Speaker 1 (00:05):

Welcome to Hospitals In Focus from the Federation of American Hospitals. Here’s your host, Chip Kahn.

Chip Kahn (00:15):

The COVID-19 pandemic has changed healthcare in unimaginable ways, and some of the true effects are still unfolding. In today’s episode, we’re going to look at how COVID impacts Medicare hospital quality reporting and value-based purchasing programs, something that is critical for patient decisions and the evaluation of care provided at every hospital in the nation.

Chip Kahn (00:39):

The key Medicare programs are as follows: inpatient hospital value-based purchasing, hospital readmissions reduction, hospital-acquired conditions and inpatient quality reporting. These programs have three main goals: transparency of data on quality and efficiency of hospital care for patients, continuous improvement in care and accountability for care provided. Each of these programs had issues and problems before the pandemic struck, but COVID threw a wrench in the gears.

Chip Kahn (01:09):

Early in the pandemic, there was a shutdown of most hospital elective procedures, which led to a major change in patient mix at hospitals generally, and was further complicated as COVID surged and dominated patient services. Additionally, CMS delayed or even stopped the collection of certain quality data. While this helped hospitals focus on COVID and special COVID reporting of cases, ICU capacity and deaths, the reporting changes and the case variations from COVID has skewed results in much of the data.

Chip Kahn (01:44):

This brings up real questions about whether the quality data collected during the public health emergency is reflective of the true quality of care patients can expect to receive in the post-COVID environment. CMS has taken some actions to mitigate the reporting of these issues for fiscal year 2022, but is it enough? This is so important a topic that I recently coauthored a blog that was just published in healthaffairs.org examining the problem, its possible long-term effects and the need for future adjustments.

Chip Kahn (02:19):

We’re going to take a deep dive into these issues today with an expert who has his finger on the pulse of quality measurement programs and the effects of COVID, Dr. Ken Sands, the chief epidemiologist at HCA Healthcare. HCA is one of the largest healthcare systems in the country and has treated more than 120,000 COVID-positive patients since the pandemic began.

Chip Kahn (02:42):

Really great to have you here today, Ken.

Dr. Ken Sands (02:44):

Delighted to be here, Chip. Thanks for inviting me.

Chip Kahn (02:47):

Ken, to get started, will you tell us a bit about your role at HCA Healthcare and your role in quality measurement?

Dr. Ken Sands (02:54):

Sure. I’m a hospital epidemiologist. My background is in infectious disease and infection prevention. I was a physician in practice for some period of time before going into that area of specialty and then expanding into quality improvement more broadly.

Dr. Ken Sands (03:10):

My role here at HCA as chief epidemiologist is overseeing programs related to epidemiology across our 185 facilities, our multiple outpatient facilities as well. During non-pandemic times, that’s really focused on a hospital-acquired infection and trying to control those rates, making sure that we don’t have clusters of outbreaks in any areas, protecting our healthcare workforce as well as our patients and visitors, evaluating trends and implementing best practices across our large organization.

Chip Kahn (03:45):

Thanks for that great introduction, Ken.

Chip Kahn (03:48):

As I mentioned above, HCA Healthcare has treated over 120,000 COVID-positive patients during the pandemic. At the get-go, treating COVID was a guessing game and there still is no cure. As an epidemiologist for this large hospital system, how did you develop protocols for treating COVID, and how quickly were you able to disseminate these best practices across your system?

Dr. Ken Sands (04:13):

Yeah, it’s a great question, Chip, and it was a place, I think, where we were able to leverage our size because we had the ability to collect information from our facilities and try and understand their needs as soon as possible, but also best practices as soon as possible.

Dr. Ken Sands (04:28):

We set up a system for cascading information here at the corporate enterprise. We had basically a team assembled, and it was one of those times where people took on different roles because of the environment. That team was looking at information coming forward from every source, CDC, Infectious Disease guidelines, and the like. We were able to turn those into guidance documents, disseminate them to the field, and then at the same time, get feedback from the field about what was working and what their needs were, and simply iterate on that process for an extended period.

