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Study: CMS Penalties for Hospital-Acquired Conditions Have Little Impact

A study published in Infection Control & Hospital Epidemiology found that hospitals may have dodged financial penalties by billing hospital-acquired conditions (HAC) as present at the time of the patient’s admission. The findings showed that a CMS policy to penalize hospitals for preventable complications had minimal impact on the reduction of hospital-associated infections.

The targeted billing codes were rarely used by hospitals, and the study found that when hospitals billed for HACs during a patient’s stay, it infrequently affected the diagnosis-related group assignment, impacting hospital reimbursement.

“With this policy, CMS was hoping to see more attention paid to improving quality care, but it appears that the original HAC policy mostly led to changes in coding practices,” said study lead author Michael S. Calderwood, MD, MPH, regional hospital epidemiologist at Dartmouth-Hitchcock Medical Center, in a release. “It’s worth further investigation to determine whether Medicare reimbursement codes are being incorrectly used, or if there is now a greater effort to document conditions at the time of the patient’s admission.”

Ten years ago, CMS’ Hospital Inpatient Prospective Payment System stopped reimbursing hospitals for HACs not present on admission (POA), with the hopes of encouraging hospitals to improve their infection prevention practices.

The researchers analyzed more than 65 million Medicare fee-for-service hospitalizations from 2007 to 2011 in acute care facilities, specifically examining documentation for central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI) and whether the codes for those HACs were submitted as POA (which aren’t counted as preventable complications).

The study found that CLABSI and CAUTI affected 0.23% and 0.06% of hospitalizations, respectively, and in the three years immediately after the 2008 CMS policy took effect, 82% of CLABSI codes and 91% of CAUTI codes were marked as POA. This was a significant increase compared with before the HAC policy was implemented.

Diagnosis coding for CAUTI and CLABSI that was not POA from 2007 to 2011 dropped dramatically. In 2007, hospitals discharged 6,172 patients with a CAUTI diagnosis code, 99.8% of whom were marked not POA; comparatively, in 2011 when 6,448 patients were coded as having a CAUTI, just 10.7% of them had the no POA designation.

First published in PSQH

CMS Reverses Plan to Cut Reporting of HAIs

The Centers for Medicare & Medicaid Services (CMS) has decided not to carry out a proposal to remove public reporting of hospital-acquired infections (HAI), medical errors, and injuries. Instead, CMS will publish the information on the Hospital Compare site and in a database.

After the plan was announced in June, there were complaints from patient safety advocates. A new rule, published last week, restores reporting of data through the Inpatient Quality Reporting Program, including infection rates of Clostridium difficile, Methicillin-resistant Staphylococcus aureus, and post-surgery sepsis.

The Trump administration had initially agreed to remove the reporting measures at the request of the American Hospital Association, which argued that they unfairly penalize hospitals for safety problems.

Survey: 36% of facilities struggle to meet TJC MRI standards

new survey found that 36% of medical resonance imaging (MRI) providers do not comply with The Joint Commission’s (TJC) standards for diagnostic imaging services, which were released in 2015.

The standards, which are in effect for hospital and ambulatory care programs, require that MRI facilities should collect data on incidents where ferromagnetic objects unintentionally entered the MRI scanner room and injuries resulting from the presence of ferromagnetic objects in the scanner room. Ferromagnetic objects, which include oxygen tanks and wheelchairs, can become dangerous when brought into an MRI room; the MRI’s strong magnetic field can pull objects at high speed toward the machine, which can lead to injuries and occasionally deaths.

Conducted by MRI safety firm Metrasens, the survey of 162 MRI professionals highlights ongoing issues with safety in those facilities. “The Joint Commission’s Revised Requirements for Diagnostic Imaging Services state that hospitals must manage safety risks in the MRI environment, but these survey results suggest that there is still room for improvement,” said Tobias Gilk, a Metrasens consultant, in a release.

TJC’s standards also cover equipment testing and maintenance, annual education for staff, minimum qualifications for medical physicists, and managing MRI safety risks.

New CMS guidance on ligature risk says Joint Commission recommendations set the bar

Expect CMS surveyors to be referring to recommendations set out by The Joint Commission last fall when looking for ligature risk and other environmental hazards in the push to make hospitals and psychiatric units safer for patients at-risk of self-harm.

For now, assess your hospital’s environmental compliance against those Joint Commission recommendations, regardless of what organization you might use for accreditation, and be prepared to provide one-to-one observation of at-risk patients if you cannot provide a ligature-resistant environment, says one safety consultant.

