NationalState Efforts Related to Serious Adverse Reportable Events

1
National/State Efforts Related toSerious Adverse
(Reportable) Events

• NAHDO Quality Workgroup
• Conference Call
• May 22, 2008

2
What are we talking about?

• There appears to be a proliferation of terms
  describing similar, if not identical events.
• Serious Reportable Events?
• Adverse Events?
• Serious Reportable Adverse Events?
• Never Events?
• HAIs?
• Hospital Acquired Conditions?
• Hospitalization Related Conditions?

3
National Quality Forum Efforts

• Serious Reportable Events Report
• NQF Priorities-Adverse Events

4
Serious Reportable Events

• In 2002, the National Quality Forum (NQF)
  endorsed a list of 27 adverse events that are
  serious, largely preventable, and of concern to
  both the public and healthcare providers for the
  purpose of public accountability.
• In 2006, an update was released for the Serious
  Reportable Events in Healthcare.
• Serious Reportable Events also came to the
  forefront at the Priority Partners Meeting in
  March of 2008.

5
NQF Preliminary Goals forSerious Adverse
EventsPriority Partners

• 1. Reduce serious adverse events in hospitals.
• 2. Require broader harmonization of serious
  adverse events across payers
• 3. Linkage to non-payment for all serious adverse
  events by date certain
• 4. Identify and prioritize the measurement gaps
  by impact on cost and lives saved

6
Serious Adverse EventsPreliminary Goal 1
Measurement Approach

• Develop a global measure that would allow
• tracking of all serious adverse events in
  hospitals with a zero tolerance goal
• Develop individual measures of NQF serious
• reportable events (SREs) and an overall SRE
• composite at the hospital level
• Develop measures that would allow tracking
• of additional serious adverse events
• associated with non-payment by CMS and
• private payers

7
Serious Adverse EventsPreliminary Goal 2
Payment Approach

• Require harmonization for serious adverse
• events across public and private payers by date
• certain
• Drive broader adoption through value-based
• approaches for all serious adverse events in
• hospitals, including non-payment and gain
• sharing
• Consider incentives for a learning environment,
• including root-cause analyses

8
CMS Measures for Non-Payment

• With the passage of the Deficit Reduction Act of
  2005 (DRA),11 the Congress took steps to revise
  the way Medicare pays hospitals so that beginning
  on October 1, 2008, they would not receive higher
  payments for patients that acquire certain
  preventable conditions (including any of three
  HAIs) during their hospital stays.
• The HAI-related preventable conditions that CMS
  identified in the final regulation implementing
  subsection 5001(c) of the DRA were urinary tract
  infections caused by catheters, infections caused
  by vascular catheters, and mediastinitis
  following coronary artery bypass graft surgery.

9
Federal Agency Databases for HAIs

• CDCs National Healthcare Safety Network (NHSN)
  --Most hospitals report on patients in selected
  critical care units and those undergoing selected
  procedures such as coronary bypass surgery and
  colon surgery.
• central-line-associated BSI
• catheter-associated UTI
• VAP
• post-procedure pneumonia
• SSI
• MDRO (data includes both hospital and community
  acquired)
• other

10

CMSs Medicare Patient Safety Monitoring System
(MPSMS) (National sample of hospitalized
Medicare patients.)

• central-line-associated BSI
• catheter-associated UTI
• postoperative pneumonia
• antibiotic-associated C. difficile
• MRSA
• VRE

11

CMSs Annual Payment Update (APU) database
-National inpatient population for selected
surgical procedures

• Practices to prevent or reduce SSIs
• providing antibiotics within 1 hour of surgery
• selecting appropriate antibiotics to prevent
  surgical infections
• stopping the administration of the antibiotics
  within 24 hours of end of surgery

12
AHRQs Healthcare Cost and Utilization Project
(HCUP) database Nationwide Inpatient Sample

• Infection types
• postoperative sepsis
• infection due to medical care (focused on
  intravenous and catheter infections)

