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SCKMC Responds to Hospital Acquired Condition Report

January 9, 2015

Thursday afternoon staff at South Central Kansas medical Center learned of Centers for Medicare and Medicaid Services data, reported initially by Kaiser Health and picked up by the local media, stating they would be penalized for high infection rates. In response to this information, SCKMC Chief Marketing Officer Clayton Pappan released the following statement:

Arkansas City, KS - Thursday afternoon staff at South Central Kansas medical Center learned of Centers for Medicare and Medicaid Services data, reported initially by Kaiser Health and picked up by the local media, stating they would be penalized for high infection rates. In response to this information, SCKMC Chief Marketing Officer Clayton Pappan released the following statement:

"We continue to research this matter and have been able to locate the report on the Centers for Medicare and Medicaid Services website, www.hospitalcompare.gov. However we still do not understand how the scores were determined and have yet to receive penalties or be notified of future penalties by CMS.

We do know this report is part of a new Medicare payment reduction program called the Hospital Acquired Condition Reduction Program, established by Section 3008 of the Affordable Care Act. The program's intent is to lower the number of reasonably preventable conditions that patients develop during stays, and looks at two specific types of hospital acquired infections - central line associated blood stream infections and catheter associated urinary tract infections. In addition, it looks at serious complications that occurred in hospitals, like collapsed lungs, surgical incisions that re-open following surgery, pressure ulcers, post-operative hip fractures and post-operative blood clots. This program looked at infections that occurred in patients discharged from January 1, 2012 through December 31, 2013. For the other adverse events, the time period is July 1, 2011 through June 20, 2013.

All in-house data does not appear to support the CMS report's findings. The information for the adverse events was calculated by Medicare itself, using claims data, which do not fully reflect the details of a patient's history, course of care and clinical risk factors. As a result, the rates derived from the measures are inexact. We have no way to replicate or validate the numbers they used. Current data furnished by CMS shows that our rate of complications are no different than the national average, and our in-house data shows we have had only one reportable hospital acquired infection during the two-year data period. It appears that because our numbers are so low in these two areas, they were excluded from the calculations used to determine the final score on these measures.

Finally, we strive to be transparent in every aspect of our organization, but particularly when it relates to patient safety and the quality of healthcare we provide. We submit all reportable infections and complications on an on-going basis, participate in patient safety improvement programs on a regional level, and work with staff on an on-going basis to improve techniques and training.

Again, we disagree with the findings of this CMS report, and believe are actual score should be considerably lower. However, we consider even that figure to be too high and continuously work to reach our goal of zero."