Hospitals with higher volumes, more accreditations, and greater offerings of advanced services performed better on publicly reported process-of-care and outcomes metrics but were penalized more frequently in the Centers for Medicare and Medicaid Services' (CMS) Hospital-Acquired Condition Reduction Program, according to the results of a study published in the July 28, 2014, issue of the Journal of the American Medical Association. The study, which merged data for hospitals participating in the fiscal year 2015 Hospital-Acquired Condition Reduction Program from CMS's Hospital Compare with data from the 2014 American Hospital Association Annual Survey and fiscal year 2015 Medicare Impact File, found that of the 3,284 participating hospitals, 721 (22%) were penalized. The data indicated that hospitals were more likely to be penalized if they were accredited by the Joint Commission, they were major teaching hospitals or very major teaching hospitals, they cared for more complex patient populations based on case mix index, or they were safety-net hospitals. Although hospitals with higher hospital quality summary scores had significantly better performance on 9 of 10 publicly reported process and outcomes measures when compared with hospitals that had lower quality scores, hospitals with the highest quality score of 8 were penalized significantly more frequently than hospitals with the lowest quality score of 0 (67.3% versus 12.6%). The researchers note that their results suggest that either traditional quality metrics (e.g., accreditations, process measures, mortality) are flawed and conflict with the measurement of performance in reducing healthcare-acquired conditions or, alternatively, the Hospital-Acquired Condition Reduction Program may not accurately measure hospital quality. The researchers also express concern about the current "bottom-quartile" approach to penalization in the Hospital-Acquired Condition Reduction Program, which penalizes some hospitals for performing statistically "as expected" and others regardless of whether they demonstrate improvement. They suggest that rather than uniformly penalizing the worst-performing quartile of hospitals, penalization should be based on statistically significant higher-than-expected adverse event rates, as in other CMS pay-for-performance programs. They conclude that their somewhat paradoxical findings may indicate that the approach for assessing hospital penalties in the Hospital-Acquired Condition Reduction Program merits reconsideration to ensure it is achieving the intended goals.

HRC Recommends: The need to measure the quality of care and to make the information available to stakeholders in the healthcare system is essential to improve care and enhance patient safety. Measuring hospital performance related to the quality of care verifies that evidence-based treatments—treatments demonstrated by scientific evidence to lead to better outcomes—are consistently provided. However, a hospital's process performance alone does not convey information about hospital quality that extends beyond what is actually being measured. As the soundness of certain clinical treatments changes and evolving evidence provides increased knowledge, so must the measures identified to monitor hospital performance change.