Value Based Purchasing – Surgical Site Infection
Abstract
Value based purchasing is fast becoming popular among the US medical service providers. As value based purchasing provides incentives for better quality delivery, it seems that in the long run, the overall quality of service will go up. The majority of this improvement will happen in the areas of preventive measures. Hospital acquired condition is something that can be significantly reduced by the implementation of the benchmark preventive measure system. Surgical site infection (SSI) is one of the major contributors to HAC, accounting for a substantial number of illnesses, hundreds of thousands of death cases, and billions of dollars of cost every year in the hospital. Hospitals should try to implement world-class Continuous Quality Improvement Initiatives to improve upon its structure and processes. As the SSI requires specific process improvement parameters in place and also a linkage between different processes in the chain from the admission of a patient to his discharge, introducing the lean six sigma initiatives will significantly help improve the process. If implemented properly, the number of SSI occurrence will come down, improving the quality and reducing the HAC costs.
Introduction
Value based purchasing is fast gaining popularity in the USA. It is a demand-driven strategy to measure the report and rewards of high performance in health care delivery (CMS, 2014). The stakeholders of value based purchasing are insurance companies, employer purchasers, public sector purchasers, individual consumers, health plans, and medical service providers. Value based purchasing deals with access to medical care, price, efficiency, and alignment of incentives. Value based purchasing proposes to reward high-performing healthcare providers with enhanced payment and improved reputation (CMS, 2014). On the other hand, it proposes penalties for low-quality medical services. The Centers for Medicare and Medicaid Services (CMS) introduced value based purchasing in the medical system to motivate the service providers with rewards for providing superior quality health care services.
Figure 1: Value based Purchasing Parameters for the Year 2013 (CMS, 2014)
Hospital Value Based Purchasing Program is a CMS initiative that rewards acute care hospitals with an incentive payment for superior quality care provided to Medicare holders. The Affordable Care Act of 2010 established the hospital value based purchasing program affecting the payment for the hospitalization in almost 3,000 hospitals across the country (CMS, 2014). The hospital value based purchasing program has created major benchmarks for all the inpatient hospitalization parameters based on which each hospital is evaluated in comparison with the baseline period. The main challenge in the USA is the significant increase of the health care cost (CDC, 2010). This value based purchasing program tries to reduce that cost by designing a framework focused on disease prevention and improved health status of the population. This essay will discuss the concept of hospital acquired condition, specifically, the surgical site infection and its legal implications and accreditation expectations. It will also take a look at the quality improvement strategies in place in the healthcare segment, trying to investigate further which of the strategies is best applicable for the SSI.
Hospital Acquired Condition
Hospital Acquired Condition is defined as conditions not present at the time of admission to a healthcare setting. As per the guidelines provided by the CMS, conditions that become clinically evident after 48 hours of hospitalization are deemed as Hospital Acquired Condition or HAC (CDC, 2010). In many cases, the infection that occurs after a patient is discharged can also be termed as HAC if the organisms that led to the condition are acquired during the stay in the hospital. Currently, the conditions listed as HAC by the CMS are those that are of high cost or high volume or those which could have been prevented through the application of the CMS provided evidence based guidelines (AHRQ, 2014). The CMS has about 1,000 conditions listed as HAC currently. Some of the major Hospital Acquired Conditions are objects left in during surgery, air embolism, blood incompatibility, pressure ulcers, catheter associated urinary tract infection, vascular catheter infection, falls and trauma, and surgical site infection (CMS, 2014).
When a diagnosis is recorded and is not found present at the time of the admission, then it is registered as a HAC, which needs to be reported to the CMS (AHRQ, 2014). For example, if a patient breaks his leg falling out of the bed, the consequence of broken leg would be demoted as ‘falls and trauma’ HAC. The hospital where such incident took place would not be compensated for the treatment of the HAC. The intent of this is to force the hospital to take preemptive actions to prevent such occurrence in the hospital.
