When Banner Desert Medical Center realized in 2006 that its heart attack patients were not receiving timely, crucial care, staff took a hard look into the time it was taking them to get a patient from the emergency room to inserting the potentially life-saving balloon catheter.
Door-to-balloon time, as it is known, is a critical performance measurement within a larger number of steps that national organizations recommend hospitals follow for treating heart attacks. The moment a patient walks in the door to the time the balloon is inserted should happen within 90 minutes, according to the measure, one of the Joint Commissions and CMS core measures. Hospitals are required to post their compliance rates to HHS Hospital Compare quality-reporting Web site.
Banner Desert, Mesa, Ariz., had been performing outside that time frame, at 101 minutes. But in the past year, staff at the 621-bed facility have dropped the time to an average of 63 minutes per patient by instigating several cultural and operational changes, says Paula Durston, a registered nurse and director of the cardiovascular service line for the hospital. We would learn about things and make immediate changes, she says. Banner set target times for moving patients through each step of the procedure and uses atomic clocks to make sure every unit is on the same exact time. Each case is reviewed in real time and changes are implemented for the next case based on that review. Monthly meetings are designed to ensure that the changes are sustained.
Since January, all patients except one were cared for under the 90-minute deadline, a feat the hospital is proud to note after the work that went into overhauling the organizations culture, says James Ganem, a physician and medical director of the cardiac catheterization lab. You have to remain ever vigilant, he says.
Vigilance is likely to play an even larger role for hospitals that want to be paid for their services, not just those that strive to provide high quality of care. Quality improvement is increasingly being used to form the basis of nonpayment models by insurers, state and federal agencies, which are cracking down on reimbursing for poor performance and for mistakes they say hospitals should prevent.
Performance measures such as door-to-balloon time still are used only to assess quality while payers focusfor nowon nonpayment models constructed around the most egregious preventable medical errors, known as never events. But by improving on these performance measures now, hospitals are getting a head start on preparation for whats coming down the pike, Ganem says. By challenging and changing the culture in one areathats been our bridge to addressing never events and other issues.
Taking their cue from the CMS, which on Oct. 1 will stop paying for 11 incidents it has deemed preventable by hospitals, insurers have started to adopt similar nonpayment policies. Medicare created part of its list from criteria by the National Quality Forum, which endorses a list of 28 never events. The others on the CMS list are considered hospital-acquired conditions. (Lists of the 11 CMS events and 28 NQF events are available at Modern Healthcare Online at modernhealthcare.com.)
The Blue Cross and Blue Shield Association announced last November that Blues plans would be rolling out their never events nonpayment policies individually. Meanwhile, many other large insurerssuch as Aetna, Cigna Corp. and WellPointhave launched similar policies. Insurers say such policies are a chance to work collaboratively with providers on quality-improvement efforts, but critics say theyre only excuses for insurers to avoid paying for care.
Thats not true, according to Blue Cross and Blue Shield of Illinois, which released its nonpayment policy in August. Not reimbursing for some errors is about shining the spotlight on performance and outcomes, says H. Scott Sarran, a physician who is chief medical officer of the Illinois Blues plan.
The Blues plan worked with Illinois providers to establish the criteria of its never events policy, Sarran says. While some hospitals were initially concerned that the policy was meant to withhold payment, he says most of the conversation is not about rejecting the nonpayment policy but about its nuts and bolts: What type of data are needed for such a policy; what payment codes and error definitions are going to be used; and how can everyone ensure accuracy of the data and what they document.
Those are questions hospitals across the nation have wanted better answers to from the federal government as it ramps up its own nonpayment policy (March 10, p. 6). How never events will be evaluated and what a hospital will be held responsible for are real concerns, says Keith Granger, president and chief executive officer of 235-bed Flowers Hospital, Dothan, Ala. The industry is treading new territory, says Granger, who also heads the Alabama Hospital Associations Quality Task Force.
Blue Cross and Blue Shield of Alabama released its nonpayment policy this year as well. The insurer has been involved in the 4-year-old Quality Task Force with the hospital association and the states quality-improvement organization, the AQAF. The task force helped the insurer craft its policy, which the hospital association follows as well, Granger says. Ultimately what we hope that will do is make a better system.
One of the more contentious issues regarding never events is the name of the term itself: Just what is a never event? The NQFwhose list of 28 events typically form at least the outline of nonpayment and nonbilling policies created by the CMS, other payers and hospital associationsdefines such an event as something that is reasonably preventable by the hospital. But the CMS and some insurers have gone beyond the NQF endorsement to include other conditions that it says hospitals shouldnt allow patients to acquire.
One standard used to determine a hospital-acquired condition is whether the condition could reasonably have been prevented by following evidence-based practicesnot that the condition always can be prevented, according to Jim Brown, spokesman for the Alabama Blues. We and the hospitals recognize this important reality, and we provide our hospitals with the latitude to perform a root-cause analysis to see if all the precautions were followed before making the determination about payment, he says.
While there is general consensus in healthcare about some events being no-brainerssuch as wrong-site surgery or leaving an object in the patient after surgeryproviders and insurers alike have expressed reluctance for the CMS to continually add to its list. The CMS recently added three more conditions to its list of nonreimbursable conditions, and says it plans to evaluate more for possible inclusion.
Hospitals are responsible for reporting on a large number of quality indicators, and when that number increases, focusing on quality becomes a tougher challenge, says Leigh Hamby, a physician and executive vice president and chief quality officer of four-hospital Piedmont Healthcare. The Atlanta-based health system works on quality initiatives with Blue Cross and Blue Shield of Georgia, which has established a never events nonpayment policy.
Hamby questions whether external payment incentives will really drive effective change. Piedmont focuses on performance specified by the American College of Cardiology in measures such as door-to-balloon time and heart-failure performancepractices that really drive down inpatient mortality, he says. The quality program it uses, dubbed Move Your Dot to refer to a hospitals mortality rate along a scatter-plot graph, was created by the Institute for Healthcare Improvement. Focusing on these types of performance measures instead of on never events will save more patients, but trying to move that concept to the front of the quality-improvement discussion has been a challenge, Hamby says.
HealthPartners, Bloomington, Minn., which established a never events nonpayment policy shortly after the states 2003 law mandated that hospitals report such events to the state Health Department, says its pay-for-performance bonus programs focus on those types of quality measures. In the past 10 years the insurer has paid about $20 million per year in bonus payments, says Babette Apland, the systems senior vice president of health and care management. The never events nonpayment policy and bonus programs deliver clear expectations about quality, she says. Its how you use payment to put the right incentives in place.
But when the largest payer, the CMS, continues to expand its list of events for which it will no longer reimburse, even insurers start to wonder how to align incentives and performance.
Adding events takes away the focus on that alignment and detracts from building on steady, continuous improvement of the same measures over time, says the Illinois Blues Sarran. It sets up a defensive system. Were not eager to see this expanded list of never events, he says.