February 2008 Vol. 3, No. 2 Quality Improvement...

IN THIS ISSUE

p. 4 Data needs to instigate changeDon’t waste your time collecting data unless its part of a closed control loop that leads to changes in your hospital.

p. 5 Real-time data can drive up SCIP performanceEven small hospitals with limited resources can perform well on Surgical Care Improvement Project measures by doing real-time data collection and getting back to clinicians immediately if there’s a miss.

p. 10 Focus on infections to ensure CMS reimbursementHospitals that plan to screen every single patient for urinary catheter–associated infections to avoid paying for preventable conditions may want to keep this in mind: The government will be watching.

p. 12 The Joint Commission releases proposed NPSGs Field review focuses on medication safety, hospital-acquired infections, medication reconciliation, and patient involvement in their own care.

Hourly rounding helpsboost scores on HCAHPS

As hospitals brace for the public unveiling of their pa-

tient satisfaction scores, one expert is recommending

hourly rounding as a way for organizations to improve

their ratings as well as their care.

“Hourly rounding is very, very popular, and it’s popu-

lar for a variety of reasons,” says Deirdre Mylod, PhD,

vice president of public policy for Press Ganey Associates,

Inc., and an expert on Hospital Consumer Assessment of

Healthcare Providers and Systems (HCAHPS).

“In terms of targeting some of the key drivers of pa-

tients’ perceptions that go into HCAHPS . . . if you have

someone checking on you on an hourly basis, you essen-

tially tick off almost all of the major things that are driv-

ing the important outcomes.”

A 2006 study by Press Ganey of more than 2.3 million

patients found the five areas that drive up overall scores.

They are:

Attentiveness to personal needs ➤

Responsiveness to concerns/complaints

Level of courtesy/respect with which the nurses

treat patients

Care with which doctors listen to patients

Extent of efforts by staff members to help with pain

Improve in four key domains

Hourly rounding, Mylod says, can improve patients’

perceptions in four of those areas. “Staff ask, ‘Is there

something else I

can do for you,

so patients know

someone is going

to come back and

they will never

feel alone and just left here,” Mylod says. “You’ve taken

care of attention to personal needs.”

Checking in on patients every hour will not only help

patients deal with their pain; it will also likely improve

that patient’s perception of the hospital’s responsiveness

to concerns and complaints, she says. And hourly check-

ins forge a stronger bond between nurses and patients,

thus improving ratings on the level of respect with

which nurses treat patients.

“It’s a very effective strategy,” Mylod says. “You get

all of it in one nice package.”

Kent Jackson, MA, LMSW, director of children’s

specialty services, behavioral health, and leader of the

patient-family experience team at St. Luke’s Hospital in

Cedar Rapids, IA, agrees. St. Luke’s, which scored in the

95th percentile in 2006, won Press Ganey’s Success Story

Award in 2007. That high performance is translating into

good scores on the HCAHPS, although Jackson sees areas

in which his 420-bed hospital could improve.

“We’re just now at a point where we’re planning to

implement hourly rounding later this year,” Jackson

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“ It’s a very effective strategy.

You get all of it in one nice

package.”

—Deirdre Mylod, PhD

> continued on p. 2

February 2008 Vol. 3, No. 2

Quality Improvement RepoRt

Data collection strategies for The Joint Commission, CMS, and beyond

© 2008 HCPro, Inc.

For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at www.copyright.com or 978/750-8400.

Quality Improvement Report February 2008

HCAHPS

says. “That alone should take care of the things where

we’re not doing as well as I think we should be.”

Not only does hourly rounding help with HCAHPS,

research shows it reduces patient falls, pressure ulcers,

and call-light usage, Jackson says.

Study best practices

St. Luke’s, he says, began its drive to improve patient

satisfaction scores back in 2004 when the hospital dis-

covered it had dropped into the 49th percentile on Press

Ganey scores.

The patient-family experience team studied best prac-

tices and immediately instituted:

Manager rounding on inpatients

A no-point policy in which staff members accompany

patients and family who look lost to their destination

instead of pointing or giving directions

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< continued from p. 1

A scripting policy whereby staff members asked pa-

tients at the end of every encounter, “Is there any-

thing else I can do for you?”