Surgical Site Infection
Surgical Site Infection (SSI) is one of the most common types of HAC. In fact, SSI almost contributes to 17% of the total cost involved in all the HACs. A SSI is defined as an infection that occurs after a surgery to that part of the body in which the surgery took place. Surgical site infections can be superficial, involving only the skin. It can also be in more serious form involving tissues under the skin, implanted material or organs (CDC, 2010). The Centers for Disease Control and Prevention (CDC) provides a clear set of guidelines for the healthcare community to prevent surgical site infection. SSIs are caused by endogenous factors or external risk factors in the pathogenesis. Most of the external risk factors can be monitored, and with proper care, the surgical site infections deriving from the external risk factors can be prevented. However, there is an increasing number of cases of SSIs after discharge (AHRQ, 2014). Studies show that in many of those cases, patients are not communicated properly about the measures that should be taken to avoid surgical site infection at home. Therefore, the CDC has provided a multi-modal approach to prevent the occurrence of SSI. The first part provides a benchmarking guideline for surgical procedures and maintenance of equipments at hospitals. The second part deals with the resources and communication that need to flow between the medical staff and the patients before, during, and after the surgical procedure (AHRQ, 2014). It is extremely difficult to reduce the number of cases of SSI to zero level, especially, in the emergency surgical procedures in which preventive measures are not always applied properly.
Figure 2: Pre and Post-Intervention cost of SSI (CDC, 2010)
As per the current literature, by taking the preventive measures, the occurrence of SSI can be reduced by up to 70%. Preventive measures help reduce the catheter related blood stream infections to almost zero level in many hospitals (AHRQ, 2014). However, it is not easy to achieve the same for ambulatory surgery, emergency surgery, contaminated surgery, and surgery in a resource lacking setting. Among the clean elective surgeries, cataracts and orthopedic surgeries have fewer cases of SSI if preventive measures are properly in place. In the case of cataracts, only 0.05% of the cases show signs of SSI for factors beyond the control of preventive measures (Reed, 2010). However, if the cataract and orthopedic surgeries are done without the application of proper preventive measures, there is a 2%-3% chance of the SSI to happen, which is 40 times higher than the chance of infection with proper preventive measures. Therefore, it is important to implement preventive care in order to reduce the number of the SSI cases. It is necessary to include the prevention measure parameters in the quality health care practices matrix.
Legal Implications
Healthcare professionals must have an understanding of the hospitalization and patient care process that includes admission, diagnosis, treatment, communication, administration of medicines, discharge instructions, and follow-ups. They should not only try to follow benchmark guidelines provided by the CDC, but also should possess a clear understanding of the legal implications of not following the same. Of late, the number of litigations in the medical sector is on the rise, making it more important for the medical practitioners to understand where they stand if something goes wrong. In 2010, the costs of litigations were more than $8 billion for cases related to the hospital acquired conditions that occurred due to clinical negligence (Reed, 2010). There are several attributes to clinical negligence, including preventive measures before a surgical procedure, communication with the patient and patient’s family before and after the surgical procedure, compliance with the benchmark practices during the surgical procedure, and comprehensive discharge instructions and follow-up treatments.
One of the primary contributing factors to the occurrence of SSI is the improper communication between medical practitioners and the patient and the patient’s family. In such cases of SSI resulting from poor communication, medical practitioners may face serious legal implications. According to the Healthcare Act of 2010, a clinician by failing to adhere to the code of practice for the prevention of infection violates the law, and therefore, his action would be deemed as a criminal offense. The gross negligence shown in taking preventive measures in the areas of HAC involves the maximum sentencing of life imprisonment (Reed, 2010). For instance, a case was registered in 2008 in which a female was admitted to the hospital for the right hip replacement Three days after the replacement surgery, she was tested positive for MRSA, a type SSI. Even after being tested positive for MRSA, no anti-biotic treatment was started for the patient, leading to severe disability and the requirement of 24 hours of care at home (Reed, 2010). This clinical negligence happened due to several reasons. Firstly, the medical staff should have communicated about the substantial risks of infections involved in such elective surgeries to the patient and her family so that they would have remained prepared for such occurrence and could have taken a more informed decision about the surgery. Secondly, in that hospital, there were several cases of MRSA in the orthopedic department earlier that year of 2008, but still they did not close the ward for the patients in accordance with the CDC guideline. Finally, in their preventive measure logbook, infection control procedure was identified as a low priority due to the lack of medical resources. All of these factors put together resulted in such unfortunate incident. The hospital had to pay $2 million as compensation to the patient.
