Healthcare Design - November 2014 - 95

Defining HACs
Fifteen years ago, the Institute of Medicine published the report "To Err Is Human," which revealed
that almost 100,000 Americans die each year
because of medical errors that occur in hospitals.
As awful as these statistics are, most patient safety
experts believe that this data underrepresents what
have been termed "never events," or those medical
errors that are unambiguous, serious, and usually
preventable. In 1999, the National Quality Forum
(NQF), a not-for-profit, nonpartisan, membershipbased organization that works to catalyze improvements in healthcare, was founded and eventually
created a list of 27 serious reportable events (SRE).
Using a consensus process, NQF defined each

ment would have been at a higher rate to cover the care
for the hip fracture. The 2005 Deficit Reduction Act was
the first enacted legislation to link reimbursement to
HACs, though some experts didn't think the penalties
were significant enough to incentivize real change.

event that results in patient injury or death (for
example, a medication error, surgery performed
on the wrong site or the wrong patient, or severe
pressure ulcers acquired after admission). The
group specified the metrics that would be used to
identify and measure each SRE. It's this work that
informed the legislation and regulations that now
target HACs.
Never events and healthcare-associated infections
(HAIs) fall under the HAC umbrella, as do patient falls
with injury. A systems-based approach is often used to
eliminate HACs. In 2013, the Institute of Medicine and
National Academy of Engineering published a paper,
"Bringing a Systems Approach to Care," in which the
authors recommend "considering the multiple elements involved in caring for patients and the multiple
factors influencing health." Understanding the individual components of healthcare, how they operate,
and how they interact can help organizations promote
better care by integrating people, processes, policies,
and place.
The built environment is an often unrecognized
element, but in this approach, designers have an
important role to play by offering evidence-based
environmental features that help reduce harm. To do
so effectively, designers will need to understand what's
being targeted for improvement and how CMS reimbursements are affected.

But in 2010, the most comprehensive healthcare
reform legislation in half a century, the Patient Protection and Affordable Care Act (ACA), was signed into
law, touching just about every aspect of healthcare
delivery. One overarching goal is to improve the quality and performance of the healthcare system through
the implementation of a variety of Medicare initiatives,
including three pay-for-performance programs, which
together this year can result in a cut of up to 5.5 percent of a hospital's Medicare payment. Two programs
were introduced on Oct. 1, 2012, the Hospital Readmissions Reduction Program and the Hospital Value
Based Purchasing Program (HVBP). These programs
fundamentally shift reimbursement practices from volume-based, fee-for-service payments to reimbursement based on the quality of care delivered. Through
HVBP, hospitals are rewarded or penalized based on
the quality of care they provide their patients and their
ability to keep patients healthy, evaluated though an
approved set of measures and dimensions.
On Oct. 1, the HAC reduction program was added
as the third component of the pay-for-performance
initiatives. In this first year, three HAC measures-
catheter-associated urinary tract infections (CAUTI),
central line-associated blood stream infections
(CLABSI), and a composite patient safety indicator (PSI) measure-are included. PSIs are measures
adopted by the Agency for Health Care Research
and Quality (AHRQ), which enable the identification of
adverse events that occur during healthcare delivery.
The PSI-90 composite represents an aggregation
measure of eight patient safety problems, such as hip
fractures and central venous-catheter related blood
stream infections, that frequently occur during hospitalizations. For each HAC, research suggests that
environmental features play a role.

The law
The first direct tie between patient harm and reimbursement began on Oct. 1, 2008, when CMS
stopped paying hospitals for the increased cost of care
tied to a variety of HACs, including care for patients
who fall and were injured or who developed certain
types of HAIs. Prior to this legislation, if a patient was
admitted for colon surgery, for example, and then fell
and broke a hip during the post-operative phase, not
only would the hospital have been reimbursed for the
care associated with the surgery, but that reimburse-

Design teams can make important evidencebased design contributions to help reduce
the targeted HACs and, as a result, reduce
patient harm and help owners improve
reimbursement results.

Maximizing reimbursement by design
Design teams can make important evidence-based
design contributions to help reduce the targeted HACs
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Healthcare Design - November 2014

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