Within six months, St. Luke’s scores shot up from the

49th percentile to the 93rd. The facility’s ratings subse-

quently rose to the 95th.

Ask patients about their priorities

St. Luke’s has undertaken many other initiatives

since 2004, including asking every patient on admis-

sion for the top two or three things it can do to provide

great care and writing those things down on the pa-

tient’s whiteboard.

More recently, the hospital has:

Instituted a “Take Five” program in which staff nurs-

es sit with patients at the beginning of every shift and

talk to them about their concerns.

Turned waiting rooms into calming rooms by stock-

ing activity carts with laptops, DVD players, movies,

and games.

➤

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➤Editorial Advisory Board Quality Improvement Report

Group Publisher: John Novack

Senior Managing Editor: Lisa Buckley, [email protected]

Contributing Editor: Tami Swartz

Sallie M. Gatlin, CPHQDirector, Quality Resource ManagementPampa Regional Medical Center Pampa, TX

Jane M. Jones, MT(ASCP), MSHS, CPHQPerformance Improvement Director Oaklawn Hospital Marshall, MI

Robert Marder, MDPractice Director of Quality and Patient Safety The Greeley Company Marblehead, MA

Barbara Oliver, RNPatient Safety DirectorManager of Quality Improvement Northwest Hospital Center Randallstown, MD

Geoffrey PagePerformance Improvement Coordinator Mount Sinai Hospital Chicago, IL

Bruce Siegel, MD, MPHProfessor George Washington University School of Public Health and Health Services Washington, DC

Marla Smith, MHSAAssociate Consultant, Quality and Patient SafetyThe Greeley Company Marblehead, MA

Quality Improvement Report (ISSN: 1934-5488) is published monthly by HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945. Subscription rate: $299/year. Postmaster: Send address changes to Quality Improvement Report, P.O. Box 1168, Marblehead, MA 01945. • Copyright © 2008 HCPro, Inc. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at 978/750-8400. Please notify us immediately if you have received an unauthor-ized copy. • For editorial comments or questions, call 781/639-1872 or fax 781/639-2982. For renewal or subscription informa-tion, call customer service at 800/650-6787, fax 800/639-8511, or e-mail: [email protected]. • Visit our Web site at www.hcpro.com. • Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. • Opinions expressed are not necessarily those of QIR. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions. QIR is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks.

Facilities can suppress data

Hospitals unhappy with their patient satisfaction scores

can suppress their data until March 2009 without a finan-

cial penalty.

In January, hospitals that began submitting data on

Hospital Consumer Assessment of Healthcare Provid-

ers and Systems (HCAHPS) in October 2006 received pre-

view reports of their performance from CMS. Organizations

have 30 days to decide whether they want to suppress that

information.

“But consumers would see that,” says Deirdre Mylod,

PhD, vice president of public policy for Press Ganey Associ-

ates, Inc. “And each hospital would have to consider: ‘How

are your consumers going to react?’

Hospitals that suppress their data after March 2009 will

forfeit 2% of their Medicare payment update.

For more information, go to www.hcahps.org.

© 2008 HCPro, Inc.



Assumed every single patient and family has some

level of anxiety that can include fear and terror.

Made follow-up calls on 100% of inpatients. Re-

search shows 25%–33% of all patients have a clini-

cal issue that needs to be addressed once they return

home, he says.

“What I’ve been saying is that the movement toward

patient safety and quality and patient satisfaction are all

part of one thing,” Jackson says. “The point is you can’t

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do well on patient satisfaction if you’re not focused on

patient safety and quality. They’re going to get you re-

sults, but they’re also the right thing to do.”

Mylod echoes that view.

“Quality improvement is quality improvement,” she

says. “If you’re using data now, and you continue to

use your data, you will see improvement as opposed to

teaching to a test . . . It’s an issue of if you’re doing good

root-cause analysis and you’re doing best practices that

work, you will see the outcomes improve.” n

Follow these five tips for success on HCAHPS surveys

Struggling with your patient satisfaction scores? Worried

about the media onslaught once the ratings are released?

Deirdre Mylod, PhD, vice president of public poli-

cy for Press Ganey Associates, Inc., has the following five

suggestions:

1. Dealing with media coverage. Quality depart-

ments should relay to the marketing department where

the problem areas are and what they are doing about

them.