In a new memo to its state survey agencies, CMS said it would use those Joint Commission recommendations — drawn from a task force convened by the accreditor that included several CMS experts in suicide prevention — as the federal agency goes forward with clarifying and updating interpretive guidelines for its surveyors.

The memo QSO: 18-21-All Hospitals, “CMS clarification of Psychiatric Environmental Risks,” from the Quality, Safety & Oversight Group (QSO), formerly known as the Survey and Certification Group, is dated July 20, although it was not posted online until Aug. 1.

CMS says Joint Commission panel good enough

In earlier communications, CMS had indicated it would convene its own group of experts to update its guidance to increase focus on ligature as well as other physical risks covered under the Condition of Participation (CoP) for patient rights to care in a safe setting.

However, since participating in the The Joint Commission panel, CMS officials now think its own panel would be redundant. “CMS felt that to repeat the work of TJC Suicide Panel (in which CMS participated) would not provide any substantive additional gains and would not be a productive use of the time and expertise of the participants,” according to the newest memo.

CMS is still working to revise the interpretive guidelines for its surveyors but referred regional offices for now to expectations set out in its Dec. 8 memo on clarifying ligature risk, S&C 18-06-Hospitals (ECL 1/1/18). That memo carried extensive guidance, including an initial update to parts of the interpretive guidelines found in Medicare’s State Operations Manual, Appendix A (SOMA).

Expect more changes in the future, though. In the most recent memo, CMS said it would continue to work on updates to Appendix A as well as Appendix AA, guidelines for surveyors at Psychiatric Hospitals, “which will incorporate the standards that were recommended via the collaborative work of the The Joint Commission Suicide Panel Special Report: Suicide Prevention in Health Care Settings.” The memo provided an online link to the November The Joint Commission recommendations.

Written by A.J. Plunkett

CMS Delays Hospital Star Ratings Update, Again

Citing “stakeholder concerns,” the Centers for Medicare & Medicaid Services has once again postponed an update to its Overall Hospital Quality Star Ratings.

“When changes are made to the underlying measures it is vital to take the time needed to understand the impact of those changes and ensure we are giving consumers the most useful information,” CMS said Tuesday in a posted notice.

“As part of this process, CMS will seek feedback from a multi-disciplinary Technical Expert Panel, a Provider Leadership Workgroup, and a public comment period,” CMS said.

No date was given for when CMS anticipates activating the ratings updates. Typically, the updates are issued every July and December. However, CMS has a history of delaying the updates, most recently in May. And the ratings themselves have been bitterly contensted ever since they were proposed, with many questioning CMS’ methods. 

News of the pushback was well-received by hospital stakeholders.

“CMS made the right call,” said Tom Nickels, executive vice president of the American Hospital Association.

“We appreciate the agency allowing more time for a fuller analysis of its methodology and measures and to hear from stakeholders, including hospitals and health systems, about concerns found in many preview reports,” Nickels said.

Bruce Siegel, MD, president and CEO of America’s Essential Hospitals, welcomed the delay and said that stakeholder reviews of the proposed July updates showed “large shifts in overall hospital star ratings from December 2017 to July 2018.”

“These changes have created confusion and raised new questions about the reliability and validity of the methodology used to calculate these ratings,” he said.

“We remain deeply concerned the star ratings could do more harm than good in their current form. We look forward to working with CMS to ensure patients and their families can make care decisions based on accurate and meaningful data,” he said.

CMS said it will update these metrics on July 25:

Outcome measures for 30-day mortality, 30-day readmissions, and CMS Patient Safety Indicators, including:

  • Outpatient imaging efficiency;
  • Payment and value of care;
  • Timely and effective care;
  • Healthcare-associated infections;
  • HCAHPS surveys.

CMS will add three new measures to Hospital Compare:

  • Hospital return days for pneumonia patients (EDAC-30-PN);
  • Percentage of patients who received appropriate care for severe sepsis and septic shock (SEP-1);
  • Average time patients spent in the emergency department before being sent home (OP-18c), which will only be reported on data.medicare.gov

CMS is no longer reporting the Pain Management composite 4 on Hospital Compare or in the downloadable databases. This composite measure is also being excluded from the calculation of the HCAHPS Summary Star Rating for the July Hospital Compare release.

In addition, CMS said it:

  • Will not publish the Overall Hospital Star Rating from the July Preview Reports on Hospital Compare.
  • Will Post the SAS Pack with the next Star Ratings refresh on Hospital Compare.
  • Will keep Star Ratings released in December 2017 on the Hospital Compare until the next update.

