Some of the best-known hospitals in the Puget Sound area may face penalties under the government’s toughest effort yet to crack down on infections and other patient injuries, federal records show.
In Seattle, Swedish Medical Center hospitals on First Hill and Cherry Hill and UW Medicine’s Harborview Medical Center and Northwest Hospital could have their Medicare payments docked this fall, based on a suite of patient-safety measures.
A quarter of the nation’s hospitals — those with the worst rates — will lose 1 percent of every Medicare payment for a year starting in October.
In April, federal officials released a preliminary analysis of hospitals on track to be penalized, including 14 out of 48 hospitals in Washington state. Nationwide, 761 face sanctions, though the list could change because the government will be looking at performance over a longer period than it used to calculate the draft penalties.
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In King County, the four Seattle hospitals plus MultiCare Auburn Medical Center were just slightly above the penalty cutoff, while eight others in the county scored better. No hospitals in Pierce or Snohomish counties were pegged for sanctions.
“We’re constantly challenging ourselves to improve, regardless of how we were already doing,” said Dr. Rick Goss, medical director of Harborview and director of Quality of Metrics Reporting for UW Medicine.
The sanctions, estimated to total $330 million nationwide, kick in at a time when many hospital infections are on the decline, but still too common.
In 2012, 1 of every 8 patients nationally suffered a potentially avoidable complication during a hospital stay, the government estimates. Even infections that are waning are not decreasing fast enough to meet government targets. Meanwhile, new strains of antibiotic-resistant bacteria are making infections much harder to cure.
“The medical profession has not covered itself with glory in terms of medical errors and events that should not occur,” said Dr. Terry Rogers, chief executive officer for the Seattle-based Foundation for Health Care Quality, a nonprofit organization. “We have chipped around the edges, but we still kill a lot of people in hospitals who should not die.”
Are the metrics right?
Medicare’s penalties are going to hit some types of hospitals harder than others, according to an analysis of the preliminary penalties conducted for Kaiser Health News by Dr. Ashish Jha, a professor at the Harvard School of Public Health.
Publicly owned hospitals and those that treat many low-income patients are more likely to be assessed penalties. So are large hospitals, ones in cities, and those in the West and Northeast. Preliminary penalties were assigned to more than a third of hospitals in Alaska, Colorado, Connecticut, the District of Columbia, Nevada, Oregon, Utah, Wisconsin and Wyoming.
The biggest impact may be on the nation’s major teaching hospitals: Slightly more than half were marked for preliminary penalties, Jha found. The reasons for such high rates of complications in these elite hospitals are being intensely debated.
Harborview, a teaching hospital, is the state’s only Level 1 trauma center and treats patients with severe injuries and burns from a four-state area. Given that status, these patients “will be more susceptible to some of the hospital-acquired conditions,” Goss said. The University of Washington Medical Center does not face penalties.
Leah Binder, CEO of The Leapfrog Group, a patient-safety organization, said academic medical centers have such a diverse mix of specialists and competing priorities of research and training residents that safety is not always at the forefront.
When calculating infection rates, the government takes into account the size of the hospital, the location where the patient was treated and whether it is affiliated with a medical school. But the Association of American Medical Colleges and some experts question whether those measures are precise enough.
“Do we really believe that large academic medical centers are providing such drastically worse care, or is it that we just haven’t gotten our metrics right?” Jha said. “I suspect it’s the latter.”
In addition, there may be little difference in the performance between hospitals that narrowly draw federal penalties and those that barely escape them. That is because the health law requires Medicare to punish the worst-performing quarter of the nation’s hospitals each year, even if they have been improving.
MultiCare Auburn Medical Center has been working to improve patient care since it was acquired by MultiCare Health System in late 2012, spokeswoman Marce Edwards said in an email. That meant bringing the organization’s safety program to the new location and standardizing processes at the hospital.
Providers with UW Medicine are likewise working to standardize many procedures across their facilities to make sure they’re all using the best approaches to reduce infections and injury, and they meet on a monthly basis to share their results.
“There is still room for improvement,” Goss said. “In all cases we try to eliminate the variation and look for any reason why one patient didn’t receive all of the care that was intended.”
Pay for performance
The Hospital-Acquired Condition (HAC) Reduction Program, created by the Affordable Care Act, is the third of the federal health law’s major mandatory pay-for-performance programs. The first levies penalties against hospitals with high readmission rates and the second awards bonuses or penalties based on two dozen quality measures. Both are in their second year.
When all three programs are in place this fall, hospitals will be at risk of losing up to 5.4 percent of their Medicare payments.
In the first year of the HAC penalties, Medicare will look at three measures. One is the frequency of bloodstream infections in patients with catheters inserted into a vein to deliver antibiotics, nutrients, chemotherapy or other treatments. The second is the rates of infections from catheters inserted into the bladder to drain urine. Both those assessments will be based on infections during 2012 and 2013.
Finally, Medicare will examine a variety of avoidable safety problems in patients that occurred from July 2011 through June 2013, including bedsores, hip fractures, blood clots and accidental lung punctures.
Over the next few years, Medicare will also factor in surgical-site infections and infection rates from two germs that are resistant to antibiotic treatments: Clostridium difficile, known as C. diff, and Methicillin-resistant Staphylococcus aureus, known as MRSA.
Nationally, rates of some infections are decreasing. Catheter-related infections, for instance, dropped 44 percent between 2008 and 2012. Still, the Centers for Disease Control and Prevention estimates that in 2011, about 648,000 patients — 1 in 25 — picked up an infection while in the hospital, and 75,000 died.
Rates of urinary-tract infections have not dropped despite efforts. These infections become more likely the longer a line is left in, but sometimes they are not removed promptly — out of convenience for the nurse or patient or simply institutional lethargy.
Swedish Medical Center on First Hill beats many U.S. hospitals when it comes to central-line associated bloodstream infections, but has higher urinary-catheter infection rates than others. To help correct that, Swedish has given nurses more authority to remove catheters instead of waiting for a physician’s order to remove it, said Dr. Michael Myint, Swedish’s vice president for quality and patient safety.
Additionally, their protocols have turned around the decision-making about catheters, said Myint, so “unless you have a clinical reason to keep the catheters in, they should come out.”
About four years ago, Swedish launched a renewed focus on safety, he said, calling on everyone from the window washers to the top surgeons to make patient safety a priority. The goal is to reduce the incidence of preventable harm to zero, Myint said. “We’re going to be relentless until we get there.”
Lisa Stiffler, a freelance writer in Seattle, can be reached at firstname.lastname@example.org. This story was produced through a partnership with Kaiser Health News, an editorially independent part of the Kaiser Family Foundation.