13
New GAO Report says

• Currently collected data on HAIs are not being
  combined to maximize their utility.
• HHS has made efforts to use the currently
  collected data to understand the extent of the
  problem of HAIs, but the lack of linkages across
  the various databases results in a lost
  opportunity to gain a better grasp of the problem
  of HAIs.
• AHRQ and CDC have not coordinated efforts and as
  a result have duplicated studies on HACs.
• CDC has over 1200 recommended practices for
  hospitalsas a result there has been limited
  uptake by regulators.
• HHS has multiple methods to influence hospitals
  to take more aggressive action to control or
  prevent HAIs, including issuing guidelines with
  recommended practices, requiring hospitals to
  comply with certain standards, releasing data to
  expand information about the nature of the
  problem, and soon, using hospital payment methods
  to encourage the reduction of HAIs.

14
The Leapfrog Group Hospital Survey (2007-2009)
Never Events Policy

• Reports on hospitals adopting the following
  policy
• We will apologize to the patient and/or family
  affected by the never event
• We will report the event to at least one of the
  following agencies
• Joint Commission on Accreditation of Healthcare
  Organizations (JCAHO), as part of its Sentinel
  Events policy
• State reporting program for medical errors
• Patient Safety Organization
• We agree to perform a root cause analysis,
  consistent with instructions from the chosen
  reporting agency
• We will waive all costs directly related to a
  serious reportable adverse event

15
Leapfrog Hospital Acquired Conditions (added in
2008)

• Hospital Acquired Pressure Ulcers
• Hospital Acquired Injuries
• Reported out as rate per 1,000 inpatient days

16
Health Plans with Payment Policies on Serious
Adverse Events

• Partners Health PlanMinnesota first
• Cigna-implemented through national policy by
  October 2008
• Aetna-implemented through contracts over next 3
  years with hospitals to end reimbursement for 28
  "never events"
• WellPoint-is testing a policy that does not
  reimburse for four never events in certain
  states. 
• UnitedHealthcare investigating policy on never
  events

17
State Initiatives in Adverse Event Reporting
18
Reporting of Adverse Events

• June 2003, Minnesota became the first state to
  require public reporting of the NQF-endorsed list
  of events
• By September 2005, twenty-five states had passed
  legislation or regulation related to hospital
  reporting of adverse events. (NASHP, Maximizing
  the Use of State Adverse Event Data to Improve
  Patient Safety)

19
Patient Safety and Quality Improvement Act of
2005- (Public Law 109-41)

• Mandated creation of state systems for tracking
  of adverse events in healthcare
• While not all states have developed adverse
  medical event reporting systems many states
  have been quick to adopt or adapt reporting
  systems to incorporate recommendations made in To
  Err Is Human (IOM, 2000), according to Rand study
  (2006)
• By 2006, 24 states had at least one formal
  adverse medical event reporting system

20
Rand Survey Results

• Twenty of the 24 systems were mandatory, that is,
  the healthcare organizations covered by the
  system are required to report certain adverse
  events to the state
• Most systems focused on General and acute care
  hospitals
• Absence of formal documentation and definitions
  few had data dictionaries or codebooks
• Nearly all aimed at improvement, rather than
  punishment
• States moving toward greater standardization
  most store data in electronic format only a few
  allow aggregated submission

21
Rand Survey Results, cont.

• Most states have list of reportable eventsmany
  are based on NQF Serious Reportable Events (SREs)
• most commonly included NQF events are
• patient death or serious disability associated
  with a
• medication error
• wrong-site surgery
• infant discharge to wrong person
• wrong-patient surgery
• wrong-procedure surgery
• retention of a foreign object

22
Rand Survey Results, cont.

• Most common elements collected by state systems
  about reportable events are
• a narrative of the event
• information on corrective actions taken
• when the event occurred
• patient information.

23
Coding Standards for Adverse Events

• Rand also assessed the utility of existing
  medical standards for coding adverse medical
  eventsthat assessment found that
• Existing standards can be used to code much of
  the IOM recommended information regarding adverse
  medical events
• Standards for other elements can be developed
  within the context of existing standardsSNOMED,
  LOINC, HL7
• Not necessary to develop special standards for
  coding Adverse Events