Achieving Key Quality and Patient Safety Measures of the Affordable Care Act

While most of the public discourse on the Patient Protection and Affordable Care Act has centered on coverage, affordability, payment and state-operated health exchanges, healthcare providers are faced with implementing a crucial aspect of the legislation: improving patient safety and quality of care.

On Oct. 1, significant patient safety initiatives went into effect, marking the beginning of a historic shift in how Medicare reimburses healthcare providers and facilities. For the first time, payments for acute inpatient care will be tied to the quality of care and services. Payments will now be based in part on how effectively hospitals meet new measures related to the quality and value of patient care. Like most components of the reform law, healthcare administrators will see pay-for-performance changes roll out steadily over the next few years, ratcheting up to a significant shift in how providers are reimbursed.   

Medicare's Hospital Value-Based Purchasing Program is one of the new efforts designed to reward hospitals that provide high-quality care for their patients. The VBP will implement a pay-for-performance approach that will affect payment for inpatients at more than 3,500 hospitals throughout the country.

Under the VBP program, the quality of care provided by hospitals will be measured through a set of 12 clinical quality measures and a composite measure of patient experience. In general, these measures revolve around reducing readmission rates, preventing hospital and surgical errors and linking payment to patient experience scores. Under these new forms of payment, all hospital services will need to work to deliver improved outcomes and increased value. The goal is to invest all players in the healthcare system — hospitals, providers, insurers and other payors — in improving the efficiency and excellence of patient care. Under this program, hospitals achieving the specified quality measures will receive higher payments, while those that fail to meet the standards will see payment reductions.

The new legislation puts the onus for improving current practices squarely on healthcare leaders, who are now challenged to assess and replace wasteful or unsafe procedures with safer, more effective approaches. To ease the burden, hospital administrators must look to other healthcare organizations that have tackled similar challenges and borrow effective strategies and approaches from their peers. Ultimately, it is far more effective to adopt clinical and operational standards that are already in use at leading organizations, and many healthcare institutions are making these solutions and best practices available.   

At, we have catalogued a wide range of free or low-cost solutions pioneered by leading healthcare institutions. These evidence-based approaches provide information, strategies, guidelines and best practices to help healthcare administrators tackle several aspects of healthcare reform legislation.

Adverse events

Lowering the incidence of adverse — or 'never' — events is a cornerstone of the VBP program.

The first step to lowering adverse events is tracking hospital errors, but a July 2012 report from the HHS Office of Inspector General found many hospitals fail to identify errors. The report noted that 27 percent of Medicare recipients experienced "care-related harm" in a one-month period, and 44 percent of these adverse events were preventable. Furthermore, hospital staff failed to report 86 percent of adverse events to incident reporting systems even though many unreported events involved serious harms, including six patient deaths.

Tens of thousands of Americans die because of adverse events, and the $500 million Partnership for Patients program is aimed at reducing hospital-acquired infections, errors and other preventable complications. The Act also requires Medicare to post individual hospitals' rates of medical errors and infections online and to cut payments to hospitals with the highest rates.

Several best practice toolkits to help leaders evaluate adverse events and improve outcomes are available. The Adverse Monitoring and Tracking Tool developed at Adventist Health System builds on the Global Trigger Tool Healthcare Trigger methodology and is used system-wide at Florida Hospital in Orlando to increase patient safety and reduce readmissions. Similar trigger tools are available for pediatric and neonatal intensive care units. The Respectful Management of Clinical Adverse Events is a free crisis-management plan developed by the Institute of Healthcare Improvement to limit the damage related to a serious adverse event.

Readmission rates

Nearly one in five Medicare patients discharged from a hospital is readmitted within 30 days.

While some readmissions are scheduled, many others are "preventable" through improved coordination of care between physicians and hospitals, and through better follow-up after patients are discharged.

CMS will begin penalizing hospitals with high levels of preventable 30-day readmissions beginning Oct. 1 by reducing payments. In 2013 the maximum payment reduction will be one percent for three high-volume conditions: pneumonia, heart attacks and heart failure. This list will be expanded to include more conditions and penalties will rise to a maximum of three percent in 2015 and beyond.

Examples of solutions to help hospital executives evaluate, monitor and improve preventable readmission include the Basoor’s Heart Failure Checklist developed by St. Joseph Mercy Oakland Hospital. This free checklist includes 27 questions related to discharge, medications and follow-up care. Another example is the Readmission Reduction Through Glycemia Management solution, which focuses on improving discharge care and outcomes among diabetics, a condition often seen in cardiac patients.

Patient discharge protocols

Improving discharge procedures works in tandem with reduced readmissions and patient satisfaction. Under the VBP, discharge protocols and instructions for medication and follow-up care will be one of the measures to gauge the quality of clinical performance.  

Healthcare administrators can find several discharge-related toolkits, guidelines and protocols at

For example, Project BOOST (Better Outcomes through Safe Transition) is a free, web-based toolkit developed by the Society of Hospital Medicine, which can guide hospital coordinators through eight key aspects of improving the patient discharge process. Administrators can also download "Care About Your Care: Tips for Patients When They Leave The Hospital," an article published by Dartmouth Institute for Health Policy and Clinical Practice and the Robert Wood Johnson Foundation, which focuses on safe hospital to home transition for patients, including assessment tools and strategies to coordinate care between patients, caregivers and hospital staff.  

Surgical safety and checklists

Several measures of the VBP focus on specific surgical processes, such as administering antibiotics and performing diagnostic tests prior to surgery. To meet these benchmarks, a range of surgical checklists, including the World Health Organization Surgical and Safety Checklist and Preventing Wrong-Site Surgery Toolkit, the Ventilator Associated Pneumonias Estimator and the Surgical Care and Outcomes Assessment Program Surgical Checklist, can be utilized by hospitals.

Another is the Perioperative Handoff Toolkit, developed by Johns Hopkins Medicine. This comprehensive methodology provides a step-by-step approach to conducting a patient transfer from the time that the patient arrives at the PACU or ICU from the operating room. Available at, the toolkit fulfills all of the Joint Commission handoff criteria, standardizes an easy-to-follow five-step protocol and includes checklists for the surgical and anesthesiology teams.

Joseph Davis is the founder and CEO of, a website with numerous online resources for hospitals and health systems. The site features an extensive inventory of free or low-cost clinical and management solutions developed by leading medical institutions including Duke Medicine, Johns Hopkins Medicine, Partners HealthCare and many others.

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