Situation: Centers for Medicare & Medicaid Services (CMS) Currently Has Two Programs That

Situation: Centers for Medicare & Medicaid Services’ (CMS) currently has two programs that effect Medicare payment to hospitals based on performance, specifically prevention and reduction of Hospital Associated Infections (HAI) compared to other facilities nationwide. HAI’s are entered into the National Healthcare Safety Network (NHSN) database after applying NHSN HAI criteria to all qualifying inpatients. It is approximated that there are 5,000 to 10,000 inpatient facilities nationwide participating in the CMS payment program.

Background: Currently, the only requirement to summit data to the NHSN database is completion of the application to gain access to the database. Although NHSN provides many avenues of training, including in person and online, there are no competency requirement’s to summit data for the CMS payment programs. CMS has made some effort to ensure hospital staff are entering into NHSN are correctly identifying HAI’s utilizing NHSN criteria. Each year, a total of 600 participating hospitals are selected to be validated for accuracy in criteria application and reporting. Of these 600, 400 are randomly selected and 200 are targeted. Of the total 600 hospital selected, half will be randomly selected to be validated for central line-associated blood stream infection (CLABSI) and catheter-associated urinary tract Infection (CAUTI); the other half will be validated on Methicillin-Resistant Staphylococcus Aureus (MRSA) laboratory-identified (LabID) events and Clostridium difficile Infection (CDI). All selected facilities will be validated on Surgical Site Infection (SSI).

Analysis: With the current payment program, hospitals are at risk to lose up to several millions of dollars annually based on NHSN measures listed above. Payment is based on comparison to other facilities. This model is very dependent on the assumption that each responsible party, entering information in to the NHSN database, has applied the NHSN HAI criteria consistently and accurately. However, without competencies and a very small sample size for validation, it is impossible to ensure each summiting facility is correctly applying NHSN criteria. This become evident in a recent study conducted by NHSN and (insert hospital) in which only 60% of those tested proved competent (need source). This statistic can have a detrimental effect on the accuracy of the CMS pay for performance model, as performance is not being accurately or consistently reflected nationally. The Hospital Acquired Conditions program (HAC) will deduct 2% of payment from facilities in the bottom 25% performance for CLABSI, CAUTI, MRSA lab ID, CDI, and SSI for Fiscal Year 2018. It is not possible at this time to determine if those in the bottom 25% are truly performing poorly to their peers, or simply more accurately applying the criteria, being that 40% of the nation has been shown to not be doing so.

Recommendation: In order for the CMS pay by performance programs to perform as intended, and truly penalize hospitals with the worst performance, it is necessary to ensure the each individual performing NHSN surveillance for the CMS reportable measures are able to demonstrate competency. At this time there is not required demonstration of knowledge or application of the criteria in order to enter HAI’s into the NHSN database. We recommend that a program be developed requiring all individuals with access to this database be required to pass a competency on each HAI, prior to having access to the database. It is important to also acknowledge that at this time a very small sample of reporting hospitals is being validated by CMS.