Mylod suggests telling reporters: “We are looking at

this. We are taking it seriously. We value patient views.

That’s why we’re participating voluntarily, and here’s

what we’re doing to fix it.”

“I think the voluntary part may be a helpful thing to

keep in that message,” she explains. “If the media asks

why aren’t you doing well in this area, remind them that

‘We’re for transparency; that’s why we participated before

it was required.’ ”

2. Putting whiteboards at every patient’s bed-

side. This allows nurses to communicate with each other

and keeps patients in the loop as well. The problem, Mylod

says, is that hospitals sometimes fail to update the white-

boards. “But if they’re being used well and updated every

day, it tells everybody, ‘This is the page we’re on, and this

is where we’re going.’ ”

3. Encouraging patients to ask questions. Staff

members should be trained to ask patients whether they

have any questions before leaving the room. “And when

the patient asks a question, say, ‘Thanks, I’m really glad

you asked that question,’ ” Mylod says. That way, patients

don’t feel like they’re bothering clinicians. Staff members

need to keep in mind that they’re experts in what happens

in hospitals every day, but the patients are novices and

don’t know how the processes work.

4. Share the comments on the surveys with

staff members. “When patients write something on a

survey, it does two things for you.” Mylod says. “It tells

you what is re-

ally going on,

and gives you

that evidence.

It also gives you

the patients

own words to

bring back to

the staff.” That

helps drive

home the point that this is real. “These are real patient

lives we’re talking about, and this is really what they’re

feeling and experiencing.”

5. Acknowledge staff members praised in sur-

veys. Even poorly performing hospitals receive surveys

praising particular employees.

“Remind people that this about improvement, and re-

ward those who receive positive comments,” Mylod says.

“Some hospitals will post comments about employees who

received positive comments in the unit, or the manager of

the unit will write a note to the person named.”

“ If the media asks why

aren’t you doing well

in this area, remind

them that ‘We’re for

transparency; that’s why

we participated before it

was required.’ ”

—Deirdre Mylod, PhD

© 2008 HCPro, Inc.



that set point, the quality department can take action

to correct the problem.

“So if we see more falls happening, we make an ad-

justment in our fall prevention program,” Rohde says.

“As soon as our fall prevention program is doing what

we want, we keep it at that point because it’s reached

our set point, or our expectation. And that’s the key

starting point with a control loop—you have to know

what your expectations are.”

Unintended consequences

Another way control loops fail is when actions cause

unexpected consequences. Rohde uses the example of

electric blankets. If the blankets are working proper-

ly, people sample the temperature, and if it’s too cold,

they initiate an action by changing the knob to make the

blanket give off more heat. “That’s a closed control loop,

and it works well,” he says.

But if the blankets have dual controllers, one for each

side of the bed, things can go awry. Often, the monitors

for the right side of the bed get mixed up with the ones

on the left side of the bed. The person on the left side of

bed then turns up the heater, but it has no effect. The

person on the right side of the bed, in turn, becomes hot

and turns down the temperature on his or her side of the

bed, to no avail. “Both think that they have some con-

trol because they have two different knobs,” Rohde says.

“But they both have broken control loops, which are

giving them outcomes that have nothing to do with the

data, or the controls that they have.”

The same thing happens in hospitals, he says. For ex-

ample, a vice president of finance might determine that

the hospital needs to save money by cutting back on

staffing. But fewer nurses may jeopardize patient safe-

ty and malpractice lawsuits could start to rise. Then the

vice president of patient safety starts asking, “How come

we’re losing all this money because of lawsuits?”

In other words, an action taken in one area of the

hospital—in this example, finance—had an unintended

Editor’s note: This is the first article in a regular series about

how to collect and analyze data.

Don’t waste your time collecting data unless it’s part

of a closed control loop that leads to changes in your

hospital.

“The reason we measure data is because data is part

of a closed loop, and the reason we have a closed loop is

that we want to change something,” says Ken Rohde,

author of the new book Making Your Data Work: Tools

and Templates for Effective Analysis, published by HCPro,

Inc., and a senior consultant for The Greeley Company,

a division of HCPro in Marblehead, MA. “We either

want to change behaviors, or we want to say, ‘It’s

exactly at the right point; let’s keep it here,’ ” he says.

