Value-Based Purchasing: The Case for Pressure Ulcers - Term Paper Example

Value Based Purchasing: The Case for Pressure Ulcers. Hospital Acquired Conditions A hospital-acquired condition, abbreviated as HAC, refers to an undesirable medical situation or outcome that affects a patient as a result of their stay in a healthcare facility (Buchbinder & Shanks, 2012). In the United States, Hospital Acquired Conditions are used by Medicaid for determining reimbursement costs on Diagnosis Related Groups. Hospital acquired conditions normally arise when a patient who had already been admitted in a healthcare facility is further degraded or infected as a result of the treatment by the hospital personnel or general hospital conditions. Currently, the United States Medicare System identifies 1000 conditions as likely hospital acquired conditions. Hospital acquired conditions are designated to be Present on Admission or Not Present on Admission. If a particular diagnosis is observed to be present on admission then it is not considered to be hospital acquired. However, if a diagnosis is not observed as being present on admission of the patient, then it is likely to be demoted to a hospital acquired condition. For instance, if a patient trips and falls as he or she is using the hospital’s washrooms and breaks a hand, the resultant fractured hand was not present upon the patient’s admission. In this case, the complication of fractured hand will be designated as a “Trauma and Falls” Hospital Acquired Condition. As a result of this occurrence, the healthcare facility will not be compensated by Medicare for the treatment of such an injury. The intention of this approach is to force hospitals to take the utmost level of care of the patients who have been admitted under their roof. Categories of Hospital Acquired Conditions include blood incompatibility; object left in during surgery; air embolism; Vascular Catheter Associated Infection; Surgical Site Infection, Falls and Trauma and Pressure Ulcers. The Financial Year 2013 Inpatient Prospective Payment System added three more categories of Hospital Acquired Conditions namely Deep Vein Thrombosis, Manifestation of Poor Glycemic Control and Iatrogenic Pneumothorax with Venous Catheterization. Pressure Ulcers and quality of healthcare Decubitus Ulcer, bedsore or pressure ulcer refers to an area of human skin which breaks when something keeps pressing or rubbing against the skin. Pressure ulcers normally cause injury to both the skin and the underlying tissue. The pressure sores or pressure ulcers always occur at the point where there is minimal body fat and the skin covers a bony body area such as the tailbone, hips, ankles, the back of the head, ear rims, knees, toes, along the spine, shoulder blades or heels. Wheel chair users are at higher risk of developing pressure ulcers on the back of their hip bones, buttocks, back of legs and arms. Pressure ulcers usually range in severity from as extreme as open wounds the expose the underlying muscle or bone to as mild as scattered patches of discolored skin. The severity of pressure ulcers is usually graded from grade one to grade five. Grade one pressure ulcer barely bruises the surface of the skin. The skin remains undamaged but it may itch or hurt. Grade two pressure ulcer damages the dermis and the epidermis. The ulcer resembles a bister or a wound. Grade three pressure ulcer damages the underlying skin tissue and skin loss takes place throughout the skin’s entire thickness. The most severe type of pressure ulcer is the grade four pressure ulcers that damage the underlying bones and muscles. Grade fur pressure ulcer often leads to tissue necrosis. Patients who develop grade four pressure ulcers always face a high probability of developing a life-threatening infection such as gangrene or blood poisoning. The cause of pressure ulcer is the lack of blood flow to the skin area which is under pressure. As a result of insufficient blood flow, the affected part of the skin usually dies leading to the formation of painful ulcers. Pressure ulcers are upsetting, unpleasant and challenging to treat. It is for this reason that a range of techniques is normally used to prevent their occurrence in the first instance. Pressures sores are considered preventable because if a medical facility has prescribed bed rest for a patient or the patient is rendered immobile because of an underlying medical condition, then the same hospital should assign a caregiver to check the patient for pressure sores after a specified duration say every half a day. It is advisable that the patient or the caregiver should examine the body for pressure sores from the head to toe. Special attention should be paid to known areas where pressure ulcers like to develop. The patient should be on the lookout for craters, sores or blisters and reddened areas on the skin. The condition is thus preventable because in most instances it is caused by other medical conditions which require someone to be under constant watch and care of a caregiver. Known steps that should be followed to protect a patient from pressure sores include changing the patient’s sleeping position for every three hours to relieve pressure; the use of items like foam padding, sheepskins, pillows, specially designed cushions or mattresses, and special powders from medical supply stores; consuming well balanced meals that can give your body enough calories to stay healthy, keeping the skin dry and clean especially after having bowel movement or urinating; and daily exercises that include a variety of motion exercises. All these specified approaches are meant to ensure that pressure point is a preventable condition. With the