Written by John Commons, HealthLeaders Media

See our previous coverage on the CMS star ratings below.

National Guidelines, Quality Measures Clearinghouses Shutting Down

If you or anyone at your hospital use the National Guidelines Clearinghouse or National Quality Measures Clearinghouse operated under the auspices of the Agency for Healthcare Research and Quality (AHRQ), download the information you need soon.

Both online clearinghouses will go dark after July 16 as federal funding runs out. Neither site is accepting new guidelines or quality measure sets in anticipation of shutting the databases down.

Announcements on each website note that that AHRQ has received “expressions of interest from stakeholders” that want to takeover maintenance of the databases, but AHRQ officials have declined to identify who those stakeholders are for now.

The clearinghouses were set up more than two decades ago as central sites to help hospitals, clinicians and others in health care find evidence-based information on which to set policy, create clinical treatment plans and objectively measure quality outcomes.

The guidelines and measures are submitted by various professional or academic health organization and must meet detailed criteria to be included in each database. As guidelines or measures are updated or become outdated, the information is removed.

AHRQ evaluating options

“AHRQ recognizes the importance of this resource and is evaluating potential options, including the participation of stakeholders who may wish to operate the Clearinghouse in the future,” stated Alison Hunt, MPH, with AHRQ’s Office of Communications, Media Division.

If public or private stakeholders are found to take over the clearinghouses, ARHQ still has not decided what role it will continue to play, Hunt said.

While the federal sites may go away, the information will still be available from each of the professional society, academy or other healthcare group that originated the material, notes Karen Schoelles MD, SM, FACP, director of ECRI Institute’s Penn Medicine Evidence-based Practice Center (EPC) and project director for both clearinghouses.

ECRI was the original contractor hired by AHRQ to set up and run the guidelines clearinghouse in 1987.

Besides having information in one place, one of the advantages in having each of the clearinghouses is that users could have some assurance that the information had been professionally vetted and was up-to-date.

Having evidence-based information to back a policy or best practice is one of the key mantras of both The Joint Commission and CMS.

Hospital leaders or others who need information about the validity of a particular set of guidelines or best practice can still seek out help from any of the Evidence-based Practice Centers (EPC) set up through AHRQ, says Schoelles. ECRI-Penn Medicine is one of 12 EPCs across North America.

EPC programs offer help

The EPCs develop evidence reports and technology assessments to assist public- and private-sector organizations, and “provide organizations with comprehensive, science-based information on common, costly medical conditions and new health care technologies and strategies,” according to a AHRQ research white paper released in December. Schoelles was a work group leader on the paper, A Framework for Conceptualizing Evidence Needs of Health Systems.

The paper sets out to determine the evidence needs of health systems to both guide future EPC programs and ultimately help organizations as they seek “evidence to inform decisions about acquiring new or emerging medical technologies; implementation or expansion of service offerings; and selection of governance, finance or delivery system models,” notes a summary.

As part of the group’s research it looked at information requests made at four large health institutions;  Kaiser Permanente Southern California, the Veterans Health Administration’s Evidence Synthesis Program, ECRI Institute’s Health Technology Assessment Information Service, and Penn Medicine Center for Evidence-based Practice.

“A wide range of clinical and administrative decision-makers requested evidence reviews, and the topics were similarly broad—ranging from evidence to guide clinical care; purchasing of medications and devices; procedural and non-procedural interventions; and processes of care,” according to the paper.

Highlighted throughout the requests was a need for trustworthiness of information, notes Schoelles.

If you are seeking to verify or evaluate information and are part of a larger health system, Schoelles suggests starting with the larger organization to see what help it can offer. Often health systems will evaluate a guidelines or best practice and then establish a policy or guidelines based on that information, or can share the evaluation throughout the system’s smaller organizations, she said.

ECRI, for instance, offers a variety of evaluation services. Some ECRI services are free to members, others are fee-based. ECRI Institute also is currently exploring ways to maintain a guideline repository, notes Schoelles.

Resources

This article was originally published in Inside The Joint Commission.

CMS’ severe sepsis bundle ISN’T a Joint Commission requirement

The April 17 issue of Annals of Internal Medicine (AIM) incorrectly stated The Joint Commission was considering creating a requirement for hospitals to implement CMS’ Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) to receive accreditation. This information is incorrect and AIM has published a correction.

Joint Commission Urges Hospitals to Protect Workers from Abuse

This story originally ran on HCPro’s OSHA Healthcare Advisor.

The Joint Commission is the latest healthcare heavy-hitter to call for better protection of healthcare workers, announcing on Tuesday the creation of Sentinel Event Alert 59, which addresses violence—physical and verbal—against healthcare workers.