A thermostat that is working properly, he says, is an

example of a closed control loop. If the temperature

falls below a set point, say the 70oF mark, the thermo-

stat initiates an action, which is to turn on the heaters.

The air then warms up and touches the thermostat,

which samples the temperature to determine whether

the room has reached that set point, or 70oF mark, and

turns off the heater if it has.

“That’s a closed control loop, and it’s got some key

parts—it’s got the data; it’s got the set point, or the ex-

pectation; it’s got the action; and it’s got the closed feed-

back loop,” says Rohde.

In this example, a data loop breakdown may mean

that either the thermostat or heater is broken, so even if

you keep raising the temperature, the room stays cold.

A broken data loop might also result if someone has

changed the expectation, set point, or temperature, to,

for example, 90oF. The heater then works to reach an ex-

pectation that might not be the right one.

Similarly, the board of directors and senior leader-

ship might have different expectations, or set points for

medication error rates. Senior leaders need to determine

what the expectation is and clearly define it to quality

directors, so if the data show performance falling below

Data collection needs to bring about change

© 2008 HCPro, Inc.



consequence in another area of the facility, and both vice

presidents feel out of control.

Oscillation problems

A third way control loops fail is by oscillation. For ex-

ample, you may get in your car on a wintry morning and

turn up the heat to full blast. Pretty soon, you’re boiling

hot, so you turn the temperature way down. Not

too much longer after, you get cold again, so you turn

the heat back up. Instead of initially setting the heater at

a good set point such as 70oF, the temperature, or perfor-

mance, keeps vacillating.

In a hospital, oscillation might involve a quality im-

provement team starting a performance improvement

project, abandoning it two months later, and then starting

it up again. “Program-of-the-month problems often are the

result of oscillations in our control loops,” Rohde writes in

his book. “We keep trying different things, never sticking

with one long enough to really see whether it works.”

Sampling mistakes

Another way hospitals err is by monitoring data at the

wrong sampling frequency. Organizations must separate

monitoring or reporting data from data used to control

processes, he says. For example, if you’re driving a long

distance in a car, your sampling might be every 15 or 20

minutes; you would frequently look at the gas gauge to

determine whether you have enough fuel.

But if you sampled this only on a quarterly basis, you

would almost certainly run out of gas.

Quarterly monitoring may be sufficient for presenting

data to regulators, who can use the information to deter-

mine whether the hospital should be shut down.

“But it’s nowhere near appropriate to help us run a

hospital, so we have to make sure people don’t fall into

the trap of sampling at a frequency that is designed for

monitoring and thinking that we can use that to control

our process,” Rohde says.

To effectively control processes, data may need to be

collected on a daily or even hourly basis—if you want to

see how many beds are available, for example. “But hos-

pitals don’t always do a good job of designing the sam-

pling frequency for the data to meet the control needs

they’re trying to use that data for,” Rohde says. n

Editor’s note: Go to www.hcmarketplace.com/prod.

cfm?id=5970&CFID=4257555&CFTOKEN=26313843

for more information about Rohde’s book.

Real-time data can drive up SCIP performanceEven small hospitals with limited resources can per-

form well on Surgical Care Improvement Project (SCIP)

measures by doing real-time data collection and getting

back to clinicians immediately if there’s a miss.

“You’re kind of killing two birds with one stone,” says

Jan Fitzgerald, MS, RN, director of quality and medi-

cal management for the division of healthcare quality at

Baystate Medical Center in Springfield, MA. “You’re get-

ting your data, and you’re improving your care.”

The spotlight on hospital performance has never

been brighter. In December 2007, CMS began publicly

reporting on its Web site Hospital Compare (www.

hospitalcompare.hhs.gov) about how well healthcare

facilities did on measures to prevent venous thrombo-

embolism (VTE). That followed the previous public post-

ing of hospital scores on three SCIP infection measures

about antibiotic timing, selection, and discontinuation.

