SCKMC Frustrated with Infection Report
December 22, 2015
A report released earlier this month by the Centers for Medicare and Medicaid Services (CMS) announced South Central Kansas Medical Center would receive a financial penalty due to the number of hospital acquired conditions (HAC) reported between July 1, 2012 and December 31, 2014.
Arkansas City, KS – A report released earlier this month by the Centers for Medicare and Medicaid Services (CMS) announced South Central Kansas Medical Center would receive a financial penalty due to the number of hospital acquired conditions (HAC) reported between July 1, 2012 and December 31, 2014. This is the second year for the HAC report. With six reportable cases in the 2014 report, and five reportable cases for the 2015 report, SCKMC has been in the bottom 25% of all reporting hospitals each year.
The CMS report ranks performance for 3,308 hospitals. Because of their score, SCKMC will receive a one-percent reduction to their 2016 Medicare reimbursement, costing up to $40,000.
“This is a program designed to reduce payments to hospitals. The fact is that we only had two infections total out of 419 patient days, and three surgical complications out of 2,600 eligible discharges. Regardless of performance, one-fourth of all hospitals nationwide must be penalized,” said Jane Campbell, SCKMC’s Director of Hospital Quality and Risk Management.
The CMS report is totaled by calculating two scores, a composite score of eight quality measures and a score for hospital acquired infections.
“They look at central line associated blood stream infections, surgical site infections, and catheter associated infections. And that is supposed to count for 75% of our score. However, because our predicted score was less than one per 1,000 patient days, their algorithm says that data cannot be used and is thrown out. That meant what was supposed to count for only 25% of our score (the surgical complications) now counts for 100% of our score,” Campbell said.
Campbell contends that the CMS report is unfairly biased against small hospitals like SCKMC who do fewer cases compared to the larger facilities.
“If we were a large hospital that had a large volume of patients we would probably not be on this list, but we fall squarely into probably the worst spot. We are small and don’t have a large population and we have a surgeon who does complicated procedures on very sick people,” Campbell said.
SCKMC’s Chief Executive Officer shares in Campbell’s dissatisfaction with the report.
“It is frustrating that we can have so few problems, and our statistics show that we are doing a good job, but the formula is set to make us fail. It’s frustrating to all of us who try to work so hard in not having any situations where we are deemed not providing quality service. It is hard to measure all of the time, energy, and effort in dollars that we put into trying to achieve that goal. And regardless of everything that we do, we still end up on the list as having not met the criteria,” Watson said.
Watson believes that CMS will need to adjust the way their report is calculated in order to give a more realistic picture of status of the Nation’s healthcare facilities.
“Just the one or two little incidents that we have out of thousands puts us in a category to say that we are not meeting the standards set out by CMS. There has got to be a reevaluation at some point in time because we don’t have enough patients to be statistically viable and we don’t meet the criteria. So they just take money away from us,” Watson said.
Until a revision is made by CMS, Watson and the rest of the hospital staff will work to reduce reportable infections and complications through in-depth continuing education. The training program is led by Infection Control Education Coordinator Joanne Holman.
“Surveillance is done every morning that looks at every one of the patient’s lab work. I then go out to the floor and check with the nurses. There is communication with all of the areas. Staff is very responsive to all suggestions on isolation, training, and patient education. They all do a very good job,” Holman said.
Staff training is constantly underway with Holman, and infection prevention is one of her top priorities.
“Hand hygiene is number one in infection control, so we train on it every four months, plus have annual and on-the-spot trainings. We also have trainings on blood borne pathogens, infection, or the latest instructions, but every year could be a little bit different depending on what we have in our locale,” Holman said.
Although Campbell, Watson, and Holman all expressed similar frustrations with the CMS report, Watson stressed that their disappointment will not discourage the staff at SCKMC.
“We are not going to quit trying. We are going to continue to try and improve our quality and to find ways to achieve all of the measures that they have set out for us. We want to be on the list of being one of the best hospitals of the United States of America and not on the list of those who failed. We will never quit trying to achieve that goal,” Watson said.