CMS proposes a vast expansion of its quality measures program
CMS proposes a vast expansion of its quality measures program
Closer ties between performance, payment put more pressure on QI
In a dramatic effort to expand its quality program for hospital inpatient services in fiscal year 2009, The Centers for Medicare and Medicaid Services (CMS) has proposed the addition of 43 new quality measures for which hospitals will have to report data in order to receive the full annual payment update for their services. This would more than double the current number of quality measures in place.
In addition, CMS is proposing to more than double the list of hospital-acquired conditions (HACs) for which it will no longer pay hospitals at a higher rate for the resulting increased costs of care (so-called "never events"). The nine new conditions, which are being added to the current eight, would be effective Oct. 1, 2008. (For a complete list of the proposed changes, go to: www.cms.hhs.gov. In the blue bar at the top of the page, click "Newsroom." Then, under "Media Releases," click "Fact Sheets," and then click the topic you wish to view.)
While the final rule will not be issued until about Aug. 1 (comments were being accepted through June 13), quality managers are already expressing concerns about the short "window" until the new requirements are enacted, and the additional burdens they will put on quality departments.
"First of all, there is a need for awareness of the measures and the implementation timeline," notes Rita Stockman, RN, MSA, director, accreditation and quality at William Beaumont Hospital in Royal Oak, MI. "Some changes will be initiated Oct. 1, so the timeline is the key. Each organization must first become familiar with the inclusions or exclusion of measures; this is a lot of measures. Then, you need to look at the personnel required to investigate the data."
This translates "the need to expand and change how we fundamentally manage the quality department," she continues. "And, if you relay your information on an EMR (electronic medical record) you have to make sure [the new measures] are "baked" into your coding or EMR; if not, you have to re-design it and put it back into the infrastructure of the medical record."
Patrice L. Spath, of Brown Spath Associates, Forest Grove, OR, agrees. "All hospitals are going to have to hire more people," she says. "I read some comments recently by a hospital CEO who said we are spending more and more resources on collecting data and less and less on taking care of patients. You may eventually reach a breaking point; if you have people who could have prevented pressure ulcers sitting in an office collecting data you are not improving quality of care but the quality of the Medicare database."
Spath is also concerned about the implications for EMRs. "Even in a sophisticated system, I don't know if all these data elements can be pulled from the records," she observes. Additional time will be required, she notes, not just to add the data elements, but to have someone else watch what is going on concurrently — "to make sure you don't have to report something that is not being done."
For example, she says, if a beta-blocker is not ordered at discharge and someone calls the physician to ask why it wasn't, the reasons have to be documented. "It's also a matter of intervening while the patient is getting care, so you don't have to end up reporting something you didn't do," Spath adds.
Are measures 'fair'?
Beyond the additional work, say the experts, some of the expectations set forth by CMS for the "never" events may not be realistic. "Even the things in the original list that people are now dealing with are not necessarily preventable events," Spath argues. "Things like urinary tract infections [UTIs] or pressure ulcers are not always preventable. They happen every once in awhile and you can't do much about them, but they got grouped in these events."
Alice G. Gosfield, a health care attorney who heads the Philadelphia-based firm that bears her name, agrees. "There is no question that one of the problems with never events is that among those the National Quality Forum has identified are some about which there can be quibbling," she says. "There is no quibbling over wrong-site surgeries, but bedsores, as an example, are a real issue, depending on the condition of the patient upon admission."
Gosfield emphasizes that she is not a clinician, but adds: "As I understand it, people who come to the hospital from nursing homes or languish in bed for awhile may have incipient [bed sores]; they show up in a degraded condition, other circumstances exacerbate the problem, and it becomes fully obvious."
"We work hard to prevent ventilator-associated pneumonia and surgical site infections, yet these are areas where our controls are limited," adds Stockman. "We can't always predict what the body's response will be." For conditions like UTIs, she continues, protocols can be followed, but for some of the new onset conditions, such as delirium, her response is, "good luck with that!" Iatrogenic pneumothorax (collapse of the lung) may present similar challenges, as this is a condition that certainly can be identified but not necessarily prevented. "These are certainly things we can strive toward, but some of it requires a more thorough medical history and communication of clinical information upon admission," Stockman asserts.
