The Route to Eliminating Hospital-Acquired Conditions

This article appears in the November 2017 issue of Patient Safety Monitor.

By Janet Spiegel, MS

The newly released hospital safety report from the Agency for Healthcare Research and Quality tells an encouraging story: Hospital-acquired conditions (HAC) are on a double-digit decline. The study showed that these conditions decreased 21% since 2010. While that progress should certainly be commended, we shouldn’t celebrate just yet. Research reminds us that patient outcomes overall are still favorable at hospitals that perform well on quality. And as the most common quality grade received by the scored facilities was a C, we know that opportunity to improve remains.
Include RCA in corrective action plans
One of the graded measures is number of methicillin-resistant Staphylococcus aureus (MRSA) events. As CMS notes, length of stay can contribute to the occurrence of MRSA events, and of course MRSA events themselves can impact length of stay. If there is an opportunity for improvement in any of the measures at your facility, it’s important not only to have a corrective action plan (CAP) in place for audit readiness and future safety surveys, but to ensure that the CAP is based on a root cause analysis (RCA).
For example, consider a hospital that experiences a spike in MRSA events. The hospital may put a CAP in place that focuses its interventions around improving wound care or changing sterilization processes. While these may be wise in theory, without a focused RCA, the facility cannot know for sure that these interventions will reduce these specific MRSA occurrences.
Recently a hospital group shared that it was incentivizing its providers to discharge patients by noon every day. It was a clear directive that providers bought into: “Let’s move our patients back to their homes as soon as they are ready to reduce the possibility of infection or other conditions and to turn over beds for those who need care.”
The positive impact to patient satisfaction, patient outcome, process, and revenue was undisputable. What unfortunately resulted was that when providers came too close to the noon deadline, they would hold their patients an extra night to meet their metric the next day.
At times, our metrics can incentivize unhelpful behaviors. Through an RCA, teams may uncover what MRSA patients have in common—whether the infections are due to delayed discharges, inadequate wound care, ineffective sterilization processes, or something else the teams hadn’t considered. This will ensure they are solving for the right problem.
Use the Plan-Do-Study-Adjust cycle in your CAP
Continuous improvement is an experimental cycle, commonly known as Plan-Do-Study-Adjust. Once the problem has been defined and the RCA with data or observation has been performed, only then should teams move into intervention mode where a solution, hypothesis, and action plan are proposed.
The intervention portion of the cycle is where the experimentation happens. Try the proposed solutions documented in the CAP, and study the results as frequently as possible. It can take a while to gather data on large-scale problems such as MRSA, but it is recommended that teams be vigilant in their quest to improve. Ask what can be done in a week, a month, six months, etc. Test against hypotheses within short time frames rather than waiting for large amounts of data. Through this method, teams will be able to test small ideas, adjust, then cycle back around to learn whether the problem has been solved.

Janet Spiegel, MS, is a Lean-certified management consultant in Portland, Maine, who has advised and coached several payer and provider organizations. For questions or comments, she can be contacted at


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