Leapfrog Group unveils policy on 'never' events

The Leapfrog Group has unveiled a new policy through which it hopes to encourage hospitals to implement strategies to avoid the 28 "never" events that have been identified by the National Quality Forum (NQF). The NQF, which recently updated its list of "never" events, describes them as "adverse events that are serious, largely preventable, and of concern to both the public and health care providers for the purpose of public accountability." The entire list, which includes events such as "patient death or serious disability associated with a fall" and "unintended retention of a foreign object in a patient after surgery or other procedure," can be found at www.qualityforum.org.

"We are focusing on the never events because we felt they are really part of our mission statement to improve patient safety and quality of care in the health care setting," explains Catherine Eikel, director of programs for the Leapfrog Group. "While they are rare, they represent the worst of the worst that could happen in a hospital, and we really wanted to support hospital policies that make sure that facilities take appropriate steps when a rare never event occurs. Our current work focuses on the 30 NQF safe practices, so the two go together, for as facilities improve, the likelihood of a never event goes down."

Leapfrog is communicating the policy to hospitals by including it in its 2007 Leapfrog Hospital Quality and Safety Survey. "This way hospitals, through the survey, can basically sign on and say, 'Yes, I will implement this in my facility," Eikel explains. "In so doing, they will receive public recognition in our web site and through our member organizations."

Apology accepted?

Leapfrog's new policy also seems to say being in health care doesn't mean "never having to say you're sorry." One of its requirements is that hospitals apologize to the patient and/or their family if they are harmed by a never event.

"There's been a lot of research showing that having one who's been aggrieved receive an apology and acknowledgement is a really important part of the healing process, and an important part of their acceptance and understanding of what has happened," says Eikel.

Conceding that this may be more of a patient satisfaction issue than a patient issue, Eikel adds that the Leapfrog Group does not specify the form such an apology should take. "Our overarching philosophy is to help the healing process of the patient and to encourage the hospital to take steps to prevent never events from occurring again, so we created a framework for that rather than getting into details," she explains.

While concerns have been raised that apologizing to a patient might be a liability risk for the hospital, Leapfrog counters: "Research indicates that malpractice suits are often the result of a failure on the hospital's part to communicate openly with the patient and apologize for its error. Patients feel the most anger when they perceive that no one is willing to take responsibility for the adverse event that has occurred."

The Leapfrog policy has several other components, including:

  • Reporting the event to at least one national reporting program, such as The Joint Commission on Accreditation of Healthcare Organizations; to a state reporting program; or to a patient safety organization.
  • Performing a root cause analysis that meets the standards of the reporting program being used.
  • Waiving all costs that were the direct result of the never event.

The Centers for Medicare & Medicaid Services (CMS) also is moving to support the elimination of never events. In a statement issued May 18, 2006, it stated: "Clearly, paying for 'never events' is not consistent with the goals of ... Medicare payment reforms. Reducing or eliminating payments for 'never events' means more resources can be directed toward preventing these events rather than paying more when they occur. In particular, CMS is reviewing its administrative authority to reduce payments for 'never events,' and to provide more reliable information to the public about when they occur. CMS intends to partner with hospitals and other health care organizations in these efforts."