As of January 1, The Joint Commission (formerly

JCAHO) began requiring hospitals that select SCIP as

one of their core measures to report about cardiac sur-

gery patients with controlled 6 a.m. postoperative serum

glucose, surgery patients on beta-blocker therapy prior

to admission who receive a beta-blocker during the

perioperative period, and surgery patients with appropri-

ate hair removal. (See the sidebar on p. 6 for Joint

> continued on p. 6

© 2008 HCPro, Inc.


Quality Improvement ReportPage � February 2008

Commission and CMS requirements). “The thing that

seems to drive improvement the most is public report-

ing,” says Fitzgerald, who is also a member of the SCIP

speakers bureau. “People can see what’s going on

around the processes of care.”

Best practices at Baystate

That transparency may trouble some low-performing

hospitals, but not Baystate Medical Center, a 670-bed fa-

cility. It scored in the 98th percentile for giving patients an

antibiotic within one hour of incision; in the 92nd percen-

tile for antibiotic selection; in the 89th percentile for anti-

biotic discontinuation within 24 hours of surgery; in the

95th percentile for VTE prevention; and in the 89th per-

centile for discontinuation of antibiotics, according to Hos-

pital Compare. “We did very well,” Fitzgerald says. “We

are leading for the state of Massachusetts, as well as na-

tionally. We are very high performers for timing, duration,

and VTE prophylaxis, which is something we’ve been

working on for a long, long time.”

Indeed, Baystate began its drive to boost quality six

years ago when it became the first hospital in Massachu-

setts to take part in a national collaborative to reduce

surgical complications. Even so, the hospital sometimes

still struggles with getting physicians to prescribe the

right antibiotic. A small pocket of surgeons at Baystate,

Fitzgerald says, were prescribing the wrong antibiotic for

colon surgery, despite the hospital’s admonitions. “This

particular group of physicians had been using the wrong

drug for the last 12 months,” she says. “They finally, in

November, started using the right drugs. But we’ve been

pounding on them for 12 months.” (See “Baystate tools”

on p. 8.) Two full-time equivalents are dedicated to col-

lecting SCIP data at Baystate, says Fitzgerald.

Hospitals struggling with VTE measures

Della Lin, MD, chief executive director of continu-

ing medical education at Queen’s Medical Center in Ho-

nolulu and the author of Surgical Care Improvement Project:

Improve Performance, Reduce Complications and Comply with

CMS, which is published by HCPro, says she’s seeing cli-

nicians struggling with the VTE measures. Facilities suc-

cessfully scoring higher than 90% for the infection

measures, she says, often see those scores at only the

60% or 70% range on VTE compliance.

SCIP < continued from p. 5

CMS requires reporting on five SCIP measures

Hospitals must submit the following data to CMS for

public reporting or forfeit 2% of their full market basket

Medicare update. The Joint Commission (formerly JCAHO)

also requires data from those hospitals that select Surgical

Care Improvement Project (SCIP) as one of their four core

measures.

The five SCIP measures are as follows:

SCIP-Inf 1: Prophylactic antibiotic initiated within one

hour prior to surgical incision

SCIP-Inf 2: Giving the patient the right antibiotic

SCIP-Inf 3: Prophylactic antibiotic discontinued within

24 hours after surgery end time

SCIP-VTE 1: Ordering the proper prophylaxis

SCIP-VTE 2: Making sure that the proper prophylaxis

was given to the patient

Reporting of the following measures is not yet linked to

Medicare payment, but The Joint Commission does require

hospitals to submit data about them:

SCIP-Inf 4: Controlling perioperative serum glucose

among major cardiac surgery patients

SCIP-Inf �: Appropriate hair removal for surgery patients

SCIP-Card 2: Major surgery patients receive a beta-

blocker perioperatively if they were on a beta-blocker

before admission

Hospitals may voluntarily submit data to The Joint Com-

mission about SCIP-Inf 7: Perioperative normothermia

among colorectal surgery patients. But it is not mandatory

because the measure has not received National Quality

Forum endorsement.

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© 2008 HCPro, Inc.



Another factor, Lin says, is that, although VTE is

the number one preventable hospital death, most phy-

sicians may not experience a VTE death in their prac-

tice. Instead, what they are more apt to experience is a

patient who has a postsurgical bleed from the use of an-

ticoagulants on his or her medication list. A physician

who has seen just one or two patients bleed may be re-

luctant to prescribe a VTE prophylaxis again, even if the

patient is at high risk. “As much as we say we like evi-

dence-based medicine, we go back to ‘I saw that patient

bleed; I’m not going to do that again,’ ” Lin says.