About 75% of workplace assaults occur in healthcare and social service sector each year, and violence-related injuries are four times more likely to cause healthcare workers to take time off from work than other kinds of injuries.

The purpose of the new alert is to help hospitals and other healthcare organizations better recognize workplace violence directed by patients and visitors toward healthcare workers and better prepare healthcare staff to address workplace violence, both in real time and afterward, The Joint Commission wrote in this latest Sentinel Event Alert publication.

Sentinel Event Alert 59 has some overlap with Alerts 40 and 57—which were released in 2008 and 2017, respectively, and focused on the development and maintenance of safety culture—and therefore were not addressed in this alert.

Per the Occupational Safety and Health Administration (OSHA), about 75% of workplace assaults annually occurred in the healthcare and social service sector. Violence-related injuries are four times more likely to cause healthcare workers to take time off from work than other kinds of injuries, according to the Bureau of Labor Statistics (BLS).

The Joint Commission cites both of those facts in this Sentinel Event Alert publication and adds that Joint Commission data show 68 incidents of homicide, rape, or assault of hospital staff members over the past eight years—and that’s mostly only what hospitals voluntarily reported.

The Joint Commission is calling for each incident of violence or credible threat of violence to be reported to leadership, internal security, and—if necessary—law enforcement, and it also wants an incident report to be created. Under its Sentinel Event policy, The Joint Commission says that any rape, any assault that leads to death or harm, or any homicide of a patient, visitor, employee, licensed independent practitioner, or vendor on hospital property should be considered a sentinel event and requires a comprehensive systematic analysis.

Additionally, The accreditor says it’s up to the healthcare organization to specifically define unacceptable behavior and determine what is severe enough to warrant an investigation.

This Sentinel Event Alert, which you can download here along with other resources, comes on the heels of an emergency preparedness rule from CMS that recently went into effect and efforts from the National Fire Protection Association to fast-track its new standard for active shooter events and other violent incidents. OSHA is also considering a standard to help protect healthcare and social workers from violence.

Avoid Eyewash-Related Regulatory Compliance Issues

Eyewash stations continue to confuse and confound healthcare organizations (HCO). Not only can they pose infection control and safety issues for workers, they can be a point of contention between HCOs and surveyors, who often seem to work by different sets of rules.

During this 90-minute webinar on May 31, former hospital administrator and accreditation expert John R. Rosing, MHA, FACHE, will explain what regulators like CMS, The Joint Commission, and OSHA expect from an HCO’s eyewash stations. He will provide the steps personnel can take to keep staff safe and the organization in compliance with rules and regulations. Attendees will learn how to avoid eyewash-related regulatory compliance issues, how to perform a risk assessment to determine when an eyewash station is necessary, and what type of eyewash station they need.

At the conclusion of this program, participants will be able to:

  • Avoid eyewash-related regulatory compliance issues
  • Perform a risk assessment to determine when an eyewash station is needed
  • Identify what type of eyewash station is needed
  • Properly maintain eyewash stations

Presented on:
Thursday, May 31, 2018
1:00-2:30 p.m. ET

Presented by:
John R. Rosing, MHA, FACHE

Level of Program:

Intermediate

To register or get more information, please visit the event page at HCMarketplace.com.

The Joint Commission: Comments open on proposed suicide risk NPSG through May 7

Wishing you could weigh in on The Joint Commission’s expectations about suicide risk? You have your chance. Through May 7, The Joint Commission is accepting comment on proposed revisions to National Patient Safety Goal 15 on reducing the risk of patient self-harm.

The Joint Commission published the revisions on its Standards Field Reviews web page on March 26. The revisions, which will require hospitals to be more proactive in removing risks from the physical environment, include proposed changes to both the general Hospital and the Behavioral Health Care accreditations programs.

Under the Hospital Accreditation program, a revised Element of Performance (EP) 1 applies only to hospitals, whereas the rest of the now seven EPs — up from just three — will apply only to those patients in psychiatric hospitals or being treated for behavioral health problems in general hospitals, according to the field review information.

The other EPs for both programs outline expectations of conducting suicide assessment of patients, documenting a patient’s risk and the plan to deal with that patient’s suicidal ideation, the need for written policies and procedures and quality monitoring of the programs, among other things.

You can comment on the proposed revisions online or by mail. To read the full set of revisions, and for links and instructions on how to comment, go to the Field Reviews page, https://www.jointcommission.org/standards_information/field_reviews.aspx. — A.J. Plunkett (aplunkett@h3.group)