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Issues up close


Healthcare-acquired conditions are a major cause of avoidable patient harm, both in terms of morbidity and mortality across settings of care. In the hospital setting, healthcare-acquired conditions are a serious threat to patient safety and account for significant, avoidable suffering and excessive cost.

Prevention of healthcare-acquired conditions is a standard of care that all members of the healthcare team are bound to strive for. Nurses, at 3.1 – 3.6 million strong, are the largest group of healthcare providers and provide the bulk of risk assessments, risk-based interventions, and other direct care to patients. Thus, nurses are well positioned to contribute to a bold campaign to improve patient safety called the Partnership for Patients. This campaign aims to reduce healthcare-acquired conditions by 40% and readmission by 20% by 2013. (For more information on the Partnership for Patients, go to http://www.healthcare.gov/compare/partnership-for-patients.)

The Partnership for Patients is one of many key campaigns to improve healthcare quality initiated by the Center for Medicare & Medicaid Innovation (CMMI). The American Nurses Association (ANA) is a partner in this campaign and is working closely with CMMI leaders through focused commitments, including leveraging ANA’s transformational quality tool, the National Database of Nursing Quality Indicators® (NDNQI®).

NDNQI-participating hospitals have been tracking and trending data as well as identifying best practices in prevention since 1998. NDNQI is the nation’s only database that measures patient outcomes from the nursing-unit level. With more than a third of the nation’s hospitals participating, the database is rich with comparative data, and NDNQI members can benchmark against like organizations to track and trend interventions that improve processes. Hospitals submit data on healthcare-acquired conditions, such as pressure ulcers, ventilator-associated pneumonias, catheter-associated urinary tract infections, and central line-associated bloodstream infections, to see how they compare to other organizations. This makes NDNQI a very useful tool for quality improvement.

Why the focus on quality reporting?

The U.S. healthcare system is inching toward transparent reporting to the public and reimbursements based on pay for quality. The impetus for the more robust
reporting system was the Deficit Reduction Act of 2005, which required the Secretary of the Department of Health and Human Services (HHS) to identify at least two conditions that meet the following requirements:

  • high cost, high volume, or both
  • a major cause of case assignments to Medicare Severity-Diagnosis Related Groups (MS-DRG) that has a higher payment when present as a secondary diagnosis
  • an avoidable adverse event that could have reasonably been prevented through the application of evidence-based guidelines.

For hospital discharges occurring on or after October 1, 2008, the Centers for Medicare & Medicaid Services (CMS) Medicare Inpatient Prospective Payment System requires that hospitals no longer receive the higher payment for cases when one of the selected conditions is acquired during hospitalization. Thus, the case is paid as if the secondary condition is not present.

Affordable Care Act pushes quality to the fore

With additional CMS pay-for-quality programs mandated for implementation by the Affordable Care Act (ACA) over time, the continued shift in focus toward pay-for-quality further penalizes hospitals for poor quality. It will also add healthcare-acquired conditions in the future. Specifically, CMS will pay differentially for quality in the hospital Value-based Purchasing Program, further reducing payments for hospitals with high benchmarked healthcare-acquired condition rates.

There has been additional movement in advancing transparent public reporting of quality measures and pay-for-quality at the national level. The ACA requires that quality measures be endorsed by a national consensus body, the National Quality Forum. The National Quality Forum endorses quality measures for public reporting and pay-for-quality that are important and feasible to measure, scientifically rigorous, and usable.

The ACA also mandated a multistakeholder group be convened to make pre-rulemaking recommendations on CMS-proposed future priority measures (such as safety measures) for public reporting and pay-for-quality across multiple federal programs. In 2011, the National Quality Forum convened a multistakeholder group under contract with HHS called the Measure Application Partnership. The goal of the Measure Application Partnership is to expedite progress on moving the dial toward what former CMS Administrator Don Berwick, MD, termed the nation’s “Triple Aim”: better care, more affordable care, and healthier people and communities.

ANA CEO Marla Weston, PhD, RN, sits on the Coordinating Committee of the Measure Application Partnership, which advises and oversees multiple workgroups that make recommendations on proposed CMS measures. For example, earlier Measure Application Partnership reports identified measure evaluation criteria and coordinated strategies for quality measurement for settings of care, complex populations, and safety across settings.

For hospitals, it comes down to the bottom line

Hospitals should consider determining how much revenue has been lost due to healthcare-acquired conditions and adverse and “never” events (such as stage III, IV, and unstageable pressure ulcers and falls with serious injury). Not only does this help organizations identify areas for improvement; it also identifies areas where revenue can be gained. For example, for a patient with a hospital-acquired pressure ulcer, the average charge is $37,800, the average length of stay is 13 days, the level of morbidity is higher, and higher levels of care are required at discharge.

To assist in the measurement of these data, The National Quality Forum’s goal is to harmonize, or standardize, measures for use across settings, such as cross-cutting measures for safety and care coordination. For example, the CMS/Yale and National Committee for Quality Assurance all-cause readmission measures will be harmonized in the future to promote alignment across payers. Both of the National Quality Forum measures are in the final phases of being endorsed by National Quality Forum board.

Current quality measures will be converted to eMeasures in the future in the three phases of “Meaningful Use.” This will be accomplished via electronic health records under CMS and the Office of Healthcare Information Technology regulations. Both CMS and the Office of the National Coordinator for Health Information Technology recently put out proposed regulations for Meaningful Use Stage 2, which proposes changes for Stage 2 and extends Stage 1. Hospitals throughout the United States are undergoing radical change with implementations of electronic health records that meet the requirements.

Health care is changing at an accelerated pace and as a result, so are regulations and reporting requirements. Healthcare organizations are struggling to keep informed and meet every changing requirement, but the increased transparency and emphasis on quality are good for patients, the public, and nurses. ANA remains committed to advocating for nurses and their patients, keeping nurses informed of changes in health care and prepared for the future.

Maureen Dailey is a senior policy fellow at ANA. Pam Hinshaw is the NDNQI program specialist at ANA.

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