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Preventing Hospital Acquired Conditions- The Road to Compliance is Paved with Good Intentions, Poor Execution, and Bad Outcomes

Susan Nedza MD, MBA, FACEP

Risk of Falling

In 2007, I had the privilege of serving as a Medical Officer on a group at the Centers for Medicare and Medicaid Services that was tasked with implementing Section 5001(c) of the Deficit Reduction Act of 20051.

The legislation required the secretary to identify at least two conditions that were (a) high cost or high volume or both, (b) result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines.

This meant that for discharges occurring on or after October 1, 2007, IPPS hospitals did not receive the higher payment for cases when one of the selected conditions is acquired during hospitalization (that is, the condition was not present on admission). The case was paid as though the secondary diagnosis was not present. In 2008, the original list consisted of 8 conditions or events including trauma and falls and catheter associated urinary tract infections2.

The team that developed the initial list was proud of its work, its commitment to evidence-based guidelines and felt that this policy change would incentivize hospitals to focus on patient safety and avoidance of harm. Everyone involved had the best of intentions when adopting this payment policy; after all it was about patient safety.

Fast-forward six years to December 2015. AHRQ released the report, Saving Lives and Saving Money: Hospital-Acquired Conditions Update3. Preliminary estimates show that in total, hospital patients experienced 1.3 million fewer hospital-acquired conditions from 2010 to 2014.  This translates to a 17 percent decline in hospital-acquired conditions over the three-year period. Should we all celebrate? Are our patients actually getting better, safer care?

My recent experience as a family member during my mother’s hospitalization for CHF and unstable angina leads me to answer no. When I arrived at the hospital, I found the above sign prominently posted outside her door. I thought, this is great; the hospital is embracing fall prevention. That said, I was a bit puzzled at the choice of “yellow” as she was taking Coumadin and had suffered a fall less than two weeks before her hospitalization.

I didn’t give it much more thought until I found myself in the bathroom with her for the third time in two hours waiting what seemed to be an eternity for help. I could only wonder what would have happened if I wasn’t there and she tried to go back to bed in the dark? Later the next day after her morning dose of Lasix my concern grew when a harried aide helped her to the bathroom, closed the door and said as she scurried from the room, “have her pull the cord when she is done.” Once again, was that a safe practice?

So what were they really doing to make her safe? A sign prominently hung across the room from her bed.


(Please note in protecting the facility I cut off the words “one concern”)

 I am not sure what protection this information provided, as without her glasses she couldn’t see across the room. In addition, it seemed a bit confusing to have ambulation as a goal when no one came to ambulate her and to also state that she shouldn’t get out of bed without assistance. The good urine output goal seemed to encourage her to get up to the bathroom early and often.

The instructions to “Ring for Help” and to “call Ext. 7900” for help seemed to direct her to use her phone (which she couldn’t reach without getting out of bed) to call for help.

All of this became more complicated on day 2 when she became progressively more disoriented. She repeated over and over again that she needed to leave this restaurant and to get back to her apartment upstairs. When I share with the staff the fact that she had wandered off the floor during another hospitalization, I received no indication that triggered increased diligence by the hospital. Not even the wristband that indicated that she was a “yellow” was ever changed to “red.” Our family decided to stay all night in her room as a precaution.

When I did venture outside of her room, I noted that other potential hazards were everywhere.


I wondered what was worse, the wet floor in the room or the sign warning about the wet floor? Was the sign there to protect the staff from slipping when they entered her room or the patient when she walked out?

These were but a few of my observations. I noted that while the IV pumps made medication mishaps less likely, they also meant that the nurses did not have to come into the room to check IVs and hence lay eyes on my mom. The ubiquitous presence of the EHR also meant that at any given time, 75% of the staff was staring at computer screens at the desk. In spite of access in her chart, no one appeared to have read her ED records or records from the assisted living facility, or records from prior hospitalizations. Everyone assumed that her change in orientation was due to being in the hospital, no workup for delirium was undertaken even though her meds had changed. The only visit from the hospitalist doctor but by the business manager who left a brochure stating that we would get a separate bill for his services (even though he never saw mom.)

In patient safety language, this was a near miss. Mom didn’t fall because her family served as a final wall protecting against a potentially bad outcome. The hospital, the nurses, the aides and others were following policies and documenting their work. No one person was responsible for recognizing or remedying the potential gaps in her care. No one and everyone was to blame.

So what would have made my mom safer? One simple thing might have been a urinary catheter. When I asked why she didn’t have one despite the large doses of Lasix she was receiving and her risk of falling, I received the response that I dreaded. “Medicare measures the hospital on catheter acquired urinary tract infections so we don’t use them any more.” I nodded my head in understanding.

Instead, I should have hung my head in shame. The Congress created a law, I helped write the CMS regulations, the NQF built the performance measures, hospitals complied, and my mother and countless other patients were put at potential risk.

This is but one example of how little thought has been given to the potential to increase patient risk that may occur due to patient safety initiatives. In the end, a system that does not monitor for unexpected consequences is not a system at all. I believe that we all have a responsibility to protect our patients from harm that comes not from care but from public policy.


  1. Deficit Reduction Act of 2005
  3. Saving Lives and Saving Money: Hospital Acquired Conditions Update December 2015. Agency for HealthHealthcare Research and Quality, Rockville, MD.


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