Medicolegal Issues

Partnership for Patients: CMS’ Ambitious Program for Patient Safety Improvement


 

Partnership for Patients brings a spotlight and an energy to the issue that will last long beyond the 24 months of this program.


—Katharine Luther, RN, MPM, vice president of hospital portfolio planning and administration, Institute for Healthcare Improvement

Last April, the Centers for Medicare & Medicaid Services (CMS) unveiled “Partnership for Patients,” a landmark event in the patient safety movement that put a national spotlight on the continuing need to improve healthcare safety and quality. A year later, the initiative is getting off the ground, attempting to tackle ambitious goals and overcome methodological hurdles in a very tight timeframe.

Partnership for Patients is a $1 billion, nationwide educational collaborative in which participants pledge that they will try to achieve two things by the end of 2013: Reduce the incidence of preventable hospital-acquired conditions by 40% compared to 2010, and decrease preventable complications during transitions of care to reduce hospital readmissions by 20% compared with 2010.

More than 3,000 hospitals and 2,000 physician and nursing organizations have signed the pledge, and CMS recently awarded contracts to 26 Hospital Engagement Networks (HENs)—state, regional, and national hospitals and health systems that will serve as mobile classrooms that mentor as they implement new intervention strategies, track progress on quality improvement (QI), and develop learning collaboratives to spread effective interventions. CMS also has contracted with outside firms to create patient safety training materials, engage with patients and families to foster more patient-centered care, and evaluate the impact and effectiveness of the initiative.

SHM was one of the first physician groups to sign on to the initiative’s pledge of support, and both its Project BOOST (to reduce preventable readmissions) and its VTE Resource Room (to prevent hospital-acquired venous thromboembolism) are among the resources it is making available to the initiative’s HENs, says Wendy Nickel, MPH, associate vice president of SHM’s Center for Hospital Innovation and Improvement.

Worthy Goals

Despite success stories at some institutions in recent years, patient safety improvement still has far to go at U.S. hospitals. Currently, about 1 in every 20 patients acquires an infection in the hospital, 1 in 7 Medicare patients is harmed in the course of their hospital care, and nearly 1 in 5 is readmitted within 30 days of discharge. CMS estimates that meeting the goals of Partnership for Patients would mean more than 60,000 lives saved over the next three years and over 1.6 million patients spared a preventable complication requiring re-hospitalization within 30 days of discharge—all of which could save Medicare $50 billion over the next 10 years.1

Formidable Obstacles

While the initiative’s goals are certainly worthy, it remains to be seen how prepared hospitals are to achieve them, and whether available metrics are up to the task.

“The initiative is a positive step to improve collaboration among government, communities, and hospital sites in service of better patient care and safety—and so it deserves our endorsement,” says Greg Maynard, MD, MSc, SFHM, health sciences professor of medicine at the University of California at San Diego, director of the UC San Diego Center for Innovation and Improvement Science, and senior vice president of SHM’s Center for Hospital Innovation and Improvement. “But it’s an open question how successful it will be, since it offers no monetary piece of the pie to participating hospitals, and no financial penalties for failing to achieve its goals. The whole project feels rushed, for a major initiative like this, with such ambitious goals.”

The primary “carrot” the initiative offers hospitals, Dr. Maynard notes, is access to patient safety improvement expertise and resources that they would otherwise have to purchase on their own, including training materials, implementation guides, webinars, and site visits by HEN representatives.

As an indirect inducement to participate, CMS’ Hospital Readmissions Reduction Program begins this October and will penalize hospitals by as much as 1% of their total Medicare billings (increasing to 3% in 2015) for high rates of readmissions related to heart attack, heart failure, and pneumonia. CMS’ Value-Based Purchasing program also continues to reward and punish hospitals for their performance on core measures and patient satisfaction, with more metrics forthcoming.

Metric Morass

A major challenge to the success of Partnership for Patients will be the ability to formulate and share reliable, uniform patient safety metrics across institutions. The initiative gives each of the 26 HENs the flexibility to tailor their activities to the sites they are mentoring, and there is no clear way of making standardized comparisons of hospital performance across the HENs, Dr. Maynard says.

Metric validity is a crucial component of any QI initiative. And yet, the ability to reliably measure patient harm/adverse event rates at hospitals—and therefore achieving a solid “denominator” baseline with which to track progress—remains elusive. In a recent report, the U.S. Department of Health and Human Services’ Office of the Inspector General noted that hospital incident reporting systems capture only an estimated 14% of the patient harm events experienced by Medicare patients, reporting requirements remain unclear, and hospital staff continue to harbor misperceptions about what constitutes patient harm.2

In what almost sounds like “back to the drawing board,” the report recommended that CMS and the Agency for Healthcare Research and Quality (AHRQ) collaborate to create and promote a list of potentially reportable events for hospitals to use, and that CMS provide guidance to accreditors regarding their assessments of hospital efforts to track and analyze events.

The problem is that voluntary incident reporting systems are only one tool for identifying patient harm. Typically, however, they miss many things that can harm patients and are grossly under-reported. As a result, they need to be used in conjunction with other data sources, such as hospital infection rates, daily safety rounding on hospital units, and patient chart sampling, says Katharine Luther, RN, MPM, the Institute for Healthcare Improvement’s vice president of hospital portfolio planning and administration.

Another excellent surveillance instrument for capturing a count of possible harm events is a Global Trigger Tool, which samples patient charts to identify aberrant lab values, drug dosages, and other untoward events that might indicate harm, even though they might not easily be recognized as harmful by hospital staff, Luther says.

Warranted Optimism

Despite its aggressive timeline and inherent methodological challenges, Luther says the Partnership for Patients will galvanize and focus hospitals’ patient safety improvement efforts and provide a much-needed framework for implementation.

“We know of organizations that have greatly reduced the incidence of pressure ulcers, and have gone for a year or more with no cases of ventilator-associated pneumonia or central-line-associated bloodstream infection (CLABSI),” Luther says. “Exemplars like these are out there, so it can be done. Partnership for Patients brings a spotlight and an energy to the issue that will last long beyond the 24 months of this program.”

Chris Guadagnino is a freelance medical writer in Philadelphia.

Goals of Partnership for Patients

Reduce preventable hospital readmissions rates by 20%.

Reduce the following preventable hospital-acquired condition rates by 40%:

  • Adverse drug events (ADE);
  • Catheter-associated urinary tract infections (CAUTIs);
  • Central-line-associated bloodstream infections (CLABSIs);
  • Injuries from falls and immobility;
  • Obstetrical adverse events;
  • Pressure ulcers;
  • Surgical site infections;
  • Venous thromboembolism
  • (VTE); and ventilator-associated pneumonia (VAP).

References

  1. CMS Fact Sheet. Hospital Engagement Networks: Connecting Hospitals to Improve Care. Centers for Medicare & Medicaid website. Available at: http://www.cms.gov/apps/media/press/factsheet.asp?Counter=4219&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date. Accessed Feb. 12, 2012.
  2. HHS Office of Inspector General. Hospital Incident Reporting Systems Do Not Capture Most Patient Harm. Office of Inspector General website. Available at: http://oig.hhs.gov/oei/reports/oei-06-09-00091.pdf. Accessed Feb. 12, 2012.

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