Why Purchasers Will Continue Efforts for
Reduction in Never Events
Barbara Rudolph, PhD, MSSW
Senior Science Director
Matt Austin, MA, ABD
Director, Leapfrog Hospital Survey
The Leapfrog Group
Today’s Webinar
• Introduction
• Background on Never Events
• Purchaser Contributions to Reduction in
Never Events
• Regulatory Interventions
• New Evidence on Financial Impacts of
Never Events/Adverse Events
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Introduction
• Perspective today is based on the purchaser
viewpoint but acknowledges the efforts of
providers to reduce and eliminate harm
• Discussion will focus on Never Events—those
events that should never occur--and Serious
Reportable events–
• These care problems resonate with those
who pay for care, provide care and those who
receive care
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Background
• Institute of Medicine publication in 1999 of “To Err is
Human” triggered attention on mistakes in care delivery—
and called on purchasers to “pursue continuous
improvements” and to reduce error related deaths by
50% in five years
• CDC Report in 2000 said hospital acquired infections
added $5 billion to medical costs
• NQF Serious Reportable Events (SRE) Report 2002
provided a framework for defining serious mistakes in care
delivery and enabled purchasers to ask for “reporting”
• 2003 Minnesota required public reporting of SRE’s
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National Quality Forum Efforts
•Serious Reportable Events Report
•NQF Priorities-Adverse Events
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 (next slide).
• In 2010, a committee was established to review and update the
report by adding new events and to change the “language” around
Never Events
*Serious describes an event that results in death or loss of a body part
or disability or loss of bodily function lasting more than seven days or
still present at the time of discharge from an inpatient healthcare facility
Never Events
Must be-• Unambiguous—clearly identifiable and measureable
• Usually preventable
• Serious—resulting in death, loss limb, loss of
functioning
• Any of the following:
--Indicative of problem in facility safety systems
--Adverse in consequences
--Important for credibility or accountability
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NQF Preliminary Goals for
Serious Adverse Events—Priority
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
* Meeting March 2008
Purchaser Efforts
• The Leapfrog Group
• Centers for Medicare and Medicaid Services
• Private Health Plans
Safe Practices: A Roadmap for
Addressing the Never Events
• In 2003, the Leapfrog Group added the NQF Safe
Practices
• Safe Practices included: Creating a Culture of
Safety, increased accountability for improvement;
greater leadership engagement; reporting to Boards
on safety improvements; continual monitoring of
safety; preventing infections (CLABSI), and
preventing pressure ulcers
• By 2007, at least 1000 hospitals nationally had
completed Safe Practices Section of the LF Hospital
Survey
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The Leapfrog Group Hospital Survey
(2007): Never Events Policy
Asked hospitals to report on whether they agreed to adopt 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 Organizations
• 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
2009 Never Events Results
100
75
65
67.8
2008
2009
50
25
0
% of Hospitals that Fully Met
Leapfrog Incorporated Hospital
Acquired Conditions Survey Section
• Hospital Acquired Pressure Ulcers (2008)
• Hospital Acquired Injuries (2008)
• Central Line-Associated Blood Stream
Infections (2009)
Reported out as rate per 1,000/ inpatient days or central
line days
Hospital Performance on Central Line-Associated Bloodstream
Infections
Fully Meets
Standards
Substantial
Progress
Some
Progress
Willing to
Report
Standardized Infection Ratio
(SIR) range for the performance
category
=0.00
> 0.00 and
<=0.90
> 0.90 and
<= 1.10
(or > 1.10 and
participates in
ON THE
CUSP)
> 1.10 and
does not
participate in
ON THE
CUSP
No. of Hospitals in Performance
Category
88
(12%)
391
(53%)
151
(20%)
110
(15%)
No. of hospitals in this
performance category that
participate in their state’s ON
THE CUSP: STOP BSI CLABSI
prevention program
30
(34%)*
141
(36%)*
116
(77%)*
* Percent based on number of hospitals in Performance Category
Based on Leapfrog Hospital Survey results as of August 31, 2010
CMS Measures for Non-Payment--2008
• With the passage of the Deficit Reduction Act of 2005 (DRA),
the Congress took steps to revise the way Medicare pays
hospitals. 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.
