Majority of hospitals won't bill for 'never events'

Survey shows commitment to 'doing the right thing'

The Washington, DC-based Leapfrog Group reports that 52% of the hospitals responding to its Hospital Quality and Safety Survey say that they have adopted the "Leapfrog Never Events" policy. This policy includes the following actions that the hospitals pledge to take whenever these medical errors — rare though they may be — occur:

  • Apologize to the patient and/or family affected by the never event;
  • Report the event to at least one of the following agencies: The Joint Commission, a state reporting program for medical errors, a patient safety organization;
  • Perform a root cause analysis, consistent with instructions from the chosen reporting agency;
  • Waive all costs directly related to the serious reportable adverse event.

This year, 1,285 hospitals reported for the first time on their adherence to the Leapfrog Never Events policy. These "never events" follow the 28 "serious reportable events" outlined by the National Quality Forum, which includes errors such as surgery performed on the wrong body part or on the wrong patient, leaving a foreign object inside a patient after surgery, and discharging an infant to the wrong person.

According to Leapfrog, hospitals that agree to the policy are twice as likely to have scored full points on the Leapfrog Safe Practices Score (SPS) than those hospitals that have not.

The SPS asks hospitals how well they implement 27 of the NQF's Safe Practices; 33% of hospitals who commit to the Leapfrog Never Events policy have scored full points on the SPS, but only 17% of those that did not commit to the policy did the same.

Leapfrog also found that the rate of adoption differed by hospital size, with a higher rate of adoption among smaller hospitals. Here is the breakdown:

  • 59% of small hospitals (1-100 beds);
  • 53% of medium hospitals (101-250 beds);
  • 48% of large hospitals (251+ beds).

A 'positive sign'

"We think that [these results are] a very positive sign," says Rachel Weissburg, program associate with The Leapfrog Group. "We hope and think that other hospitals are going to respond to that kind of leadership."

She adds that asking hospitals to submit to what may be normal customer service principles in other industries "is radical" in health care.

As for the willingness of hospitals to forego charging for services when such events occur, Weissburg admits to being surprised that she has not had much negative feedback. "I thought I would hear a lot more complaints," she says.

That may be because some hospital leaders, such as Children's National Medical Center in Washington, DC, already had been pursuing a similar policy.

"We've been writing off bills for over 10 years, but our practice has evolved to where we are doing it more frequently," says Mary Anne Hilliard, Esq., BSN, CPHRM, the hospital's chief risk counsel.

Hilliard says this increased frequency began about five years ago, but that the scope of bill write-offs is broader than just "never events." "Whenever there is a serious, unexpected error," she says, "we try to do the right thing. We investigate, we disclose, and where appropriate, we apologize, and write the bill off if we find we have caused harm." Such a practice, she adds, is simply a case of "doing the right thing."

Practice is rewarded

Hilliard says that Children's National has definitely benefited from this policy. "It's absolutely had a positive impact [in terms of minimizing] litigation," she asserts. "These cases are much more likely to settle; I believe we have saved hundreds of thousands of dollars by doing the right thing."

In most cases, she continues, that is all that families want you to do. "When they see you've done all you can to mitigate the harm, a lot of them are magnanimous," she shares.

"Paying for what you asked for makes common sense; paying for what you didn't ask for doesn't make common sense," adds Weissburg.

Such a policy "also goes a long way with insurance carriers," Hilliard adds. "They are always surprised; it's not uncommon for us to write off a bill before it even comes to them, as we are pretty transparent. When we operate that way and build trust, it has all sorts of implications down the road for you to be able to work together."

Greater adoption needed

What is stopping the other 48% of hospitals from adopting the policy? "Each piece of the policy has implementation challenges," notes Weissburg. "A lot has to do with the legal climate in each state — I've had many discussions with hospitals that want to implement the policy but say they do not have a place to report, or they are not accredited, or they are not in a state that has a reporting program in place, so they are in a 'no-man's land.'" For hospitals with such problems, she adds, there is an "FAQ" section on the organization's web site ( that addresses many of them.

Quality managers, she adds, are the logical individuals to take a leadership role in the hospital adopting this policy. "The hospital quality manager should be the first to see the value of adopting this policy," she asserts. "It's a tool for hospitals to use to handle rare but ubiquitous events."

Finally, warns Hilliard, while this policy makes sense, hospital professionals should remain wary about others using it as an excuse to perhaps place unwarranted financial penalties on their facility. "We are worried about a spin-off effect; some insurance companies may use [the policy] as an excuse not to pay for other others things," she concedes.

For example, she observes, the recent announcement by the Centers for Medicare & Medicaid Services that it would no longer reimburse hospitals for certain preventable HAIs, or hospital-acquired infections, "could become a trend — a slippery slope, if you will. Denials [of reimbursement] do have the potential to get into areas that are gray."

[For more information contact:

Mary Anne Hilliard, Esq., BSN, CPHRM, Chief Risk Counsel, Children's National Medical Center, 111 Michigan Avenue, NW, Washington, DC 20010. Phone: (202) 476-3000.

Rachel Weissburg, Program Associate, The Leapfrog Group, 1801 K Street NW, Suite 701-L, Washington, DC 20006. Phone: (202) 292-6725. Fax: (202) 292-6825.]