’s
February 6, 2015 edition
The Pulse
Your regular check up on SCKMC activities Share your thoughts, story ideas, and comments by e-mail to claytonp@sckrmc.org.
HAC Report Based on Minimal Cases A report released in December by the Centers for Medicare and Medicaid Services (CMS) announcing SCKMC would receive a financial penalty due to a high number of hospital acquired conditions (HAC) made both local and regional headlines. Hospital administration was surprised to learn the facility had been named and began a prompt investigation into the newly established payment reduction program. Jane Campbell, SCKMC’s Director of Hospital Quality and Risk Management, spent a significant amount of time researching the number of preventable conditions that patients develop during stays, specifically hospital acquired infections and serious complications. “Medicare looked at two different kinds of infections, over a two year period. We had one reportable infection over the entire two year period. That meant that our rates were extremely, extremely low,” Campbell said. However, according to Campbell the infection rate was so low that CMS did not account for it in the report’s calculation, and therefore did not register two-thirds of the overall score. “Because our score was so good in the hospital acquired infection domain, they threw those scores out. They didn’t allow us to average them,” Campbell said. The third category of the report considers hospital acquired conditions, like collapsed lungs, pressure ulcers, and postoperative blood clots. “What (CMS) found when they looked at us is that we had one case that was coded a pulmonary embolism (blood clot in the lung) out of about 140 possible surgeries. The imaging studies that were done show that there was no pulmonary embolism, but the way the doctor had written their discharge summary it had to be coded that way. Then there were three accidental lacerations during surgery out of 853 surgeries. None that caused an infection, none that caused any harm to the patient at all. Finally, we had one surgical patient with multiple comorbidities. Their surgical wound reopened (dehiscence). The wound was repaired, and the patient did fine after. Somehow (CMS) determined that we had one out of 32 cases with a wound dehiscence. That is five, if you count the pulmonary embolism, out of 2,801 total surgeries,” Campbell reported. Those five outcomes gave SCKMC a score of nine and landed the facility in the bottom 25-percent of hospitals. A score hospital administration disputes. “Theoretically that (hospital acquired conditions) score that they calculate should have been averaged by the zeropercent score that we had in the hospital (continued)
The Pharm Forum with Homer Mah, D.Ph. Dry eyes can cause a lot of discomfort and may lead to blurred vision. The medicines you take and other medical problems you have may cause dry eyes. There are some things you can try to help prevent symptoms: • avoid long sessions of reading and watching TV • stay away from dusty and windy environments • avoid rubbing your eyes • limit alcohol consumption • stop smoking • use a humidifier Artificial tears or lubricants can be purchased at your local pharmacy and come as drops, gels, and ointments. Drops are the easiest to use while ointments should be saved for bedtime since it may cause blurred vision. Remember, OTC products only help relieve symptoms not cure the problem.
Employee of the Month Congratulations Scott Stevens, Director of Maintenance, for being named the SCKMC Exceptional Service Award winner for the month of February. Scott was nominated by a coworker for always ensuring the facility and grounds are top-notch. If you would like to nominate someone for next month's award or view all of our past exceptional service nominees, visit us at www.sckmc.org.
HAC Report - continued acquired infection realm. Which would have given us a score of three, one of the highest rated hospitals,” Campbell said. “We know that we don’t want any complications. We don’t want any adverse events with our patients. Zero is always the best, but four out of 2,801, that’s pretty close to zero.” The result of the final score is that CMS will be withholding one-percent of SCKMC’s annual payment, or roughly $40,000. The score cannot be appealed or reversed and will be in effect for the 2015 fiscal year. “This is an algorithm that was designed to make 25% of the hospitals fail, and that’s the bottom line. It is very frustrating, but we are a great hospital and we do great work here. And not withstanding what the media reports, or what CMS says, we’re doing a good job,” said Campbell.
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