highest standard of care, it is possible to take proper preventive measures for pressure ulcers even amongst the most vulnerable population including the elderly. Reducing and preventing the occurrence of pressure ulcer is indicative of a good quality healthcare practice. For patients who are struggling with individual mobility, it means that the healthcare provider was professional enough to ensure that such patients are frequently turned as they sleep or sit so as to even out the pressure across the skin surface. It also means that the healthcare provider took steps to provide comfortable mattresses and other preventive inputs that prevented the occurrence of this type of Hospital Acquired Condition. Pressure Ulcers and the Law Cases of legal litigation involving patients who are suffering from pressure point are on the rise. This has become an unpleasant reality for many care givers who are entrusted with the responsibility of managing the patient’s welfare. It is for this reason that Kevin Yankowsky, the Managing Partner of the Boston based Health Law Litigation firm Fulbright & Jaworski LLP observes that there exists two types of caregiver in America, those who will be sued and those who have been sued (Pozgar, 2013). In wound care, health law litigation obviously focuses on pressure ulcers because this is the area where caregivers are likely to apply an oversight in their practice. The most common argument patterns when pursing litigation claims that are funded on pressure ulcers include: “the development of pressure ulcers is an obvious sign of abuse of the elderly who have been entrusted to stay at a nursing home. This is a sign of negligence”. Another common argument pattern is that health care facilities have since developed very strict guidelines to ensure that pressure sores are prevented. If the facility had followed these protocols, the patient would have not suffered from pressure sores. Litigation lawyers also often allude to the number of caregivers who are assigned to a particular facility as a cause of cases of pressure sores. According to such litigation claims, the occurrence of pressure points could be as a result of insufficient number of nurses within the healthcare facility. The litigation claim further argues that if the facility had a sufficient number of nurses, then cases of skin breakdown would not have happened. But because most healthcare facilities want to make more money by cutting down on cost, they end up employing a minimal number of nurses. Litigation claims arising from bed sores can be very painful and expensive to the healthcare facility. Notable examples in the recent past include the 2008 civil liability claim between Adams v. Valincia Health Care Center. A patient died from sepsis which was caused by an advance case of pressure ulcers. Valincia Health Care Center was slapped with a $2 million compensatory damage claim. This happened in the state of California. In 2008 in Pennsylvania another civil liability claim saw Wilson v Genesis Health Care Corp facing off in the courts. Genesis Heath Care was being accused of medical negligence which led to the wrongful death as a result of pressure ulcers. In this particular instance, the plaintiff was awarded compensatory damages totaling to $3.5 million. In New York, the Menorah Home and Hospital was subjected to a litigation claim in 2007 as a result of medical malpractice that involved the negligent treatment of pressure ulcers. This particular litigation cost the healthcare facility $1.25 million in damages award. The most expensive litigation claim in the gone decade was the 2007 hearing in Tennessee between Myers v. National Healthcare Corp. Just like in the other cases, the plaintiff was arguing the case for causation of wrongful death due to instances of pressure ulcers. The total damages awarded in this case were $32.7 million split between a $28 million punitive damage award and $4 million compensatory damage award (Pozgar, 2013). Also notable is the recent transition from civil liability to criminal liability in cases involving pressure ulcers. In 2008, the owner of a Hawaiian nursing home was sentenced to serve a prison term on charges of man slaughter after a patient died as a result of infections occasioned by advance pressure ulcers. The transition from civil to criminal prosecution for medical negligence provides the law with a new weapon to fight against the provision of poor nursing care (Pozgar, 2013). The Centre of Medicare and Medicaid Services has already established preset guidelines which are to be followed to arrive at civil monetary penalties for cases of bed sores which are avoidable. Long term care surveyors must first determine if the particular case of pressure ulcer is unavoidable or avoidable. In this particular case, unavoidable or avoidable are used to determine compliance with the Federal Law and not medical determinations. Cases of avoidable pressure ulcers automatically lead to financial penalties and deficiencies. In extreme cases, a facility can lose its operational license and be deemed ineligible to receive Medicare payments. The Centre of Medicare and Medicaid Services is also in the process of extending its mandate on pressure ulcers to acute care hospitals. The legal challenges that accompany the occurrence of pressure ulcers is no longer limited to Long Term Care. Anger, grief, greed and most often the search for answers is what drives patients or their families towards attorneys. Communication between the healthcare team and the patient family or the patients can play a big role in mitigating all the above causes especially the patient’s family or the patient’s search for answers. Effective