Even as the COVID-19 pandemic battered Sanford Health, the health system rededicated itself to quality efforts, racing to address concerns and change processes in real time and to report patient safety data.
"We believe that quality needs to be maintained, regardless of conditions and the situation," said Dr. Jeremy Cauwels, the Sioux Falls, South Dakota-based health system's chief physician. "It's been a constant area of focus."
At other health systems, the pandemic derailed safety and quality programs as hospitals were beset by resource and staffing shortages, waves of high acuity patients, and overtaxed intensive care units.
To ease the burden on a healthcare system struggling to sustain operations, the Centers for Medicare and Medicaid Services suspended some safety measurement requirements and financial penalties tied to quality at the start of the pandemic. The agency has proposed continuing to waive them even though COVID-19 cases have plummeted from their heights.
With that choice comes trade-offs. The government and the public now have less information about whether hospitals are providing safe, high-quality care, and little insight into how some facilities overcame the pandemic's challenges and maintained high standards.
CMS published a proposed rule in April that would halt the calculation and reporting of hospitals' composite Patient Safety Indicators 90, or PSI 90, metric for the Hospital-Acquired Condition Reduction Program in fiscal 2023. Under the draft regulation, the agency wouldn't levy financial penalties or weighted payment adjustments related to the hospital-acquired condition program or the Hospital Value-Based Purchasing Program in that fiscal year.
The agency hasn't indicated when it will resume its suspended quality and safety initiatives or the penalties associated with some of them.
CMS hasn't stopped collecting quality data and will continue to make information on measures such as hospital-acquired infections available to the public, according to a spokesperson. CMS will adjust quality measurement and reporting rules to anticipate future infectious disease outbreaks, the spokesperson wrote in an email. The proposed rule would require hospitals to continue reporting data about COVID-19 and seasonal influenza through April 2024.
"CMS's top priority is to ensure access to safe, comprehensive healthcare, and patient safety will always be our primary concern," Dr. Lee Fleisher, CMS chief medical officer and director of the Center for Clinical Standards and Quality, said in a statement. "An important part of CMS's commitment to patient safety is ensuring public access to the highest quality data regarding the performance of healthcare facilities."
CMS needs to balance transparency with fair assessments of hospital performance amid an emergency, and using metrics distorted by the pandemic conditions would complicate that, said Akin Demehin, senior director for quality and patient safety policy for the American Hospital Association.
"No one designed any CMS quality measurement and value programs to account fully for the once-in-a-century pandemic," Demehin said. Because COVID-19 impacted hospitals at different times and with varying intensity, equitable comparisons are difficult, he said.
The American Medical Rehabilitation Providers Association was among the trade groups that asked CMS to delay changes to the Inpatient Rehabilitation Facility Quality Reporting Program. Employee turnover, stress and burnout will continue to hinder health systems' compliance with quality measures and data collection, said Kate Beller, executive vice president of government relations and policy development.
"These challenges are going to persist, and even if it's not under the public health emergency, waivers are a relief," Beller said. "We hope that the penalties and compliance thresholds for the quality reporting program are assessed closely to make sure that they are in line with where the field currently is and the ability to handle more extensive reporting going into next year," she said.
Risks of suppressing data
Collecting less quality data at a time when quality is most challenged is the wrong approach, said Leah Binder, president and CEO of the LeapFrog group. "We are not in support of suppressing data," she said. "We believe that in a public health emergency, we need all the information we can get on how safe people are in hospitals."
To create more accurate, unbiased patient safety data and avoid withholding information, CMS could consider refining its technical measures to account for the pandemic, Binder said. That could include using COVID-19 as a risk factor for 30-day mortality and readmission measures, making COVID-19 diagnoses at admission a risk-adjustment variable, and excluding coronavirus patients from calculations to allow more accurate comparisons to years before the pandemic. Expanding the measurement period to seven months in 2019 and seven months in 2021 would increase the number of hospitals rated and improve reliable results overall, she said.
Unless CMS rethinks its proposed rule and finds a way to publish this information, the industry won't be able to learn from the hospitals that maintained safety under emergency conditions, said Bill Kramer, executive director for health policy at the Purchaser Business Group on Health.
"Hospital leaders and clinical leaders need to make sure their systems are working and remain in place to ensure quality," Kramer said. "We know that usually problems of patient safety are not caused necessarily by one single error or random events, but are usually caused by a breakdown in quality management."
Even with geographic variations, whether a hospital responded well to COVID-19 or experienced spikes in infections and readmissions is useful information that reflects different levels of performance, said Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform.
Because hospitals have data on how many COVID-19 cases they had, how full their intensive care units were and during which months cases rose, it would be better to have an adjusted measure that isn't perfect than to exclude the data entirely and give all hospitals a pass, Miller said.
"If you say, 'We're just not going to pay attention anymore because it's a pandemic,' it isn't fair to the patients who are getting those infections," Miller said.
Focus on 'high-quality care'
At Sanford Health, hospital staff have submitted data to CMS and managed internal measures of mortality and infections throughout the pandemic, Cauwels said.
By making caregivers responsible for speaking up about safety, Sanford Health was able to improve its quality outcomes during the pandemic, reducing central line bloodstream infections by 60% and decreasing the overall number of serious safety events by 40%, Cauwels said.
Hartford HealthCare in Connecticut has also emphasized quality in every part of its operations, from acute care to home care to surgical centers, said Dr. Ajay Kumar, the health system's chief clinical officer. While Hartford HealthCare welcomes a lesser burden when it comes to data collection, the health system sees data as a cornerstone of its work to address patient safety risks and meet CMS quality requirements, he said.
"Patient safety indicators are important," said Dr. Marlon Priest, chief clinical officer at Greensboro, North Carolina-based Cone Health System. "The more we can put them out in front of the American public, not only for the patients, but also so board members of the systems, insurance carriers and the community can see those and hold us accountable to deliver high-quality care." The acquired conditions that hospitals were dealing with before the pandemic haven't gone away, he said.
Rather than slowing down or sliding backwards on quality, health systems should work even harder to avoid situations in which a patient might survive a prolonged course of COVID-19 but die later due to a catheter infection, Priest said.
Looking ahead on quality reporting
Quality information is something hospitals should want to report as a way to get better regardless of regulations and payment policy, Cauwels said. "Healthcare should hold itself accountable for the people that we take care of every day, and I don't feel that it needs to be a financial accountability that the government holds," he said.
Although it helps to have a national agreement for reporting standards and maintaining safety, hospitals truly committed to quality will likely continue their efforts regardless what CMS mandates, Miller said. Moving forward, there is also the question of whether the quality measures themselves are valuable if they cannot be used during a pandemic, he said.
"Many hospitals will experience flu outbreaks, natural disasters, floods, tornadoes, hurricanes, fires," Miller said. "If we suppress [measures] for COVID, why shouldn't we be suppressing them for some of these other things? Are there no other circumstances that affect individual hospitals that should require them to have their measures adjusted or suppressed?"