Compliance rates at Queen’s Medical Center for SCIP

are 92% for antibiotic timing; 96% for antibiotic se-

lection; 85% for antibiotic discontinuation; 63% for

physician ordering of prophylaxis to prevent VTE and

antibiotic timing; and 52% for the number of patients

who actually received the prophylaxis, according to its

publicly reported numbers on Hospital Compare. But in

the last three quarters of 2007, its VTE ordering prophy-

laxis rate has jumped to higher than 88% and patients

receiving prophylaxis has jumped to 85%.

Anesthesiologists key to antibiotic timing

Both Lin and Fitzgerald say anesthesiologists taking

ownership for antibiotic timing is critical to succeed at

the SCIP antibiotic timing measure.

“We were lucky early on, because one of our clinical

champions was an anesthesiologist,” Fitzgerald says. “We

gave him the data, and the next day he came back and

said, ‘Oh my God. Why aren’t we doing this?’ He was

pretty aggressive, and he really led the charge, and the

physicians all got it.” Baystate also made it clear that it

was a physician’s responsibility to prescribe the antibiotic

and an anesthesiologist’s job to administer it.

Lin recalls years ago hearing complaints from her

fellow anesthesiologists. “There were times where

we would sit around and talk about antibiotic timing,

and people said, ‘Well, why can’t the surgeon do it?

Why can’t the nurse do it? Why are you making me

do this? I have so many other things to do.’ ” Those con-

versations, she says, don’t happen anymore among

anesthesiologists at the 526-bed hospital, who are now

solidly behind the antibiotic measure.

A key factor in winning buy-in from the anesthesiolo-

gists, Lin says, is making them part of the process, and not

letting them feel as though they were just clinicians as-

signed to a task. Anesthesiologists at Queens now get re-

ports from the seven-person SCIP team about how they’re

doing and to see whether they’ve had any falloffs.

Immediate response to slips

At Baystate, performance on the day’s cases is collect-

ed by that afternoon. If there is a miss, a clinical cham-

pion immediately gets back to the physician to find out

what went wrong. Continuous display of data and feed-

back, Fitzgerald says, has helped sustain energy for

SCIP. “We just had our SCIP meeting yesterday, and

we probably have 30–35 people talking about it,” she

says. “Staff nurses are talking about it, surgeons are talk-

ing about it, anesthesiologists are talking about it. We’ve

done a really good job in infiltrating the front lines.” n

Editor’s note: Lin and Fitzgerald will be speaking during

the HCPro audioconference about SCIP on March 21. For more

information, go to http://www.hcmarketplace.com/help/

about.cfm. For more information about Lin’s SCIP book, go to

http://www.hcmarketplace.com/prod.cfm?id=5232&CFI

D=4257555&CFTOKEN=26313843.

We want to hear from you

How many resources do you have devoted to the Sur-

gical Care Improvement Project (SCIP)? Share information

with your colleagues about SCIP by e-mailing lbuckley@

hcpro.com the answers to the following questions:

1. What is your bedsize?

2. What is your surgical volume per month?

3. How many full-time equivalents (FTE) do you utilize to

collect information for SCIP?

4. How many FTEs do you utilize for quality/performance

improvement implementation of SCIP?

5. Who leads your SCIP initiative?

�. Who is your identified physician champion?

© 2008 HCPro, Inc.



Baystate tools

Source: Baystate Medical Center, Springfield, MA. Reprinted with permission.

© 2008 HCPro, Inc.


Quality Improvement Report Page �February 2008

Baystate tools (cont.)

Source: Baystate Medical Center, Springfield, MA. Reprinted with permission.

© 2008 HCPro, Inc.



Focus on infections to ensure CMS reimbursementHospitals that plan to screen every single patient for

urinary catheter–associated infections to avoid paying for

preventable conditions may want to keep this in mind:

The government will be watching.