Although legal implications are mostly damaging for the hospitals, still the hospitals tend to hide the occurrence of surgical site infection from the patient and his family in order to avoid any litigation resulting out of it. However, the medical staff should understand that the disclosure is a big part to avoid serious litigation. If a SSI is developed due to clinical negligence, and the news is not disclosed to the patient and his family, then such an action not only may lead to a serious litigation from the patient and his family but also from the government (Reed, 2010). A timely disclosure to the patient and his family may save the hospitals from paying millions of dollars as legal fees and compensation. In fact, as per the current health care law, if a clinical negligence is disclosed with proper immediate measures taken by the hospital, then even if the patient and his family members file a lawsuit, there is a much lower chance for the hospital to pay a higher compensatory fee for damage. The hospital staff should understand that involuntary clinical negligence is not a criminal offense per se, but the clinical negligence reinforced by non-disclosure and non-action is a serious criminal offense (Reed, 2010). Therefore, it is advisable for the medical staff to timely communicate about the surgical site infection, if there is any, to the patient and his family.
Accreditation Expectations
It is not only important to identify the causes of the surgical site infection, but also important to create a procedure that will reduce the number of SSI cases. The Joint Commission in its 2010 ‘National Patient Safety Goals’ publication provided the guidelines for evidence-based practices for preventing the occurrence of SSI (The Joint Commission, 2011). The accreditation expectations as published by the Joint Commission are as below:
- Education: The education of medical staff and licensed independent practitioners about SSI and the importance of prevention is of paramount importance. The educational process should not only take place during the hiring, but also should continue thereafter periodically. The education of the patient and his family members are also important and should be provided as needed when a patient is undergoing a surgical procedure. Finally, the patient and his family should also be provided education about the preventive measures related to the SSI after the patient is discharged from the hospital (The Joint Commission, 2011).
- Benchmark Practices: The healthcare service providers should implement policies and procedures that meet the regulatory requirements and align with evidence-based preventive measure practices. For example, a hospital can implement the guidelines as provided by the CDC (The Joint Commission, 2011).
- Inspect and Monitor: It is not enough to implement a benchmark policy and procedure. Once a policy is implemented, it is important to implement further measures to assess the risks, effectiveness of the procedure, and compliance with the best practices (The Joint Commission, 2011).
- Measurement: It is important to measure SSI parameters up to 30 days after the surgical procedure, which does not involve implanting a foreign object. For surgical procedures involving the implantation of a foreign object, the hospital should constantly take measurement for up to 1 year (The Joint Commission, 2011).
- Reporting: As per the CDC guidelines, the hospital should provide process and outcome results regularly to the key stakeholders like the government, the insurance companies, the hospital board of directors, and patients, if necessary (The Joint Commission, 2011).
Outcomes related to Cost and Quality
Strategies
Figure 3: CQI Improvement (NLC, 2013)
Like any industry, healthcare industry also needs Continuous Quality Improvement Initiatives (CQI). In order to implement any CQI initiatives in healthcare, one must consider three components of health care, 1) structure, 2) process, and 3) outcome. In health care, the structure includes people and technology, and the process is the actual medical process. When these two come together in harmony, they provide the desired output, and the desired output often leads to the end result, which is often known as outcome. CQI initiatives target the structure and process part of the health care for getting the desired outcomes. As per the current health care directives, the focus is on improving quality and the reduction of cost (CMS, 2014). There are several leading strategies of CQI used in healthcare practices. One of the most common strategies is the IHI model for improvement. This model promotes improvement by answering three questions,
- What are we trying to accomplish?
- How do we know that the change will be an improvement?
- What changes can make an improvement?
Figure 4: IHI Model (NLC, 2013)
Lean is another continuous improvement strategy used in healthcare services. The concept of lean was borrowed from the Toyota production system. Lean tries to improve a system continuously by reducing the non-value added activities, relentlessly focusing on reducing waste to improve medical care delivery, and mistake-proofing tasks. The five principles of lean are 1) identify value, 2) specify value, 3) workflow processes, 4) push-pull activities, and 5) process delivery. The lean approach is useful for simplifying over complicated processes and processes that are interlinked and require workflows (NLC, 2013). Typically, lean is not suitable for small and discrete changes to a process.
Figure 5: Six Sigma DMAIC methodology (NLC, 2013)
Six sigma, which was borrowed from the manufacturing industry, is another methodology used in the healthcare industry. The five principles of six sigma are 1) define, 2) measure, 3) analyze, 4) improve, and 5) control. Six sigma is a useful implementation in any kind of small and large healthcare processes in an isolated manner (NLC, 2013). However, it is not always well-suited for connecting processes and workflows.
