It's Now or Never...
Eliminate Costly Never Events
By Rich Bluni and Julie O'Shaughnessy
Last October, the Centers for Medicare and Medicaid Services (CMS) implemented its new policy to no longer reimburse hospitals for 11 conditions that were not present upon admission. Since then, CMS had added three additional conditions. (See sidebar on page 3).
Each year, more than 650,000 patients experience one of these preventable errors leading to needless pain, injury, and even death. Never Events are costly for your organization, too. Not only do they sap caregivers’ passion, purpose
and sense of worthwhile work when they occur, but they steal money from your bottom line.
Consider: An infection that occurs after a coronary artery bypass graft can cost as much as $30,000 to treat. Now hospitals will not receive reimbursement for that treatment cost. Similarly, the 257,412 cases of Stage III and IV pressure ulcers in 2007 (not present on admission) cost a non-reimbursable average of $43,180 per stay. And 193,566 cases of falls and trauma cases in 2007 cost an average of $33,894 that CMS will no longer pay.
It’s definitely Now or Never. CMS views this reimbursement change as the beginning of a major step forward in their shift toward “valuebased purchasing”, a philosophy of paying hospitals based on their performance on certain measures (e.g. Never Events, HCAHPS results), rather than the amount of service provided.
The Good News
Fortunately, Never Events are preventable. And, if you are using Studer Group’s Evidence-Based LeadershipSM model, you can achieve dramatic cost reductions with minor adjustments to tools you’re already using for execution and accountability.
Engage your staff so they understand how their actions and behaviors impact the occurrence of Never Events. If an unfortunate event occurred in your organization, share it widely so everyone can learn about how to better sustain a culture of safety. Be sure to communicate to all employees—and patients— the actions the organization is taking to reduce the occurrence of Never Events.
9 Ways to Reduce Never Events
1. Hold leaders accountable. If you are using an objective leader evaluation system such as Studer Group’s Leader Evaluation Manager SM (LEM), include specific measurable goals on Never Events from the CEO to front-line supervisors for maximum alignment and results. Some examples of goals include:
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Reduce the incidence of Never Events resulting in a cost avoidance of $500,000 by the end of the fourth quarter;
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Reduce the incidence of surgical site infections by 25%;
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Reduce the incidence of vascular catheterassociated infections by 30%;
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Achieve fewer than two nosocomial pressure ulcers during 2009.
2. Develop your leaders. Ensure that leaders understand which medical errors are classified as Never Events and how their actions and behaviors are aligned to the organization’s goal to eliminate them. If your organization already offers quarterly training to leaders, ask the CEO to present an update on the organization’s performance related to Never Events—and the financial savings—at each Leadership Development Institute.
3. Engage staff. Be sure employees understand how their actions and behaviors impact the occurrence of Never Events. Connect to passion, purpose, and worthwhile work by sharing stories of missed opportunities and good catches on Never Events. Reward and recognition goes a long way with patient safety so be sure to acknowledge those who are willing to speak up to create a culture of safety (e.g.; “I noticed you just touched your cell phone with those gloves. You might want to change them.”) Everyone’s on the same team so egos shouldn’t be at issue. A second pair of eyes should be welcomed.
4. Round for Outcomes. Are you already rounding on employees and physicians? Be sure to include questions that will help identify barriers and harvest best practices for reducing the occurrence of Never Events.
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Were you able to care for your patients this week as safely as possible? If not, why not?
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Is there anything we could do to prevent the next adverse event?
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Have you developed any personal practices that you do to specifically prevent making errors (memory aids, double-checking, forcing functions, etc.)?
5. Send Employee Thank You Notes. Already sending hand-written thank you notes to employee and physician homes? Seek out opportunities to recognize employees and physicians who have made changes in behavior to prevent Never Events. For example:
Dear Dr. Robinson,
While rounding in the OR last week, the staff shared with me that you are serving as a role model in using the “time out” to confirm the correct patient, site, and procedure. This practice is key to preventing surgical errors. I appreciate your commitment to providing a safe environment for our patients.
6. Use Key Words at Key Times. Train employees on how key words can be used to reduce the occurrence of Never Events and involve patients and their families. For example, you can involve patients in understanding the “why” of what you do for more compliance with the “what” and the “how.” If you are working to reduce pressure ulcers, you might say, “Mr. Smith, we want to move you onto your side. I know it’s a little less comfortable for you, but your doctor asked me to change your position frequently as you are at risk for pressure ulcers and we want to ensure your safety.” If the issue is falls, say, “Ms. James, I am going to put up this side rail on your bed to ensure you don’t fall. Did you know you were on fall precaution? That means we’d like you to press your call light so we can help you if you need to get out of bed.”
7. Use hourly rounding. Research clearly shows that rounding hourly on patients reduces falls by 50% and pressure ulcers by 14%. Doesn’t it make sense that if caregivers are in a patient’s room every hour they can also reduce infections and catch other Never Events through a visual inspection of the patient? Ask patients to report any sensitivity or pain from an IV, central line, or surgical site during hourly rounds.
Ask caregivers to document their assessment. If they are adjusting a patient’s position, ask them to mark an L, R, or B (for left, right, or back) on the patient’s chart. If they notice a patient has increased pain medication or had a change in blood pressure that might make them more prone to falls, note it on the chart for review on the next round.
8. Pre-Visit Phone Calls. Use pre-visit phone calls to explains steps a patient can take to reduce the chance of infection (e.g.; “It’s very important to prepare your skin by washing with the solution the doctor provided you the night before your surgery.”)
9. Tighten up assessment, documentation, and coding. Be sure to assess patients upon admission. New “present on admission” codes must be applied correctly to ensure full reimbursement if a condition was already present when a patient is admitted.
Ensure Never Events Never Happen
Never Events aren’t just expensive for your bottom line. All of us have seen the effect that Never Events have on our patients, their families and our organizations. When we talk about Never Events, it’s easy to get “distracted” by the numbers. While they’re important, they don’t tell the whole story. Behind a fall with a fracture, there may be a grandfather who can no longer take his granddaughter for a walk by their favorite pond. Behind a nosocomial infection, there may be a young mother who misses her son’s first day of kindergarten because of a prolonged hospital stay. There are stories behind every Never Event that have a profound impact on individuals and whole families. While the numbers help us to track and trend, we must not become distracted by them. Remember—this is about protecting human beings from harm.
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