“Increased use of the present-on-admission [POA]

variable is certainly going to occur as it is implemented

in states across the country, but what we don’t want to

see happen is the unintended consequence that there’s

increase and potentially unnecessary use of diagnos-

tic testing on admission,” said Chesley Richards, MD,

MPH, FACP, deputy director of the Division of Health-

care Quality Promotion National Center for Prepared-

ness, Detection, and Control of Infectious Diseases for

the Centers for Disease Control and Prevention (CDC).

“The example we’ve already been hearing about is

people doing unnecessary testing for . . . patients who

have catheters but who are not symptomatic with uri-

nary tract infection [UTI] on admission,” said Richards,

who spoke during the December 2007 HCPro audiocon-

ference. “Before diagnosing a UTI, clinical symptoms

should be present.”

Richards said the CDC also discourages the use of an-

tibiotics as a preventive measure when there is no evi-

dence of infection. “These are the kind of behaviors we

want to discourage over time.”

CMS will monitor these issues as well, according to

Thomas Valuck, MD, MHSA, JD, medical officer and

senior advisor to Herb Kuhn, acting deputy administra-

tor of CMS.

“It is an issue that will inform the selection of condi-

tions [in the future], and if we find that the incentive

is actually encouraging bad practice of medicine, then

we’re going to have to figure out how to change the in-

centives to make sure that isn’t the case,” said Valuck.

“Practice of medicine . . . that would overtreat and/or

provide preventive services that aren’t necessarily re-

quired, that would lead toward resistance . . . we would

certainly not want to see that inappropriate practice of

medicine happening because of the payment incentive.”

Valuck and Richards urged hospitals to focus on elim-

inating hospital-acquired conditions (HAC) instead of

overusing the POA indicator and diagnostic testing.

The new payment system will no longer pay for eight

conditions unless they are documented as POA. Staff

members should not only work on eliminating HACs,

says Valuck; they will need to learn how and when

to document and code POA conditions. If hospitals un-

der the Medicare Hospital Inpatient Prospective Payment

System fail to reduce HACs and correctly document POA

conditions by October 1, they will pay the consequence.

The eight conditions CMS will no longer pay for are:

Serious preventable events—object left in surgery

Serious preventable events—air embolism

Serious preventable events—blood incompatibility

Catheter-associated UTIs

Pressure ulcers

Vascular catheter–associated infections

Surgical site infections—mediastinitis after coronary

artery bypass graft

Patient falls

Preventing HACs requires the implementation of evi-

dence-based guidelines provided by the CDC, according

to Richards. He said the CDC’s guidelines, which include

catheter-associated infection guidelines (currently under

revision), will aid hospitals seeking to implement systems

that will decrease cost and increase patient safety.

Even as early as April 1, POA claims documented

incorrectly will be returned, unpaid, and must be re-

submitted. By October 1, all claims with HAC not docu-

mented as POA will not be reimbursed by CMS.

Proper documentation and coding will be essential to

receive correct payments. The indicator must be assigned

for each principal and secondary diagnosis.

A coder looking for the POA indicator can look at

emergency department notes, history and physicals, ad-

mitting notes, progress notes, discharge summary, and

any other documentation used in other Medicare claims.

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© 2008 HCPro, Inc.



refuse to pay, or allow the patient to pay, in its renewal

contracts.

CMS is also looking ahead to proposed conditions for

2009. Currently, ventilator-associated pneumonia, staph

infection (staphylococcus aureus septicemia), deep vein

thrombosis, and

pulmonary embo-

lism are on the list

for proposed condi-

tions CMS will not

pay for.

“There are cer-

tainly evidence-

based approaches

to preventing hos-

pital-acquired

conditions,” said

Richards. “We know that for some of these conditions

there is more research that’s needed, but we do know

that if we just got hospitals to implement what we already

have in terms of recommendations, I think we would see

a dramatic decrease in hospital-acquired conditions.” n

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“The condition itself and whether it was present on

admission requires physician documentation for substan-

tiation,” said Valuck.

Each admission is also considered separate, even if it’s a

transfer, although Valuck predicts this will be addressed in

2009’s ruling. Currently, if a patient develops a HAC not

POA and is transferred, that condition would need to be

documented as POA in the second facility.

