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Elizabeth Eaken Zhani
Media Relations Manager
The Joint Commission

Bret Coons
Media Relations Specialist
The Joint Commission


  Fairview Health Services Reduces Birth-Related Injuries and Saves $284,985 in Costs, in the August 2013 issue of "The Joint Commission Journal on Quality and Patient Safety"  
(Oak Brook Ill., July 30, 2013) Today, Joint Commission Resources announced the release of the August 2013 issue of the “The Joint Commission Journal on Quality and Patient Safety,” which features an article on how the Minnesota-based Fairview Health Services hospital system reduced its rate of adverse outcomes related to births by a mean of 11 percent over three years, resulting in substantial reductions in costs. In “A Perinatal Care Quality and Safety Initiative: Are There Financial Rewards for Improved Quality?” Katy B. Kozhimannil, Ph.D., M.P.A., and her co-authors describe Fairview Health Services’ establishment and use of a Zero Birth Injury (ZBI) initiative between 2008 and 2011 to increase perinatal safety and quality in all six of its hospitals.

The foundation of the ZBI initiative was developed using evidence-based practices recommended by the Institute for Healthcare Improvement (IHI) and was supplemented through participation in the Premier Perinatal Safety Initiative, which provided access to additional quality metrics and lessons learned. As a result of reducing the adverse events, the hospital system saved $284,985 in costs; but it earned $324,333 less revenue, resulting in a net financial decrease of $39,348 (or a $305 net financial loss per adverse event avoided).

"Our findings highlight the need for payment systems that align incentives between patients, providers, and payers to improve care and financially reward, rather than penalize, the health care delivery systems that produce quality improvements,” said Kozhimanill. “Changes under the Affordable Care Act, such as Accountable Care Organizations and other shared-savings plans, may provide a foundation for transforming perinatal care payments."

“The Joint Commission Journal on Quality and Patient Safety,” published monthly by Joint Commission Resources, is a peer-reviewed journal, available by subscription, which serves as a forum for practical approaches to improving quality and safety in health care.


Performance Improvement
A Perinatal Care Quality and Safety Initiative: Are There Financial Rewards for Improved Quality?

Katy B. Kozhimannil, Ph.D., M.P.A.; Samantha A. Sommerness, DNP, R.N., CNM; Phillip Rauk, M.D.; Rebecca Gams, R.N., M.S., CNP; Charles Hirt, M.D.; Stanley Davis, M.D.; Kristi K. Miller, R.N., M.S.; Daniel V. Landers, M.D.
In 2008 Fairview Health Services hospital system in Minn. launched the Zero Birth Injury (ZBI) initiative to guide management of obstetric services. After adjusting for relevant covariates, ZBI implementation was associated with a mean 11 percent decrease in the rate of maternal and neonatal adverse outcomes between 2008 and 2011. The hospital system saved $284,985 in costs but earned $324,333 less revenue, which produced a net financial decrease of $39,348 (or a $305 net financial loss per adverse event avoided). These results highlight the important role for shared-savings collaborations (among patients, providers, government and third-party payers, and employers) to incentivize quality improvement.

Organizational Leadership
Improving Patient Care Through Leadership Engagement with Frontline Staff: A Department of Veterans Affairs Case Study 
Sara J. Singer, M.B.A., Ph.D.; Peter E. Rivard, Ph.D.; Jennifer E. Hayes, M.Ed.; Priti Shokeen, M.S.; David Gaba, M.D.; Amy Rosen, Ph.D.
Leveraging Frontline Expertise (LFLE) is a patient safety intervention for engaging senior managers with the work-systems challenges faced by frontline workers and ensuring follow-up and accountability for systemic change. LFLE was pilot tested in an urban, East coast-based Department of Veterans Affairs Medical Center. The program generated information about quality and safety problems—previously unknown to senior managers—that were considered high priority by frontline staff. 

Infection Prevention and Control
Bringing Central Line–Associated Bloodstream Infection Prevention Home: CLABSI Definitions and Prevention Policies in Home Health Care Agencies
Michael L. Rinke, M.D., Ph.D.; David G. Bundy, M.D., M.P.H.; Aaron M. Milstone, M.D., M.H.S.; Kristin Deuber, B.A.; Allen R. Chen, M.D., Ph.D., M.H.S.; Elizabeth Colantuoni, Ph.D.; Marlene R. Miller, M.D., M.Sc.
The policies of a national sample of 57 home health care agencies associated with children’s hematology or oncology centers varied significantly from national inpatient and home health care agency–targeted standards for central line–associated bloodstream (CLABSI) definitions and prevention. For example, only 24 percent of the agencies were able to report their agency’s CLABSI rates per 1,000 central line days, and only 11 percent were able to report their agency’s pediatric CLABSI rate per 1,000 central line days. Future research should assess strategies for standardizing home health care practices consistent with evidence-based recommendations.


Tool Tutorial
A Toolkit to Disseminate Best Practices in Inpatient Medication Reconciliation: Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS)

Stephanie K. Mueller, M.D., M.P.H.; Sunil Kripalani, M.D., M.Sc.; Jason Stein, M.D.; Peter Kaboli, M.D., M.S.; Tosha B. Wetterneck, M.D., M.S.; Amanda H. Salanitro, M.D., M.S., M.S.P.H.; Jeffrey L. Greenwald, M.D.; Mark V. Williams, M.D.; Edward Etchells, M.D., M.S.c; Daniel J. Cobaugh, Pharm.D.; Lakshmi Halasyamani, M.D.; Stephanie Labonville, PharmD, BCPS; David Hanson, M.S.N., R.N.; Hasan Shabbir, M.D.; John Gardella, M.D., M.B.A.; Rebecca Largen, Pharm.D., BCPS; Jeffrey Schnipper, M.D., M.P.H.
Medication safety during transitions in care remains a major issue in patient safety, resulting in calls to action to improve the process of medication reconciliation. A toolkit of best-practice recommendations for medication reconciliation was developed for quality improvement efforts across a broad range of health care organizations and systems. The toolkit consists of first steps a hospital should undertake before beginning any interventions, including preparation and site assessment, to allow for maximum likelihood of successful implementation; intervention components; and ready-to-use tools. Pending further refinement and evaluation, this toolkit and associated mentored implementation has the potential to substantially improve the medication safety of patients during and following hospitalization.

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Joint Commission Resources (JCR), a not-for-profit affiliate of The Joint Commission, is the official publisher and educator of The Joint Commission. JCR is an expert resource for health care organizations, providing consulting services, educational services and publications to assist in improving quality and safety and to help in meeting the accreditation standards of The Joint Commission. JCR provides consulting services independently from The Joint Commission and in a fully confidential manner. Please visit our Web site at