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Management Issue 4:
Ensuring Patient Safety and Quality of Care

Why This Is a Challenge

As a purchaser of health care for over 100 million Americans, the Department faces challenges in ensuring the quality of care rendered to Federal health care program beneficiaries. Despite increased attention to patient safety, quality problems persist. According to the Joint Commission, 40 wrong-site surgeries are performed in U.S. hospitals and surgicenters every week. In a 2010 report, OIG found that 13.5 percent of hospitalized Medicare beneficiaries suffered harm from adverse events (i.e., patient harm resulting from medical care) during their hospital stays. Forty-four percent of these adverse events were preventable and were caused by care failures, such as medical error, substandard care, or inadequate monitoring. OIG continues to conduct followup work on studying adverse events, including determining the extent to which adverse events occur in other care settings, such as nursing homes.

Other OIG work has raised concerns about overmedication with atypical antipsychotic drugs in nursing homes; more than 20 percent of atypical antipsychotic drugs claimed for Medicare patients in nursing homes violated Federal standards to protect nursing home residents from unnecessary drug use. OIG also found that nursing homes generally were not meeting all requirements for care plans and resident assessments when administering antipsychotics. OIG has also identified concerns with the licensure and qualifications of health care providers across various health care settings.

Quality of nursing home care remains a critical challenge. OIG investigations have uncovered various problems, including inadequate staffing, failure to provide adequate nutrition and hydration, patients' development of preventable or untreated pressure wounds (bedsores), inappropriate medication practices, and other serious deficiencies. Other enforcement actions target nursing homes that maximize reimbursement by rendering excessive therapy services that are medically unnecessary or even harmful to beneficiaries.

Progress in Addressing the Challenge

A doctor and her patient

The Department has taken steps to improve quality of care and promote patient safety, both targeting specific populations, such as improving care coordination for Medicare beneficiaries with multiple chronic conditions, and improving care for all patients. The Department has committed up to $1 billion in ACA funding to the Partnership for Patients Initiative, a public-private partnership to keep patients from becoming injured or sicker while undergoing treatment and to help patients heal without added complication. Two specific partnership goals are to reduce hospital readmissions by 20 percent and reduce preventable harm to hospital patients by 40 percent by the end of 2013.

CMS awarded $218 million to State, regional, national, or hospital system organizations to establish Hospital Engagement Networks to make health care safer and less costly by targeting and reducing preventable injuries. Pursuant to the ACA, CMS specifically committed $500 million towards a Community Based Care Transition Program to improve patient outcomes following hospital discharge.

The Department is also testing and implementing new care delivery models in the Medicare and Medicaid programs designed to improve the quality of care by enhancing provider accountability for quality and improving coordination of care and care transitions. The Department continues to provide incentives for improved quality of care through its value-based payment policies, including policies that link payment to quality measures and that address hospital-acquired conditions. The Department also continues to promote the adoption of electronic health records and electronic prescribing, which promise to improve quality of care, reduce medication errors, and otherwise promote patient safety. The Department established tools to help beneficiaries compare facility-specific quality indicators to better inform their decisions regarding where to seek treatment. (See also Challenge 5, Avoiding Waste and Promoting Value in Health Care, for more discussion of promoting value and coordination in health care and Challenge 9, Integrity and Security of Health Information Systems and Data, for more discussion of electronic health records.)

The Five Star Quality Rating System and Nursing Home Compare report on many important quality measures for nursing homes. Recent regulation has also targeted therapy utilization in nursing facilities. In March 2012, CMS launched a new initiative aimed at improving behavioral health and safeguarding nursing home residents from unnecessary antipsychotic drug use. A primary goal is to reduce antipsychotic drug use in nursing homes 15 percent by the end of 2012. Additionally, CMS' Nursing Home Value-Based Purchasing demonstration is currently testing ways to improve care for this population.

OIG continues to pursue enforcement actions against health care providers that render substandard care. OIG maintains corporate integrity agreements with several nursing homes, hospitals, assisted-living facilities, and dental clinics that include quality-monitoring provisions. CMS and OIG continue to work closely with law enforcement partners at the Department of Justice and through the Federal Elder Justice Interagency Working Group to promote better care for elderly persons and to prosecute providers that subject them to abuse or neglect.

What Needs To Be Done

The Department should continue to prioritize quality of care and patient safety and build upon its past efforts, including continuing to implement the quality improvement provisions of the ACA and achieving the goals set by the Partnership for Patients and the National Quality Strategy. OIG has offered recommendations that can assist the Department in this mission. For example, OIG suggested enhancements to nursing home oversight to ensure that Medicare does not pay nursing homes to overmedicate or otherwise inappropriately medicate beneficiaries. OIG also suggested enhancements to outpatient prescription drug claims that could help the Department ensure that Medicare and Medicaid beneficiaries receive only the drugs that are appropriate for their medical indications. The Department should also continue denying payments for services of such low quality that they are virtually worthless and work with OIG to exclude providers that have rendered grossly substandard care, thereby preventing additional harm to vulnerable beneficiaries.

The Department must also ensure that health care professionals working in all sites of service, such as hospitals, nursing homes, school-based facilities, and beneficiaries' homes, meet qualification and licensure requirements before they treat Federal health care program beneficiaries.

Key OIG Resources

  • Summary and index of OIG reports related to adverse events among hospitalized Medicare beneficiaries
  • Testimony of Inspector General Levinson on Medicare claims for atypical antipsychotic drugs for nursing home residents, November 30, 2011

Management Issue 5: Avoiding Waste and Promoting Value in Health Care

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Office of Inspector General, U.S. Department of Health and Human Services | 330 Independence Avenue, SW, Washington, DC 20201