For all these reasons, says Stockman, "you have to be as fully aware as possible of the patient's admitting condition. It affects all care, and for a quality person to trace each element of the event or condition of the patient, you have to look all the way back to their status at the time they entered the health care system."
Who is harmed?
"Let's focus on the real issues," offers Gosfield. "It's not like the hospital would be paid nothing. They will still be paid for what the patient was admitted for, but if it degenerates, CMS argues you should have been clear on what you have been admitting patients for to begin with.
"The point of the never event policies, though, is not to punish people, but to create an incentive to develop systems that work better and prevent problems," she continues. She concedes, however, that "the level of problem analysis that is necessary to be able to prevent these errors is not without challenge," pointing to the recent, well-publicized incident in Minnesota where the wrong kidney was removed from a patient (See "Wrong-site surgery: We're not doing all that we can," HBQI, June 2008, p. 49)
"I am told the problem arose because when the X-rays were done, they were mislabeled," Gosfield says. "All of the checks after that confirmed action to be taken in accordance with a mislabeled image, so where the problem can begin may be very far from the site of the 'never event.'"
Which is precisely Spath's concern — along with her fear that patients may not ultimately benefit from these additional measures. "What continues to concern me is that hospitals might 'cherry pick' patients," she says. "As more and more data are required, and as hospitals naturally want to look good, the less likely they may be to want to admit someone who is 65, with multiple co-morbidities and more likely to develop pressure ulcers or get a UTI. That raises the issue of ethics — are we going to start admitting only healthy patients?"
There is certainly the chance that not everything that is present on admission would be found, says Gosfield, "but that does not mean you wouldn't admit them."
A liability issue?
But Spath is not so sure, fearing that never events are things that plaintiff's attorneys would "love." "This says to the public that all these things shouldn't happen, so consequently every time one of them does happen, you could have a lawsuit," she posits. "It basically creates a list that is a menu for patients' attorneys."
This has a real risk management twist, she asserts. "Why would I want to admit people with all these problems?"
Spath points to a recent article in the Journal of the American College of Surgeons1 that indicates others have similar concerns. Spath says it uses "liability fears" as a motivator to practice infection reduction guidelines.
But Gosfield says these events might not present such a serious liability issue. "From a litigation perspective, the real issue is the standard of care," she explains. "Proximate cause — what created the injury — is an essential aspect of proving a case. The mere fact that a never event occurred won't in and of itself be dispositive of liability, but it sure puts the care into the category of: How will you justify what happened?"
In addition, she points out, most such cases end with a settlement and an apology.
Economy against us?
Finally, says Stockman, the economy may present quality managers and health care providers with another difficult challenge. "People make choices about health care, [and because of the poor economy] it's more likely people will enter the health care system with a higher level of acuity than years ago," she says. "So our risk as a facility will exponentially increase just because of the economy. The patients come in, they are sicker because they refrained from getting the care they needed, and it's more likely they will present with a higher number of co-morbidities."
For example, she says, it will "absolutely" increase the number of people who use EDs as primary care, "and that will have a huge domino effect."
Such trends, she continues, "are some of the things we as an organization truly cannot control from a clinical standpoint."
Still, Gosfield argues, most of the quality requirements address things hospitals "should be doing," and basically raise "a payment issue associated with what should be the standard of care." She does concede, however, that quality managers "may have to reprioritize."
[For more information, contact:
Alice G. Gosfield, Alice G. Gosfield and Associates PC, 2309 Delancey Place, Philadelphia, PA 19103. Phone: (215) 735-2384. E-mail: [email protected]:
Patrice L. Spath, Brown Spath Associates, P.O. Box 721, Forest Grove, OR 971116. Phone: (503) 357-9185. E-mail: [email protected].
Rita Stockman, RN, MSA, Director, Accreditation and Quality, William Beaumont Hospital, Royal Oak, MI. Phone: (248) 551-3104. E-mail: [email protected].]
Reference
- Demteriades D , May A, and Gamble H. When Does a Centers for Disease Control and Prevention Recommendation Become Standard of Care? Perhaps in the Courtroom. American College of Surgeons Mock Trial: Line Sepsis Liability. Doi:10.1016/jamcollgurg.2007.07.040.
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