CMS Wrong Surgical/Procedure--2009
• In 2009, CMS’s Wrong Surgical or Other
Invasive Procedure position to consider
wrong surgeries performed as non-covered
services was implemented via National
Coverage Determinations effective Jan. 1,
2009. Wrong surgeries include:
• Surgery on the wrong body part
• Surgery on the wrong patient
• Wrong surgery performed on a patient
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HACs Resulting in Reduced Medicare
Payment for FY2009
•
•
•
•
•
•
•
•
Pressure ulcer stages III and IV
Falls and trauma
Vascular-catheter associated infection
Catheter-associated urinary tract infection
Administration of incompatible blood
Air embolism
Foreign object unintentionally retained after surgery
Surgical site infection after bariatric surgery for
obesity, certain orthopedic procedures, and bypass
surgery
• Deep vein thromboses and pulmonary emboli
associated with knee and hip replacements
• Certain manifestations of poor glycemic control
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Impact of Payment Adjustment for
Hospital-Acquired Condition—Pressure
Ulcer
Inpatient PPS Wage Adjusted Rate
$ 6,602.57
Weight
DRG 195 Simple Pneumonia w/out CC
DRG 194 Simple Pneumonia w/CC
Payment
0.8398 $ 5,544.61
1.0235 $ 6,757.41
707.01 Pressure Ulcer - Elbow
Potential Payment Reduction
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$ (1,212.80)
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Health Plans with Payment Policies on
Serious Adverse Events
• Partners Health Plan—Minnesota first
• Cigna-implemented through national policy in 2008
2008 consistent with CMS policy
• Aetna-implemented Leapfrog’s policy through
contracts over 3 years with hospitals to end
reimbursement for 28 "never events" beginning in
March 2008
• Wellpoint also adopted “never events” policy
covering 27 events—policy announced in Jan
2008 (covers 35 million members)
• Humana has followed CMS lead in payment policy
changes for NQF Reportable adverse events
Health Plan Implementation of Never
Event Policies
• BCBSA national policy announced in November
2007, pushing affiliated plans to no longer pay for
serious errors and hospital-acquired conditions.
• Blue Cross Blue Shield of Massachusetts adopted
policy that 28 kinds of medical and surgical errors
were no longer billable in 2008
• WellPoint is testing a policy that does not reimburse
for four “never events” in certain states.
• United Healthcare has incorporated LF’s policy
statement into its hospital contract forms beginning
3rd qtr 2009 for future contracts
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Regulatory Interventions
• In 2003, the Minnesota Legislature passed the
Adverse Health Care Events Law, requiring hospitals
and ambulatory surgical centers to report to the
Minnesota Department of Health whenever one of 27
– now 28 - serious adverse health events occurred.
• 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)
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State Activity
• 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)
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Minnesota Events
In their 2008
report, the state
totaled over 800
“never events”
reported
between 2003
and 2008
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Why we need to keep going!
• Report sponsored by
Society of Actuaries’
Health Section,“ The
Economic Measurement
of Medical Errors”. (June
2010), © Milliman
• Based on claims data–
found cost of $19.5
billion—for medical errors
in 2008
• Direct increase in
medical costs ($17
billion or 87%)
• Indirect costs of
approximately $1.4
billion related to
increased mortality
• $1.1 billion related to
lost productivity from
short-term disability
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Errors with Largest Annual Measureable Cost
J. Shreve, J. VanDenBos, T.Gray, M.Holford, K. Rustagi, and
E. Ziemkiewicz. Economic Measurement of Medical Errors, Society
of Actuaries, June 2010.
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Overall Result of Errors in 2008
•
•
•
•
•
Approximately $13,000 per error
Total cost to US $19.5 billion
2,500 excess deaths
10 million excess days missed from work
And, not all costs can be coded and thus are not
included..for example, deaths occurring outside the
hospital, pain and suffering, malpractice payments or
insurance payments, no administrative costs
associated with hearings
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But wait! Is the data right?
Authors reference Layde et. al., study
reporting that, in at least 90% of claims with
ICD-9 DX Codes indicating a medical error,
the patient actually experienced an error.
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Keep up the pressure?
It is working! But we have a ways to go• 30% of hospitals haven’t agreed to
policy—citing that they do not have legal
protections to apologize or admit errors
• Some hospitals at zero errors, but many
still experiencing preventable errors
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The University of Michigan Health
System (UMHS) Never Events
• Study released—showing significant
reductions in litigation and malpractice costs
using honesty and apology following medical
errors
• Greater than 50 percent reduction in average
litigation costs and reduced malpractice
claims by 55 percent between 1999 and
2006.
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MN DOH Report: Significant Impact of
Never Events Reporting
 72 percent of facilities
feel--reporting law has
made hospitals safer
than we were in 2003
 Facilities have made
numerous changes in
policies, processes, and
approaches to
prevention of the most
common types of
adverse events
 Increased sharing of
adverse events data
with boards of directors,
staff and other facilities,
disclosing adverse
events to patients and
family members,
 leadership engagement,
and assessment of
each organization’s
safety culture.
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Reporting Impact
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Resources
• NQF Safe Practices Report
www.qualityforum.org
• Leapfrog’s Hospital Results can be found at:
www.leapfroggroup.org
• The Economic Measurement of Medical
Errors paper is available at:
http://www.soa.org/files/pdf/research-econmeasurement.pdf
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