School of Medicine, University of Colorado Denver, Aurora, CO 80045, USA.
Implement Sci. 2012 Aug 28;7:78. doi: 10.1186/1748-5908-7-78.
Preventable adverse events from hospital care are a common patient safety problem, often resulting in medical complications and additional costs. In 2008, Center for Medicare and Medicaid Services (CMS) implemented a policy, mandated by the Deficit Reduction Act of 2005, targeting a list of these 'reasonably' preventable hospital-acquired conditions (HACs) for reduced reimbursement. Extensive debate ensued about the potential adverse effects of the policy, but there was little discussion of its impact on hospitals' quality improvement (QI) activities. This study's goals were to understand organizational responses to the HAC policy, including internal and external influences that moderated the success or failure of QI efforts.
We employed a qualitative descriptive design. Representatives from 14 Nurses Improving Care of Health System Elders (NICHE) hospitals participated in semi-structured interviews addressing the impact of the HAC policy generally, and for two indicator conditions: central-line associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI). Within-case analysis identified the key components of each institution's response to the policy; across-case analysis identified themes. Exemplar cases were used to explicate findings.
Interviewees reported that the HAC policy is one of many internal and external factors motivating hospitals to address HACs. They agreed the policy focused attention on prevention of HACs that had previously received fewer dedicated resources. The impact of the policy on prevention activities, barriers, and facilitators was condition-specific. CLABSI efforts were in place prior to the policy, whereas CAUTI efforts were less mature. Nearly all respondents noted that pressure ulcer detection and documentation became a larger focus stemming from the policy change. A major challenge was the determination of which conditions were 'hospital-acquired.' One opportunity arising from the policy has been the focus on nursing leadership in patient safety efforts.
While the CMS's HAC policy was just one of many factors influencing QI efforts, it may have served the important role of drawing attention and resources to the targeted conditions-particularly those not previously in the spotlight. The translational research paradigm is helpful in the interpretation of the findings, illustrating how the policy can advance prevention efforts for HACs at earlier phases of research translation as well as pitfalls associated with earlier phase implementation. To maximize their impact, such policies should consider condition-specific contextual factors influencing policy uptake and provide condition-specific implementation support.
医院护理中可预防的不良事件是常见的患者安全问题，通常会导致医疗并发症和额外费用。2008 年，医疗保险和医疗补助服务中心（CMS）根据 2005 年《赤字削减法案》的要求，实施了一项政策，针对一系列“合理”可预防的医院获得性条件（HAC）进行报销减少。随后，人们对该政策可能产生的负面影响展开了广泛的辩论，但几乎没有讨论其对医院质量改进（QI）活动的影响。本研究的目的是了解组织对 HAC 政策的反应，包括内部和外部因素，这些因素调节了 QI 工作的成败。
我们采用了定性描述性设计。14 名参与护士改善医疗保健系统老年人护理（NICHE）医院的代表参加了半结构化访谈，内容涉及 HAC 政策的一般影响，以及两个指标条件：中心静脉置管相关血流感染（CLABSI）和导管相关尿路感染（CAUTI）。每个机构对政策反应的关键组成部分进行了案例内分析；跨案例分析确定了主题。用典型案例来说明调查结果。
受访者报告说，HAC 政策是促使医院解决 HAC 的众多内部和外部因素之一。他们一致认为，该政策将注意力集中在预防以前投入资源较少的 HAC 上。政策对预防活动、障碍和促进因素的影响因条件而异。CLABSI 措施在政策之前就已到位，而 CAUTI 措施则不太成熟。几乎所有受访者都指出，由于政策的改变，压疮的检测和记录成为一个更大的关注点。一个主要挑战是确定哪些条件是“医院获得性”的。该政策带来的一个机会是关注护理领导在患者安全工作中的作用。
虽然 CMS 的 HAC 政策只是影响 QI 工作的众多因素之一，但它可能起到了重要作用，将注意力和资源集中到目标条件上——特别是那些以前没有受到关注的条件上。转化研究范式有助于解释研究结果，表明该政策如何在研究转化的早期阶段推进 HAC 的预防工作，以及与早期阶段实施相关的陷阱。为了最大限度地发挥其影响，此类政策应考虑影响政策采用的特定条件的背景因素，并为特定条件的实施提供支持。