Finally, Baldrige quality award criterion is a strategy that enables continuous excellence through self-assessment. Unlike other three strategies that take benchmarks into account, the Baldrige model is built on the core values and concepts of an organization. The six principles of Baldrige quality award criterion are 1) scope of the self-assessment, 2) select champions, 3) select team for each champion, 4) collect data and information to answer questions, 5) share the answers among the teams, and 6) create and communicate an action plan for improvement (NLC, 2013). The Baldrige quality award criterion is best suited for identifying problems in the healthcare organizations. This strategy takes a holistic approach, and it is well-suited if the organization takes a strategic shift or implements cultural changes.
Examples of Performance Levels and Role of Research
There are different performance improvement benchmarks defined by the CMS guidelines. For example, in the evidence based preventive measure category, surgical hand preparation is probably the most important surgical site infection prevention strategy. For example, the compulsory introduction of the hand antiseptics for obstetricians using chlorinated lime in the surgical hand preparation procedure can significantly lower the chances of post-partum maternal infections (AHRQ, 2014). Other preventive measures for SSI can be achieved by exploring the promising avenues of research. For instance, preventive research techniques like screening for MRSA carriage on admission can significantly lower the chances of MRSA infection afterwards. There are researches that support this evidence. However, glycopeptide prophylaxis is a matter found present in the known carriage of MRSA, but researches are inconclusive, and hence, more researches need to be conducted for finding better preventive screening for MRSA (AHRQ, 2014). This will help reduce the cost of SSI in the long run. There are local measures like preoperative bathing or showering that can also help in reducing surgical site infections.
Best Strategy for Prevention of SSI
Among the four major strategies discussed above, a combination of lean and six sigma will provide the best result in reducing the number of the SSI cases. Six sigma methodology will take the CMS provided guidelines as benchmarks in all the processes that may lead to surgical site infections, whereas lean will help create the linkage between all the processes from the admission of a patient to his discharge, and how the improvement of one process can help another. As these two methodologies are quite focused, the waterfall approach can be taken for the implementation of lean six sigma that will reduce risk, improve quality and reduce costs.
Conclusion
In the modern day world, both the employers and health care carriers know that the cost effective policies may be useful for the short term, but may not be as effective for the long term outcome. Therefore, employers, individual buyers, and health care carriers prefer value based purchasing of insurance. The parameters that define value based purchasing are more likely to become important in the future. Hospital acquired condition is one of the most important parameters that defines the quality of services offered by the hospitals. Surgical site infection is a major contributor the hospital acquired condition, accounting for 17% of the total costs involved in the HAC. SSI can be improved through various ways. However, implementing the CMS policies, procedures, and guidelines is the most used by the hospitals. Hospitals can improve their SSI parameters by implementing CQI strategies. The implementation of lean six sigma in the preventive measures process for the reduction of SSI occurrence seems to be the most rational and cost-effective solution. In the coming days, as more and more hospitals come under the umbrella of value based purchasing and feel motivated by the reward structure of the CMS for improving upon the quality parameters like HAC, the overall quality of healthcare practices in the USA will only improve with the cost significantly coming down.
References
Agency for Healthcare Research and Quality (AHRQ) (2014). Surgical site infection: prevention and treatment of surgical site infection. Retrieved from http://www.guideline.gov/content.aspx?id=13416
Bailey, Tracey M. & Ries, Nola M. Legal Issues in Patient Safety: The Example of Nosocomial Infection. Retrieved from http://www.longwoods.com/content/17680
Centers for Disease Control and Prevention (CDC). (2010). Surgical Site Infection (SSI). Retrieved from http://www.cdc.gov/hai/ssi/ssi.html
CMS. (2014). Hospital Value-Based Purchasing. Retrieved from http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/index.html?redirect=/hospital-value-based-purchasing
National Learning Consortium (NLC). (2013). Continuous Quality Improvement (CQI) Strategies to Optimize your Practice. Retrieved from http://www.healthit.gov/sites/default/files/tools/nlc_continuousqualityimprovementprimer.pdf
Reed, A. (2010). Legal consequences for SSIs. The Clinical Services Journal. Retrieved from http://www.clinicalservicesjournal.com/Print.aspx?Story=7308
The Joint Commission. (2011). Accreditation Programs: Hospitals. Retrieved from http://www.jointcommission.org/assets/1/6/2011_NPSGs_HAP.pdf