“Getting this documentation right is going to require a

lot of communication, especially in the early phases, among

the various involved parties, both within and outside of the

hospital,” said Valuck. “That communication should build

awareness, primarily with the medical staff, and also with

the coding professionals, and should provide guidance and

tools with standard approaches for getting the coding right

and monitor how it’s going,” said Valuck.

The aim is to prevent the wait for claims to come

back, he said, and many staff members should be in-

volved, from executives to compliance officers.

“Remember that this data is useful for more than just

the hospital-acquired conditions payment policy; it can

also be used for internal quality improvement purposes,”

said Valuck.

Private insurers are also beginning to consider a ban

on paying for serious preventable conditions such as

wrong-site surgery, according to The Wall Street Journal.

One insurer, Aetna, has begun to include The Nation-

al Quality Forum’s 28 “never events” as events it will

“ Getting this

documentation right

is going to require a

lot of communication,

especially in the early

phases, among the

various involved parties,

both within and outside

of the hospital.”

— Thomas Valuck,

MD, MHSA, JD

Senior Managing Editor Lisa Buckley

Telephone 781/�3�-1872, Ext. 3715

E-mail [email protected]

Questions? Comments? Ideas?

© 2008 HCPro, Inc.



Proposed goals focus on infection control, med rec The Joint Commission (formerly JCAHO) in January

announced proposed 2009 National Patient Safety Goal

(NPSG) requirements and implementation expectations

(IE) for field review.

These proposed NPSGs affect hospitals and critical ac-

cess hospitals, ambulatory care and office-based surgery,

behavioral healthcare, disease-specific care, home care,

laboratories, and long-term care.

The Joint Commission seeks comments about these

potential new NPSGs and will be accepting feedback via

an online survey through February 27.

The field review focuses on the following areas:

Goal #1, patient identification

Goal #3, safe use of medications

Goal #7, hospital-acquired infections focusing on

methicillin-resistant staphylococcus aureus (MRSA)

and clostridium difficile–associated disease (CDAD);

catheter-associated bloodstream infections

(CABSI); and surgical site infections (SSI) in acute

care hospitals

Goal #8, medication reconciliation

Goal #13, patient involvement in their care

Universal Protocol for Preventing Wrong Site, Wrong

Procedure, Wrong Person SurgeryTM

In 2007, after the NPSGs were finalized, healthcare

organizations faced one new NPSG in preparation for

2008 requiring clinicians to respond rapidly to changes

in a patient’s condition, and another new requirement

about anticoagulant therapy.

Goal #1

Under the proposed revisions, Requirement 1A would

be expanded to include an IE requiring that the patient

be actively involved in the identification process, when

possible, before any venipuncture, arterial puncture, or

capillary blood collection procedure. Proposed Require-

ment 1C aims to eliminate transfusion errors related to

patient misidentification.

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Goal #7

Perhaps most newsworthy is the inclusion of a new

proposed requirement aimed to stop drug-resistant or-

ganism infections in hospitals. Specifically, proposed Re-

quirement 7C targets MRSA and CDAD. Among its 16

IEs, 7C requires education for healthcare workers, pa-

tients, and their families, as well as the measurement

and monitoring of infection rates. It also requires lab-

based alert systems when MRSA patients are detected,

and a surveillance system for CDAD.

Requirement 7D proposes 13 IEs, including IEs for

before and after insertion of the catheter.

Goal #8

Proposed revisions to Goal #8 are composed of new

and revised requirements and IEs intended for clarifica-

tion, not alteration, of previous requirements. Revisions

have been made to Requirements 8A, 8B, and 8C for the

reconciliation of patient medication across the continu-

um of care.

Goal #13

Two IEs have been proposed to Goal #13, which tar-

gets increasing patient involvement in their own care.

The first new IE would require facilities to provide pa-

tients with information regarding infection control (e.g.,

hand hygiene or respiratory hygiene practices), and the

latter requires facilities to provide surgical patients with

information about preventing adverse events during sur-

gery (e.g., patient identification or surgical site-marking

processes).

Universal Protocol

Proposed changes to the Universal Protocol, like those

made to Goal #8, are not meant to change the overall

concept of the goal but rather to clarify existing require-

ments. According to the draft 2009 NPSGs, the Universal

Protocol contains the same concepts as it has in previous

iterations. n

February 2008 Vol. 3, No. 2 Quality Improvement...

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