Becker's Clinical Quality & Infection Control

45 QUALITY IMPROVEMENT & MEASUREMENT CMS drops proposal to reduce public reporting of hospital infections, safety issues By Megan Knowles C MS will publicly disclose hospital errors, injuries and infections it pro- posed removing from one of its pub- lic reporting programs, the agency said in a new rule published Aug. 2. Under the rule, CMS will collect safety data from hospitals through two ACA payment programs, even though it does not have a way to collect and publicly report data through the programs. e information will be published on Hos- pital Compare and be made available in a downloadable database. e reports will in- clude dates and details of various safety inci- dents reported through the Inpatient Quality Reporting Program, including rates of Clostrid- ium difficile, methicillin-resistant Staphylococ- cus aureus and sepsis aer surgery. e American Hospital Association pre- viously urged the Trump administration to stop publicly disclosing this data in the proposed rule. In a December 2016 letter to then Presi- dent-elect Donald Trump, the American Hospital Association asked him to remove measures added to CMS programs in the last two years, USA Today reported. AHA CEO Richard Pollack said measures that finan- cially penalize hospitals for safety problems should be removed from the programs. Leapfrog sent a letter to CMS in June, calling the proposal a threat to transparency in hospi- tals and urging the agency share the informa- tion on infection rates and safety incidents. "ese kill a lot of people and patients deserve to know how hospitals are doing in preventing them," Leah Binder, CEO of Leapfrog, told USA Today. Along with publicly reporting safety data, CMS said it is also working to improve transparency related to other sur vey reports, including for hospital accrediting organizations. n Joint Commission will require hospitals to report percentage of newborns with unexpected complications By Megan Knowles B eginning Jan. 1, the Joint Commission will require hospitals to identify the percentage of infants with unexpected new- born complications among full-term newborns who do not have pre-existing conditions. The new requirement, called PC-06 Unexpected Complications in Term Newborns, will add to the organization's five measures required for Joint Commission-accredited hospitals that have at least 300 live births annually. Hospitals seeking perinatal care certification from the Joint Commission will also have to report PC-06. "While measures have been developed to assess clinical practic- es and outcomes in preterm infants, the Joint Commission has identified a lack of metrics that specifically assess health outcomes of term infants who represent more than 90 percent of all births," the organization said. "PC-06 is designed to address the metrics gap and gauge adverse outcomes resulting in severe or moderate morbidity in otherwise healthy term infants without pre-existing conditions." The Joint Commission recently approved requirements for hospi- tals to avoid misidentifying newborns after delivery by requiring hospitals to use distinct naming systems and identification tools for newborns. Earlier this year, the organization also approved standards to improve the identification of mothers at risk for trans- mitting infectious diseases to their newborns near delivery time. n Hospital Compare spotlights hospitals' sepsis performance By Megan Knowles C MS on July 25 added hospitals' sepsis performance data to its Hospital Compare website. Hospital Compare users can view a new sepsis care measure under the website's timely and effective care tab. Users can then compare their hospital's score to state and national averages. Nationally, the average percentage of patients who received appropriate care for severe sep- sis and septic shock is 49 percent, according to Hospital Compare. The sepsis performance measure is based on data from the first quarter of 2017 through the third quarter of 2017. The preview period for this change spanned from May 4 to June 2. "With each release, the most recent quarter is added, and older quarters removed, so a full rolling year's worth of performance data are included, similar to other chart abstract- ed measures," CMS said in a February 2018 educational webinar on the Hospital Inpatient Quality Reporting Program. n

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