The Centers for Medicare and Medicaid Services (CMS) publishes a list of health care-acquired conditions (HACs) that reasonably could have been prevented through the application of risk management strategies. What actions has your health care organization (or have health care organizations in general) implemented to manage or prevent these “never events” from happening within their health care facilities?
Preventing Health Care-Acquired Conditions: Strategies and Actions in Modern Health Care Organizations
The Centers for Medicare and Medicaid Services (CMS) plays a critical role in promoting patient safety by identifying and targeting health care-acquired conditions (HACs) that should rarely or never occur in well-managed health care environments. These “never events,” such as catheter-associated urinary tract infections (CAUTIs), pressure ulcers, and surgical site infections, are considered preventable through the implementation of evidence-based risk management strategies. CMS’s non-reimbursement policy for care associated with HACs has incentivized health care organizations to take proactive steps to reduce these adverse events.
Understanding the Impact of CMS Policies
In 2008, CMS began denying additional payments for certain HACs, holding institutions accountable for substandard care and emphasizing the importance of quality over quantity. The list of HACs continues to evolve but generally includes hospital-acquired infections, falls resulting in injury, retained surgical items, air embolism, and certain deep vein thromboses (DVTs) after orthopedic procedures. This policy shift underscored the urgency for health care organizations to adopt robust preventive strategies, not only to safeguard patients but also to protect institutional financial health and reputation.
Risk Management Strategies in Health Care Organizations
Health care organizations have responded to CMS’s regulations with a variety of clinical, administrative, and technological interventions. Some of the most notable strategies include:
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Standardized Protocols and Evidence-Based Guidelines
Institutions have adopted protocols from organizations such as the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Disease Control and Prevention (CDC). For example, surgical teams use checklists to reduce retained surgical items and infections, while nurses follow turning schedules to prevent pressure ulcers. -
Electronic Health Records (EHRs) and Clinical Decision Support
The implementation of EHRs has been critical in tracking patient risk factors, medication errors, and clinical signs of potential complications. Decision-support tools embedded in EHRs alert providers about patient-specific risks, such as high fall risk or the need to remove a urinary catheter promptly. -
Staff Education and Training
Continuous education is essential to sustaining a culture of safety. Health care workers are trained in infection prevention, hand hygiene, wound care, and the early detection of complications. Simulation labs and interprofessional training have become standard in preparing teams to respond to complex scenarios effectively. -
Surveillance and Reporting Systems
Many institutions have implemented real-time surveillance systems to monitor HACs and trigger immediate interventions. Reporting of near misses and adverse events has been encouraged through anonymous or non-punitive platforms, fostering transparency and learning. -
Use of Specialized Teams
Dedicated teams, such as wound care nurses, infection control specialists, and falls prevention committees, regularly audit practices, assess high-risk patients, and implement targeted interventions. For instance, rapid response teams (RRTs) are deployed for early signs of patient deterioration, potentially avoiding a cascade of preventable events. -
Patient and Family Engagement
Increasingly, health care organizations involve patients and families in safety initiatives. Educational materials on how to prevent infections, identify early signs of complications, and participate in care decisions empower patients to be active members of the care team.
Real-World Application: An Example from Practice
In many acute care hospitals, including my own health care organization, specific programs such as the Hospital-Acquired Pressure Injury (HAPI) Prevention Bundle have been instituted. This includes risk assessments using the Braden Scale, moisture management strategies, nutritional interventions, and the use of pressure-relieving devices. Additionally, CAUTI reduction campaigns have successfully decreased catheter use through nurse-led protocols and daily assessment of catheter necessity.
Conclusion
Health care-acquired conditions represent a significant challenge and a critical opportunity for quality improvement in health care delivery. Through the directives issued by CMS, health care organizations have been pushed to adopt and sustain risk management strategies that prioritize patient safety. Although “never events” may never be entirely eradicated, the collective effort to prevent them has dramatically improved care quality, accountability, and outcomes across the industry.
References
Centers for Medicare & Medicaid Services (CMS). (2022). Hospital-Acquired Conditions. Retrieved from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond
Agency for Healthcare Research and Quality (AHRQ). (2021). Preventing Healthcare-Associated Infections. Retrieved from https://www.ahrq.gov/hai/index.html
Centers for Disease Control and Prevention (CDC). (2023). Healthcare-associated Infections. Retrieved from https://www.cdc.gov/hai/