communication is always rued as preventive legal care especially in issues which are founded on Hospital Acquired Conditions (Hugman, 2009). Some of the concepts that patients and their family members do not understand in relation to pressure sores include the fact that the skin is an organ, the formation of pressure ulcers and the delicate balancing of the risks associated with pressure ulcer. Effective communication as a tool for preventive legal care entails the management of the patient’s and his or her family’s expectations way before. Explain the pressure ulcer realities and risks. An accurate, quick empathetic answer to any emerging questions afterwards will be a definite plus. Caregivers must learn to prioritize the management of expectations before working towards delivering satisfactory results. A caregiver must always endeavor to provide answers to the patients or the family members, else an adversary will, leading to elements of suspicion and malice (Hugman, 2009). Such are the ramifications of avoiding discussing the development of pressure ulcers with the family and the patient. The link between litigation and disclosure is to be found in the underlying documentation procedure. A plaintiff’s lawyer will always go first for the documentation when evaluating the validity of his or her case. A caregiver should always make an effort to evaluate the accompanying documentation with consideration on how it will be relevant for patient care needs as discussed hitherto and how it will appear in case a litigation suit is brought against the facility. Joint Commission and Pressure Ulcers Goal 14 of the National Patient Safety Goals which have been effective from January 1, 2014 aims to prevent hospital acquired pressure ulcers (Joint Commission, 2014). The utilization of clinical practice guidelines can be of great benefit in identifying residents and patients who are at risk of developing pressure ulcers and prescribing early interventions in such instances. Elements of performance assessed by surveyors from the Joint Commission on behalf of the Centre for Medicare and Medicaid Services include the existence of a written plan for the prevention of and identification of risk for pressure ulcers; the performance of an initial test on admission to identify residents and patient who are at risk for pressure sores; the ability of the healthcare facility to deploy risk assessment tools such as Norton Scale or Braden Scale to validate risk of pressure ulcers; the ability to reassess pressure sore risk at predetermined intervals; staff education level on how to prevent and identify risk for pressure ulcers; and lastly, the health facility’s efforts to act on already identified risks to the resident or patient for pressure ulcers (Joint Commission, 2014). The latter will include the prevention of injury to residents and patients by either improving or maintaining facilities to prevent injury and the protection against external mechanical forces and their adverse effects. Outcomes related to cost and quality Continuous quality improvement strategies in relation to the occurrence of pressure ulcers are varied. Firstly, members of the health care team will be required to attend trainings on how to mitigate organizational risks associated with pressure ulcers. An in house research team consisting of the healthcare team can be formed to conduct continuous research on the issue and bring other members up to speed during a monthly peer sharing forum. This is an example of an organizational learning approach. Localized improvement efforts will combine the input from the various organizational departments to come up with ways to improve the current approach to pressure sores (McLaughlin, Johnson, & Sollecito, 2012). In this particular approach, the legal department can sit separately and look the issue at hand from a legal perspective while the nursing department can view it from a medical perspective. Administrators can address the issue from an administrative view. The output from the various departments is then merged to come up with an improved model. Process engineering will involve a broader look of the current approaches towards pressure ulcers from an outsider’s perspective. Weaknesses which are then identified are worked on. Evidence based medicine will attempt to replicate the best case scenarios in dealing with pressure sores as observed from other facilities. This approach will be the least effective as different health facilities face different operational realities. An organizational learning process which is peer led will generate the best outcomes and cost the least to implement. This is because it does not involve the hiring of external consultants and the healthcare team will find it much easier to learn from one of their own or amongst themselves. This is in contrast to other approaches like process reengineering which might require extra input from external consultant who will charge exorbitant service fees. References Buchbinder, S. B., & Shanks, N. H. (2012). Introduction to health care management. Burlington, Mass: Jones & Bartlett Learning. Hugman, B. (2009). Healthcare communication. London: Pharmaceutical Press. McLaughlin, C. P., Johnson, J. K., & Sollecito, W. A. (2012). Implementing continuous quality improvement in health care: A global casebook. Sudbury, Mass: Jones & Bartlett Learning. Miller, R. D., & Steiner, J. (2014). Problems in health care law: Challenges for the 21st century. Burlington, MA: Jones & Bartlett Learning. Pozgar, G. D. (2013). Legal aspects of health care administration. Sudbury, Mass: Jones & Bartlett Learning. The Joint Commission. (2014). The National Patient Safety Goals. Read More