By Alexa Epitropoulos | aepitropoulos@alextimes.com

Inova Alexandria Hospital was fined in both 2016 and 2017 by the federal Department of Health and Human Services for having unacceptably high rates of infections and injuries that occur during hospital stays.

The hospital was one of 751 nationally to be penalized in 2017. The fine of $580,009 is equal to one percent of the hospital’s Medicare payments throughout the fiscal year, which extends from October 2017 to September 2018.

The penalties are assessed as part of Medicare’s Hospital Acquired Conditions program, which was created four years ago through the Affordable Care Act. It is intended to create financial incentives for hospitals to avoid infections, including MRSA, CAUTI (catheter-associated urinary tract infections) and CLABSI (central line associated blood stream infections) and injuries, including falls. The lowest-performing 25 percent of hospitals nationally according to HAC’s measures are fined.

Dr. Rina Bansal, chief medical officer at Inova Alexandria, said, when it comes to the incidents Medicare is measuring at the hospital, infections at Inova Alexandria account for about 85 percent, with injuries accounting for the remaining 15 percent.

Bansal said the hospital has been improving steadily on its rate of infections and injuries by tracking the data through its staff and through individual departments. The data is displayed prominently in every department on what’s called a “true north board,” a magnetic board that displays procedures, policies, goals and recent data. Once the data is recorded and shared, Bansal said the hospital uses it to go back and take a deeper look into what happened.

“We have a very robust surveillance system to really track all of this and what happens, once we get this information … we go back and do a deep dive,” Bansal said.

Inova Alexandria’s data reported three CLABSI infections, five CAUTI infections, 11 CDI (clostridium difficile infections), two MRSA infections and two SSI (surgical site infection) colon infections in 2017, in comparison to seven CLABSIs, eight CAUTIs, 35 CDIs, three MRSA and seven SSI colon infections in 2016.

Bansal said the improvement year-over-year was made by working in partnership with the hospital’s medical staff to encourage improvements in hygiene, including safe hand hygiene. That means doctors, nurses and others who interact with patients wash
their hands after every interaction, which could mean six to seven times per patient. All Inova employees are encouraged to talk to co-workers about complying with hand hygiene,
including non-medical staff like custodial employees, she said. The hospital has gone from a 57 percent compliance rate to a more than 90 percent rate at the end of 2017, according to Bansal.

The hospital has also improved when it comes to communication, according to Bansal. The leaders of each Inova Alexandria department meet every Monday at 9:30 a.m. in a “huddle” to discuss hospital business, including any injuries or infections that have transpired throughout the week. Huddles are also held twice per day in most departments to get those on day shifts and night shifts on the same page and to communicate about incidents and at-risk patients.

Bansal said the team also talks about injuries or infections by using patients’
first names.

“We talk about the person and what their name is. We really want to make sure we’re not losing a patient among the numbers,” Bansal said. “This is a person we did potential harm to.”

She said improving the rate of infections and injuries is an overarching goal for Inova as a company.

“This is a journey [Inova has] been on as a system. At Alexandria, specifically, this was a journey that started two years ago. The executive team has really made a commitment to look toward zero harm,” Bansal said. “Anytime we have any hospital acquired condition, or HAC, we consider that a harm event. Our goal as an organization and as a system is to move to zero harm.”

Susan Carroll, regional executive officer of Inova’s eastern division, comprised of Inova Alexandria and Inova Mount Vernon hospitals, said the data, in addition, can’t measure all progress.

“One thing that’s important to gather here is, unfortunately, this was created by the Affordable Care Act four years ago. … This is about balancing a budget for them,” Carroll said. “The bottom quarter of all hospitals will be fined every year. Every year, at least 750 hospitals, and sometimes it’s a little more than that, will get this penalty.”

Carroll said, even though Inova Alexandria is improving, other hospitals are improving along with it.

“To get us out of that 25 percent we really have had to strive so much to get much, much higher decreases than what you would normally see. When you have a pool that’s done this way, even as you improve by 10 percent, some hospitals will get stuck in this fine area,” Carroll said.

Carroll said Inova Alexandria has, instead, aimed for a zero harm goal, while striving for sizable reductions to injuries and infections. Between 2016 and 2017, CLABSIs decreased by 70 percent, CAUTIs dropped by 40 percent, CDIs by 69 percent and SSI colon infections by 75 percent.

“This is our goal across the whole system,” Carroll said. “Our true north and our key priority is zero harm.”

Carroll and Bansal said the aim for the coming year isn’t to simply get out of the bottom quartile. It’s to focus on improving and striving toward positive outcomes.

“The type of reductions we have seen, the sheer number of it, it is truly unheard of. We

can only hope that is going to trigger us to get out of the 25 percent quartile,” Carroll said.
“… You don’t get points for improvement necessarily. Without understanding how everyone else is doing, it’s hard to know.”

“We have some good signs we can look at – seeing these numbers and seeing how great our reductions are. We did receive [a] Premier award, which ranks us in the top 10 percent [in harm event reduction]. … We’re trying to keep our eye on it, while not necessarily understanding where we’ll fall. I do have a feeling. I would be surprised at the amount of work and with the positive outcomes if we don’t see harm reduction,” Carroll said.

Bansal said Inova Alexandria will continue on the path toward improvement, including gathering data, improving from that data and encouraging compliance on staff preventative measures.

“Our expectation is to continue on this journey and to continue the reductions that we’ve had and aim for zero harm, but, as we improve, so does every institution,” Bansal said.
“Where we end up on that percentile is hard to say.”

“No one wants to be in the bottom 25 percentile, but we do own it and we didn’t try to argue the data, but the methodology is not always easy to follow or fair,” Carroll said. “Reducing harm and getting to the place where we strive for zero harm is our goal. … Four years ago, we were struggling a little bit and now with a dedicated partnership, we’ve seen a reduction in these harm events and that’s what you should expect to see.”