have joined the voluntary initiative.
The Maryland effort is believed to be the first time that government funds are going to train secret observers to keep an eye on doctors. At the same time, Rhode Island health officials have ordered video monitoring of surgeries at one hospital after a rash of wrong-site surgical errors.
Hospitals increasingly are turning to these surveillance methods and others, such as motion sensors and radio frequency identification chips, say patient safety experts. But even some surveillance advocates worry that patient safety's prying eyes could go too far, and, if implemented sloppily, surveillance could prompt a backlash from health professionals.
If surveillance techniques are used to "find out what the performance is and what's affecting performance, it can be a very helpful aid," said Mark Chassin, MD, MPH, president of the Joint Commission, the nation's hospital accrediting body. "But if it's used to simply generate data for entering directly into the personnel files of individuals who don't comply, that's an invitation for revolt, rebellion and sabotage."
Compliance rates on hand hygiene among health care workers hover between 40% and 50% nationally, despite Centers for Disease Control and Prevention guidelines and Joint Commission requirements. The CDC estimates the 1.7 million health care-associated infections annually -- and the 99,000 related deaths of hospital patients -- are caused in part by poor hand hygiene.
Maryland hospitals will get monthly updates on compliance rates by unit and be able to compare how well doctors did as a group -- not individually -- versus nurses or other health care workers. Hospitals also will have access to data on how all other Maryland hospitals are doing in the aggregate. The hand hygiene compliance rates will not be released publicly. Training is occurring now before the start of data collection in January 2010.
The observers are "trained to observe in a standardized way and be as invisible as they can be," said William F. Minogue, MD, executive director and president of the Maryland Patient Safety Center, which is coordinating the effort for the state health department. "They learn to blend in."
Gene M. Ransom III, CEO of MedChi, the Maryland State Medical Society, said that although he is not "overly enthused" about the surveillance project, hospitals' participation in the initiative is not mandatory. "That's reasonable," he said.
While hopes in Maryland are high for the hand hygiene project, infection-control experts say the human surveillance method is imperfect. Sometimes observers are found out, and the method is labor-intensive.
Vendors are hoping to sell hospitals on a range of automated surveillance techniques using radio frequency identification chips, wireless technology and video recording.
Mount Kisco, N.Y.-based Arrowsight Inc. is bringing its expertise in using video monitoring for safety in manufacturing settings to the medical world. The firm installs video cameras that focus on sinks and sanitizer-dispensing areas. The cameras are connected to motion-sensing lasers that trigger recording activity, and data on compliance can be sent nearly immediately to highly visible screens in intensive care units.
A 2007 pilot test at an ambulatory surgery center with about 20 workers improved hand hygiene compliance from 35% to more than 90% in two months and sustained the rate for the yearlong study period. The 13-hospital North Shore-Long Island Jewish Health System in New York also has tested the Arrowsight technology for 13 months, and researchers are preparing a study of its effectiveness for peer-reviewed publication.
Suzanne Delbanco, PhD, president of Arrowsight's health care division, said video monitoring could be a breakthrough in patient safety.
"Arrowsight's approach of measuring 24 hours a day, seven days a week, 365 days a year and providing feedback on an ongoing basis is the key not only to rapid improvement but also to sustained high performance," said Delbanco, formerly CEO of The Leapfrog Group, an employer-backed organization that rates hospitals on patient safety. Human observers give hospitals "a false sense of security," she said.
Delbanco did not say how much Arrowsight's "hospital video auditing" service costs but said monitoring a typical ICU would cost thousands of dollars monthly. Some experts have doubts not only about the costs, but also whether video monitoring will do more harm than good.
"We get into the 'is Big Brother always watching me?' situation," said Mark E. Rupp, MD, professor of infectious diseases at the University of Nebraska Medical Center and president of the Society for Healthcare Epidemiology of America. "There will be health care workers who would resent that sort of approach. In infection control, we want to work collaboratively with our colleagues and get people invested in doing the right things."
Video recording is not always voluntary. In early November, Rhode Island Hospital was ordered by the state's health department to install video and audio recording equipment in each of the hospital's operating rooms by mid-December. The move came after five wrong-site surgeries at the hospital during the last two years.
Though the Massachusetts Legislature in 2007 considered legislation to mandate videotaping surgeries, patient safety experts said this appears to be the first government-ordered surgical recording to go forward.
Each Rhode Island Hospital surgeon must have at least two surgeries recorded over the next year. A spokeswoman said the hospital is working with the health department to implement the changes. The hospital also is participating in a wrong-site surgery prevention project coordinated by the Joint Commission's new Center for Transforming Healthcare.
The American College of Surgeons did not grant an interview request regarding the mandated surgery videotaping by this article's deadline. Neither did the Rhode Island Medical Society.
Dr. Chassin, of the Joint Commission, said the move toward greater surveillance reflects a shift to more patient-safety accountability.
"The true safety culture is not a no-blame culture," Dr. Chassin said. "The true safety culture has a clear and transparent way to separate blameless acts -- the kinds of errors that happen every day because we're human -- from blameworthy acts -- the kinds of things people knowingly engage in that they should be held accountable for."