Ensuring that Never Events Never Happen

September 23, 2008

Last week, this blog focused on the importance of talking to your staff about the external environment. In today’s blog I want to focus on one of those external changes that will impact every hospital in the country: beginning next week, CMS will no longer pay for certain hospital-acquired conditions such as falls and pressure ulcers.

On our website you can see the full list of 11 conditions that CMS deems to be preventable, and therefore no longer reimbursable. Several of these are also known as “Never Events”.

As leaders of progressive healthcare organizations, I know that you are committed to eliminating these errors. We are, too, which is why you will see an aggressive mobilization at Studer Group to help you eliminate these Never Events. Because of the size of our national lab, we have the ideas, tactics and passion to help you bring this number down to zero.

We have created four short videos that you can access at no charge on our website. The first video provides an overview of the Never Events and specific tactics that we suggest implementing to prevent them. The other three videos are focused on how to prevent the most prevalent and costly of these conditions: falls, pressure ulcers and infections. We hope they will help you spread the word faster in your organization.

A few facts:

  • Each year, more than 650,000 patients experience one of these preventable errors, leading to needless pain, injury, even death.
  • Some of these events, such as an infection after having a coronary artery bypass graft, can cost as much as $300,000 to treat. That’s the same amount hospitals will no longer receive if the event occurs during the patient’s stay.
  • This reimbursement change is only the beginning. CMS views this as a major step forward in their shift toward Value-Based Purchasing, a philosophy of paying hospitals based on their performance on certain measures (such as these events and HCAHPS results), rather than the amount of service provided.

But that’s not the reason I’m writing about the “Never Events.” I’m writing to share specific tactics that will help prevent these conditions. Here are just a few to get started:

  • Communicate: Now is the time to ensure that your entire organization understands the significance of this external force and how it will impact employees’ daily activities. You can use the free videos on our website to help with this. Also, add this as an agenda item for your next senior leader and departmental meetings.
  • Identify the impact: Determine how you are performing now on these 11 conditions and calculate the reimbursement impact.
  • Harvest and share stories: Eliminating these adverse events requires the full engagement of everyone in your organization. Numbers don’t engage people to act; but individual, human stories do. Publicly celebrate when solid prevention efforts avoid harm from occurring. Also share stories of when events did occur that caused harm, since they require everyone’s attention in the future to ensure that others will not need to experience the consequences.
  • Tighten up assessment, documentation and coding: These are important areas to focus on during any change in reimbursement; and even more so with these “Never Events” since this change also introduces new “present on admission” codes that must be applied correctly to ensure full reimbursement if a condition was already present.
  • Focus on your biggest opportunities: For most organizations these are falls, pressure ulcers and infections. We created quick videos on each of these three adverse events, where you’ll hear tips of how you can eliminate these events without spending additional time or dollars, such as: how to use specific Key Words to engage patients in preventing these errors; Pre-Visit Phone Calls to reduce surgical infections; and bedside shift reports to conduct visual assessments of catheters and wound sites.

I hope you take a moment to visit www.studergroup.com/never, where you can access the free videos I’ve mentioned above. You can also read more about these 11 hospital-acquired conditions and review the latest evidence on how to prevent them. We’ll keep this site updated as new information comes in.


One Response to “Ensuring that Never Events Never Happen”

  1. We are in the process of incorporating shift change rounding. Based on other research we have read we are also incorporating bedside report to include the patient or primary family caregiver when available in the report. I would like to here from others that have already started this process and how they implemented the change.

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