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May 10, 2017

CMS failed to investigate 96 hospitals' suspect infection data, OIG finds

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    Nearly 100 hospitals reported suspect data regarding potentially dangerous infections to CMS officials, but the agency did not further investigate the submissions, according to an HHS Office of Inspector General (OIG) report released Thursday.

    7 imperatives to transform your quality strategy


    According to NPR's "Shots," most U.S. hospitals under Medicare's Inpatient Quality Reporting Program self-report infections that occur among their patients while they are being treated at the facilities. In turn, the hospitals under the program can receive bonuses or penalties that affect their Medicare payments.

    However, some of the reports in the past have included atypical data, such as unusually low infection rates, rapid changes in infection rates, or claims that almost all of a hospital's patients with infections contracted the infections before they arrived at the facility. CMS each year is supposed to examine up to 200 cases in which hospitals reported such suspicious data.

    Report details

    OIG conducted the report to examine CMS' efforts to validate hospital-reported data under the Inpatient Quality Reporting Program and to suggest "ways to strengthen program integrity safeguards." Investigators looked at CMS validation data for the 2016 payment year to identify the number of hospitals CMS had selected to review, why CMS selected the hospitals it reviewed, and what CMS found during the reviews.

    In addition, OIG interviewed five experts about any concerns they might have with the quality data hospitals report and with CMS' method for validating the data. Investigators also interviewed CMS and CDC staff about regular quality assurance efforts for hospital-reported data.

    Further, OIG reviewed CMS and CDC training materials on how hospitals should report quality data.


    OIG found that CMS reviewed 2013 and 2014 data from 400 randomly selected hospitals, as well as from 49 "targeted" hospitals that had scored low on a review in the prior year or had previously underreported infections. According to OIG, six hospitals failed the reviews and were penalized with a 0.6 percent reduction in Medicare payments.

    However, OIG stated that CMS' targeted review should have included an additional 96 hospitals that submitted "aberrant data patterns" related to patient infections in 2013 and 2014. OIG wrote that CMS' "approach to selecting hospitals for validation … made it less likely to identify gaming of quality reporting" because it "did not include any hospitals in its targeted sample on the basis of their having aberrant data patterns."


    OIG recommended that CMS "make better use of analytics to ensure the integrity of hospital-reported quality data."

    For instance, OIG wrote, "CMS could use analytics to select an increased number of hospitals in its targeted validation sample" by using data to "identify outliers, … determine which of those outliers warrant further review, and then add them to the sample." According to OIG, "Targeting hospitals with aberrant patterns for further review could help to identify inaccurate reporting and protect the integrity of programs that make quality-based payment adjustments."

    CMS Administrator Seema Verma in a letter responding to the report wrote that the agency agreed with OIG's findings and will "continue to evaluate the use of better analytics … as feasible, based on [Medicare's] operational capabilities" (Jewett, "Shots," Kaiser Health News/NPR, 5/9; HHS OIG report, April 2017).

    7 imperatives to transform your quality strategy

    The central mission of hospitals and health systems will always remain constant: provide high-quality care to patients.

    But with a sea of market changes impacting clinical quality goals, the conventional quality path that most hospitals are on is no longer sufficient—or smart.

    Read our briefing to see what trends are altering health care, where the typical strategies fall short, and how to build a new quality plan that delivers the best care for patients, reduces costs, and engages physicians.

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