Prevention and Early Detection of "Never Events" Within Ambulatory Settings to Enhance Quality and Safety and Prevent Financial Losses

In the last ViewPoint "Health Care Reform" column (Haas, 2011), accountable care organizations (ACOs) that include patient centered medical homes (PCMHs) or ambulatory care settings created by the Patient Protection and Affordable Care Act (PPACA) were defined and discussed. Within ACOs and PCMHs there are incentives, the proverbial ‘carrots,’ to increase safety and quality of care. However, there are also penalties for not enhancing quality and safety, the proverbial ‘sticks.’ A new, final Centers for Medicare and Medicaid Services (CMS) rule required by Section 2702 of PPACA will disallow federal funding under Medicaid effective July 1, 2012, for certain "never events" that State Medicaid Programs are required to define. The events to be defined are health care-associated conditions (HCACs) and other provider-preventable conditions (OPPCs) (CMS, 2011).

Never events include adverse (sentinel) events that are clearly identifiable and measurable, and serious events (resulting in death or significant disability), which are usually preventable (U.S. Department of Health and Human Services, Agency for Healthcare and Research and Quality [AHRQ], 2011). Hospital-acquired conditions (HACs), such as wrong site surgery for which Medicare already denies payment to hospitals, must be included in the State Medicaid Program definition of HCACs. The new OPPC designation is intended for conditions more likely to occur in settings outside hospitals such as outpatient or office-based surgery centers, skilled nursing facilities, and ambulatory practice settings (specifically office-based practices). OPPCs must be determined from evidence-based guidelines (CMS, 2011). It is expected that public reporting on incidence of never events in settings outside of hospitals will also be publically reported – another ‘stick’ to enhance accountability.

The National Quality Forum (NQF) is a nonprofit organization that strives to improve the quality of American health care by establishing goals for performance improvement, endorsing national standards for measuring and reporting on performance, and promoting the attainment of national safety goals through education (NQF, 2011a). Using a consensus model, the NQF has been the organization working with the AHRQ to name and define the never events specified in CMS rules. The NQF Board recently approved a list of 29 serious reportable events (SREs) in health care in their 2011 Consensus Report. Of these 29 events, 25 were updated from 2006 and four new events were added to the list (NFQ, 2011b). This newly expanded list of serious reportable events (never events) is available and it provides health care professionals with an opportunity to improve patient safety. Table 1 shows the updated NQF never event list.

Currently, never events or HCACs are publicly reported, with the goal of increasing accountability and improving the quality of care. Public reporting began with NQF dissemination its original list of never events in 2002; 11 states have mandated reporting of these incidents whenever they occur, and an additional 16 states mandate reporting of serious adverse events (including many of the NQF never events) (AHRQ, 2011). Not only must the health care facilities report the events, they are accountable for correcting systematic problems that contributed to the event, with some states (such as Minnesota) mandating performance of a root cause analysis and reporting its results (AHRQ, 2011).

So what does this mean for ambulatory care nurse leaders? Ambulatory settings performing surgery, interventional radiology, or infusion therapy will, in about six months, be denied payment for never events that occur. Many of the never events listed in Table 1 are rare (AHRQ, 2011), but in 2009, data from Minnesota’s public reporting indicated that falls in hospitals account for 30% and pressure ulcers 39% of adverse events (Minnesota Department of Health, 2009). Both pressure ulcers and falls of patients and caregivers in ambulatory settings are potential never events across most patient populations. Never events should not occur because there are evidence-based methods of preventing them and detecting them early.

First and foremost, ambulatory nurse leaders need to be involved in proactively planning for development and implementation of evidence-based guidelines to prevent potential never events in their settings. If guidelines are not already in place, then work should begin on developing guidelines for those high-volume, high-cost events such as falls and pressure ulcers. Please note that pressure ulcers can begin in as little as four to six hours, so procedure areas where patients are immobile for such time frames should have guidelines in place to provide for a full body skin assessment at the beginning of a visit as part of early detection of current or potential areas of breakdown and should address positioning and repositioning as well as appropriate support surfaces. Ambulatory care nurses should also be at the table when Electronic Medical Record (EMR) documentation screens are developed for care provided by nurses in ambulatory settings, so that there is opportunity for nurses to document assessments, interventions, evaluations, and outcomes in the EMR.

References Centers for Medicare & Medicaid Services (CMS). (2011, February 17). Medicaid program; Payment adjustment for providerpreventable conditions including health care-acquired conditions. Federal Register: The Daily Journal of the United States Government. Retrieved from articles/2011/02/17/2011-3548/medicaid-program-paymentadjustment- for-provider-preventable-conditions

Haas, S. (2011). Understanding "value driving elements" of ACOs and PCMHs. ViewPoint, 33(6), 8-9.

Minnesota Department of Health. (2009). Adverse health events in Minnesota: Fifth annual public report. Retrieved from ahereport.pdf

National Quality Forum (NQF). (2011a). About NQF. Retrieved from

National Quality Forum (NQF). (2011b). NQF releases updated serious reportable events. Retrieved from http://www.quality Releases_Updated_Serious_Reportable_Events.aspx

National Quality Forum (NQF). (2011c). Serious reportable events in healthcare 2011 update. Washington, DC: Author. Retrieved from Serious_Reportable_Events_in_Healthcare_2011.aspx

U.S. Department of Health and Human Services, Agency for Healthcare and Research and Quality (AHRQ). (2011). Patient safety primers: Background. Retrieved from primer.aspx?primerID=3

Sheila A. Haas, PhD, RN, FAAN, is a Professor, Niehoff School of Nursing, Loyola University of Chicago, Chicago, IL. She can be reached at