First Posted at Educate the Young on 10/1/2012

David Mayer, MD – Host of Educate the Young (and on occasion regulate the old)

Guest Post: By Sarvashwari Singh

Sarvishwari is a senior at George Washington University majoring in biology. She plans on a career in family medicine and caring for older adults while remaining a lifelong student of quality improvement and patient safety. She is the first in a series of guest student and resident writers who are trying to learn more about the future of healthcare and reform. Being a patient safety and medical education site, ETY is delighted to share student and resident research and reflections with you, as they represent the next generation of caregivers. Additionally, the issues discussed and educational materials shared by students on ETY are aspects of healthcare infrequently included in today’s medical curricula. Sharing them with other students and residents will help future caregivers better understand the issues and challenges facing healthcare in the years ahead.

Starting today, Medicare is launching its most comprehensive quality initiative.  Authorized by the health care reform law, the Value-Based Purchasing Initiative is rewarding better performers on certain measures, and penalizing those that perform poorly. Hospitals will lose 1 percent of their Medicare base payment, but can earn it back if they provide better care.

Seventy percent of a hospital’s total performance score is based on different clinical process measures:

Acute myocardial infarction 
–Fibrinolytic therapy received within 30 minutes of hospital arrival
–Primary PCI received within 90 minutes of hospital arrival

Heart Failure
–Discharge instructions

–Blood cultures performed in the ED prior to initial antibiotic received in hospital
–Initial antibiotic selection for CAP in immunocompetent patient

Surgical Care 
–Prophylactic received within 1 hour prior to surgical incision
–Prophylactic antibiotic selection for surgical patients
–Prophylactic antibiotics discontinued within 24 hours after surgery end time
–Cardiac surgery patients with controlled 6 a.m. postoperative serum glucose
–Surgery patients on a beta blocker prior to arrival that received a beta blocker during the perioperative period
–Surgery patients with recommended venous thromboembolism prophylaxis ordered
–Surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hours

Thirty percent of performance is based on patient experience of care using the Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS):

Nurse Communication
–How often did nurses listen carefully to you?
–How often did nurses explain things in a way you could understand?
–After you pressed the call button, how often did you get help as soon as you wanted it?

Doctor Communication
–How often did doctors treat you with courtesy and respect?
–How often did doctors listen carefully to you?
–How often did doctors explain things in a way you could understand?

Hospital Cleanliness and Quietness
–How often where your room and bathroom kept clean?
–How often was the area around your room quiet at night?
–Did you need help from nurses or other hospital staff in getting to the bathroom or in using a bedpan?
–How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted?

Pain Medication
–Did you need medicine for pain? If so, how often was your pain well controlled?
–How often did hospital staff do everything they could to help you with your pain?

Medication Communication
–During this hospital stay, were you given medicine that you had not taken before?
–Before giving you any new medicine, how often did hospital staff tell you what the medicine was for?
–Before giving you new medicine, how often did hospital staff describe possible side effects in a way you could understand?

Discharge Information
–After you left the hospital, did you go directly to your home, to someone else’s home, or another health facility?
–Did doctors, nurses or other hospital staff talk about whether you would have the help you needed when you left the hospital?
–Did you get information in writing about what symptoms or health problems to look out for after you left the hospital?

Overall Hospital Quality
–Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your stay?
–Would you recommend this hospital to your friends and family?

Hospitals will see only minor changes in payment, according to Rachel Werner and R. Adams Dudley in Health Affairs, “…redistribution is not likely to cause major problems because the amount being redistributed is…small,” they say.

In upcoming years the financial stakes will be higher — 2% will be at risk in 2017 — and outcome measures will be added, as discussed in the New England Journal of Medicine Perspective, Value-Based Purchasing — National Programs to Move from Volume to Value by Jordan M. VanLare, A.B., and Patrick H. Conway, M.D. in July of this year.

Looking ahead, many Americans are concerned about patient safety.  A recent Wolters Kluwer poll found that 70 percent of respondents are “very” or “somewhat” concerned about medical mistakes.

Future iterations of hospital performance measures should include patients’ experience with safety. Also, the informed consent process needs to be improved so it serves the patients’ needs.  Patients can be surveyed for how well doctors explained a treatment, options, and their benefits and risks.  That would be a big step forward and offer real value from a patient-centered perspective.

Patricia Salber MD, MBA (@docweighsin)
Patricia Salber, MD, MBA is the Founder and Editor-in-Chief of The Doctor Weighs In. She is also the CEO of Health Tech Hatch, the sister site of TDWI that helps innovators tell their stories to the world. She is also a physician executive who has worked in all aspects of healthcare including practicing emergency physician, health plan executive, consultant to employers, CMS, and other organizations. She is a Board Certified Internist and Emergency Physician who loves to write about just about anything that has to do with healthcare.


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