CMS’ HOSPITAL ACQUIRED CONDITIONS

1. CMS’ HOSPITAL ACQUIRED CONDITIONS Mary Nickel, RN, MSM Director, Medical Staff Support/Clinical Quality Saint Clare’s Hospital

2. OBJECTIVES • Provide background on CMS’ Hospital Acquired Conditions (HACs) • Present CMS’ criteria for selecting HACs • Explain reporting requirements • Emphasize the importance of medical record documentation • Discuss the importance of evidence-based practices

3. BACKGROUND • Common medical errors total more than $4.5 billion additional health spending/year (Centers for Disease Control) • National Quality Forum (NQF) created a list of 28 Never Events • NQF defines Never Events as errors in medical care that are: • Concerning to both public and healthcare professionals and providers, • Clearly identifiable and measurable, and • Significantly influenced by the policies and procedures of the healthcare organization.

4. NQF’S NEVER EVENTS • Surgical Events • Surgery on wrong body part • Surgery on wrong patient • Wrong surgery on a patient • Foreign object left in patient after surgery • Post-operative death in normal health patient • Implantation of wrong egg • Product or Device Events • Death/disability associated with use of contaminated drugs • Death/disability associated with use of device other than as intended • Death/disability associated with intravascular air embolism

5. NQF’S NEVER EVENTS • Patient Protection Events • Infant discharged to wrong person • Death/disability due to patient elopement • Patient suicide or attempted suicide resulting in disability • Care Management Events • Death/disability associated with medication error • Death/disability associated with incompatible blood • Maternal death/disability with low risk delivery • Death/disability associated with hypoglycemia • Death/disability associated with hyperbilirubinemia in neonates • Stage 3 or 4 pressure ulcers after admission • Death/disability due to spinal manipulative therapy

6. NQF’S NEVER EVENTS • Environment Events • Death/disability associated with electric shock • Incident due to wrong oxygen or other gas • Death/disability associated with a burn incurred within facility • Death/disability associated with a fall within facility • Death/disability associated with use of restraints within facility • Criminal Events • Impersonating a heath care provider (i.e., physician, nurse) • Abduction of a patient • Sexual assault of a patient within or on facility grounds

7. CMS’ HACs Criteria • Medicare’s Hospital Acquired Conditions (HACs) somewhat overlap with NQF’s 28 Never Events • Not all HACs are included in the NQF’s Never Events • Medicare’s HACs are based on the following criteria: • High cost, high volume, or both, • Identified as an ICD-9-CM coded complicating or major complicating condition resulting in an secondary discharge diagnosis = higher payment (higher MS-DRG), and • Reasonably preventable through evidence-based practices.

8. REPORTING • CMS required reporting on claims for discharges starting 10/1/07 • Starting 10/1/08, CMS will no longer pay for the extra cost of treating patients with HACs • Insurance companies in alignment with CMS

9. CMS’ HACs - 2008 • Pressure ulcer stages III and IV • Falls and trauma • Fractures • Dislocations • Intracranial Injuries • Crushing Injuries • Burns • Electric Shock

10. CMS’ HACs - 2008 • Surgical site infections following: • Coronary Artery Bypass Graft (CABG) - Mediastinitis • Bariatric Surgery • Laparoscopic Gastric Bypass • Gastroenterostomy • Laparoscopic Gastric Restrictive Surgery • Orthopedic Procedures • Spine • Neck • Shoulder • Elbow

11. CMS’ HACs - 2008 • Vascular-catheter associated infection • Catheter-associated urinary tract infection • Administration of incompatible blood • Air embolism • Foreign object unintentionally retained after surgery

12. CMS’ HACs - 2009 • Additional categories to be added under CMS’ HACs policy effective 10/1/08

13. CMS’ HACs - 2009 • Manifestations of Poor Glycemic Control • Diabetic Ketoacidosis • Nonketotic Hyperosmolar Coma • Hypoglycemic Coma • Secondary Diabetes with Ketoacidosis • Secondary Diabetes with Hyperosmolarity

14. CMS’ HACs - 2009 • Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) • Total Knee Replacement •  Hip Replacement

15. CMS’ POA INDICATOR OPTIONS

16. POA INDICATOR REPORTING • POA indicator is mandatory for all inpatient hospital claims • POA is defined as present at the time the order for inpatient admission occurs • Conditions that develop during an outpatient encounter, i.e. clinic, ED, outpatient surgery are considered POA • POA indicator is applied to both principal and secondary diagnoses

17. CASES/CHARGES

20. MEDICAL RECORD DOCUMENTATION • Documentation in the record is very important • Must be consistent • Must be complete • Must be timely • Completed by a healthcare provider who is legally accountable for establishing a diagnosis

21. IMPLEMENTING EVIDENCE BASED PRACTICES • Performing and documenting risk assessments • Obesity • Diabetes • Smoking • Prior history of PE/VTE • Prior history of UTIs • Other co-morbidities • Risk assessment criteria established by various professional practice organizations • American College of Cardiology • Society of Thoracic Surgeons • American College of Chest Physicians • Centers for Disease Control and Prevention

22. IMPLEMENTING EVIDENCE BASED PRACTICES • Decreasing risks through operational practices • Monitoring • Positioning • Timing • Marking • Maintaining • Decreasing risks with appropriate antibiotics

23. HOW WOULD YOU DECREASE RISK TO PREVENT… • Pressure ulcer stages III and IV

24. HOW WOULD YOU DECREASE RISK TO PREVENT… • Falls and trauma • Fractures • Dislocations • Intracranial Injuries • Crushing Injuries • Burns • Electric Shock

25. HOW WOULD YOU DECREASE RISK TO PREVENT… • Surgical site infections following: • Coronary Artery Bypass Graft (CABG) - Mediastinitis • Bariatric Surgery • Laparoscopic Gastric Bypass • Gastroenterostomy • Laparoscopic Gastric Restrictive Surgery • Orthopedic Procedures • Spine • Neck • Shoulder • Elbow

26. HOW WOULD YOU DECREASE RISK TO PREVENT… • Vascular-catheter associated infection

27. HOW WOULD YOU DECREASE RISK TO PREVENT… • Catheter-associated urinary tract infection

28. HOW WOULD YOU DECREASE RISK TO PREVENT… • Administration of incompatible blood

29. HOW WOULD YOU DECREASE RISK TO PREVENT… • Air embolism

30. HOW WOULD YOU DECREASE RISK TO PREVENT… • Foreign object unintentionally retained after surgery

31. HOW WOULD YOU DECREASE RISK TO PREVENT… • Manifestations of Poor Glycemic Control • Diabetic Ketoacidosis • Nonketotic Hyperosmolar Coma • Hypoglycemic Coma • Secondary Diabetes with Ketoacidosis • Secondary Diabetes with Hyperosmolarity

32. HOW WOULD YOU DECREASE RISK TO PREVENT… • Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) • Total Knee Replacement •  Hip Replacement

33. WHAT WOULD YOU DO ONCE A HAC OCCURS… • Disclose incident to patient and apologize • Conduct a Root Cause Analysis (RCA) • Ask “why” 5 times • Involve those who provided the care/services; include physicians • Create an action plan based on the root cause(s) • Implement and monitor the plan for improvement

34. CMS’ HACs • Next steps • Continue to assess each HAC against your hospital’s practices • Develop policies and procedures to decrease your patients’ risks • Monitor for HACs and analyze incidents • Educate your staff and physicians on HACs and prevention • Involve your patients

35. QUESTIONS