CMS ties financial incentives to reliability through pay for performance programs focused on care provided in hospitals, home care, physician practices, and skilled nursing settings (Centers for Medicare and Medicaid Services, 2018a, 2018b, 2018c, 2018d). The three hospital‐based pay for performance programs are the value‐based purchasing (VBP) program, the readmission reduction penalty program, and the hospital‐acquired conditions( HAC) reduction program. Hospitals with better than expected outcomes receive higher reimbursement for patients insured under Medicare, while those with worse than expected outcomes receive lower reimbursements.
Value‐Based purchasing
In value‐based purchasing (VBP), hospitals earn scores based on achievement of or improvement in their safety, quality, patient experience, and financial performance (Centers for Medicare and Medicaid Services, 2018a, 2018b, 2018c, 2018d). VBP evaluates a hospital on five domains: patient and caregiver centered experience of care and care coordination; clinical care outcomes; efficiency and cost reductions; safety; and clinical care processes.
Hospital Readmission Reduction Penalty Program
The hospital readmission reduction penalty program focuses on patients being readmitted to hospitals for six specific conditions: acute myocardial infarction, coronary artery bypass graft surgery, chronic obstructive pulmonary disease, heart failure, pneumonia, and total hip and knee arthroplasty. The hospital's actual readmission rate is compared to the expected rate of readmissions given the patient's comorbidities (Centers for Medicare and Medicaid Services, 2018a, 2018b, 2018c, 2018d). Comorbidities are two or more coexisting medical conditions or disease processes that are additional to an initial diagnosis. For example, a patient may be admitted for pneumonia. If the patient also has diabetes and heart failure, these coexisting conditions must be documented because they make patient care more complex.
HAC Reduction Program
The HAC reduction program examines hospitals' performance on safety indicators and hospital‐acquired infections. Safety indicators are based on physician, advanced practice registered nurse, and physician assistant documentation. The coded data are then analyzed as part of the Agency for Healthcare Research and Quality Patient Safety Indicators (PSI‐90). For hospital‐acquired infections, hospitals are required to submit their data on central line‐associated bloodstream infections, CAUTI, surgical site infections for colon and hysterectomy surgeries; methicillin‐resistant Staphylococcus aureus bacteremia, and Clostridium difficile infections to the Center for Disease Control and Prevention National Healthcare Safety Network (NHSN) databases. Each hospital's performance is compared to the mean. Poor performing hospitals receive a 1 % penalty (Centers for Medicare and Medicaid, 2018).
CMS publicly reports each hospital's performance on these measures. In addition, many states require health care organizations to report specific adverse events and safety, quality, and staffing indicators. These indicators are available to the public at state websites.
Medical Product Safety Network
The Medical Product Safety Network (MedSun) is an adverse event reporting program within the U.S. Food and Drug Administration's Center for Devices and Radiological Health (FDA, 2018). MedSun's goal is to work collaboratively with the clinical community to identify, understand, and solve problems with the use of medical devices.
The Safe Medical Devices Act requires hospitals and other health care organizations to report medical device problems that result in serious illness, injury, or death. Once a problem is identified, MedSun clarifies the problem and shares information with the clinical community and the public, without facility and patient identification, so that other clinicians can take preventive actions. MedSun participants are also highly encouraged to voluntarily report problems with devices that resulted in actual or potential harm. By monitoring reports about problems and concerns before a more serious event occurs, the FDA, manufacturers, and clinicians can work together to prevent serious injuries and death. Sometimes, this results in a product redesign.Current Educator, Clinical Educator, Novasyte Health representing Hill‐Rom Figure 4.10
Source: Nancy Withers.
Real World Interview
Nancy Withers
I was providing care for a patient who had just been transferred into ICU after a rapid response. I saw what appeared to be a purple band on the patient. At my hospital, like at many hospitals across the country, a purple band designates a DNR (Do Not Resuscitate) code status. There was no indication of a DNR order for this patient, so I asked the patient about the purple band. The patient told me she was wearing it because she'd had an implantable port placed, and the band was part of the kit provided by the vendor. Staff at the surgical center suggested that the patient wear the band to remind health care providers of her port. When I looked at the band closely, I noticed it was actually a gradation of colors, purple fading to gray. I clarified the patient's code status with her and removed the band for patient safety.
I also completed an unusual occurrence, which brought the situation to the attention of our risk manager. The risk manager reported the event to the FDA through a MedSun report as a near miss. MedSun told us later that they worked with the manufacturing company to change their practices. The company was not aware of the national efforts underway to standardize arm band colors and has now stopped including the purple band in their port kits.
Nancy Withers, BSN, RN
Former Clinical Leader, ICU, Edward HospitalCurrent Educator, Clinical Educator, Novasyte Health representing Hill‐Rom.
Baldrige Award
The Baldrige Award is conveyed by the National Institute of Standards and Technology (NIST), which is part of the U.S. Department of Commerce. NIST recognizes organizations that have improved and sustained quality results. The Baldrige Award in health care is designed to challenge organizations to improve their effectiveness of care and health care outcomes to pursue excellence, which moves organizations toward becoming an HRO. The Baldrige framework is built on core values and concepts and requires measurement, analysis, and knowledge management. The framework embraces integration between leadership, strategy, customers, workforce, operations, and results (National Institute of Standards and Technology (NIST), n.d.).
Accreditation Agencies
The three hospital accrediting agencies address patient safety. These agencies include Det Norske Veritas Healthcare, Inc. (DNV), Healthcare Facilities Accreditation Program (HFAP), and TJC.
Det Norske Veritas Healthcare, Inc.
Det Norske Veritas Healthcare, Inc. (DNV) empowers quality and patient safety through an outcomes‐based accreditation program. They received authority from the Centers for Medicare and Medicaid (CMS) to provide accreditation to hospitals in 2008, and integrate the CMS Conditions of Participation with the ISO 9001