Dr. Ken Sands (05:06):

At the beginning, as you say, we were largely having to come up with our own guidance because there was nothing out there really as an alternative. As time progressed, there started to be a scientific literature, and there’s really been an explosion of information in terms of the evidence base that we were able to draw upon, as well as increasing guidance from the CDC that we were able to incorporate.

Dr. Ken Sands (05:29):

But what we learned along the way is that we had greater capability than we may have thought in order to adopt and adapt to new information, that our workforce was very committed and also very agile in order to meet the needs of the large organization.

Chip Kahn (05:47):

Ken, can you give us a couple of examples of how COVID affected hospital operations and patient care? And talk about the effect that it had and continues have on how quality data is collected.

Dr. Ken Sands (06:01):

Well, it’s really affected operations very dramatically. Obviously, the significant shifts in patient populations, not just the influx of COVID patients, but also the decrease in elective surgical volume, major shifts in staffing because of COVID, and so we were dealing with multiple changing factors simultaneously, obviously adapting new practices that have significant roles in operations, such as the use of PPE, controls on visitation, all of which had to be adapted.

Dr. Ken Sands (06:38):

We made strong use of information systems so that we were able to understand where COVID volume was occurring and also begin to understand what treatment practices were taking place. And because we had good flow of information, we could see and leverage best practice to make sure that the right therapeutics were being used at the right time, that our ICUs and our ventilators were being used in the most appropriate fashion to create the best patient outcomes, all of which was a major part of our monitoring program for measuring outcomes. It meant that our focus was on these measures, as opposed to the standard set of measures that were being typically evaluated as part of ongoing federal measurement programs. Not that those are not important, but clearly with only so much ability to focus the organization, we were clearly focused on our COVID-related outcomes.

Chip Kahn (07:39):

CMS really recognized the issue that you just raised, compliance is so important. But let’s take a look at the response of the regulators, CMS, when they stepped in early with waivers and quality reporting to help mitigate issues and burden on providers. Could you talk a little bit about what they did and how that helped you, at least in the short term?

Dr. Ken Sands (08:02):

Well, I think their putting down measures waiving the requirement to report metrics was instrumental in relieving some burden. Our frontline clinicians were, obviously, very busy managing COVID and learning a new set of skills related to that discipline. But also our administrative structure was working overtime to create the data systems to support that enterprise, as I said, create the measures that we were using to judge our performance. That was a full-time effort to simply understand where our COVID patients were, how they were using ICU capacity, how we can best staff. So it was key that we were relieved of that burden, entirely separately from the importance of the fact that we did not understand how performance on the standard metrics was being influenced by COVID.

Dr. Ken Sands (09:02):

So really two key agendas here that were an important part of that maneuver. One was the relief of the reporting burden, and two was relief of the concern that understanding performance was really an unknown, given how different the inpatient environment had been during the COVID surge.

Chip Kahn (09:22):

Ken, looking forward, and hopefully looking forward beyond COVID for the federal fiscal year 2022 that begins in October, CMS is proposing additional changes to their rules in their inpatient prospective payment system rule. How do you rate these proposals, and do they recognize all of the issues that you’ve seen raised regarding quality measurement reporting and the effects of COVID on hospital care?

Dr. Ken Sands (09:55):

I think it’s a very good first step that they have carved out some periods of time for reporting measures as part of what they’ve announced for the 2022 program. It was such a different year in 2020 that I’m glad that we are not trying to model the performance metrics for that period of time. I think we understand with some level of confidence that there’s clearly a direct association between COVID and certain quality metrics.

Dr. Ken Sands (10:28):

I’ll just mention in our own case, we’ve looked at our performance on hospital infection, and we see a change in performance that we can directly correlate with volume of COVID patients in our facilities. But we do not know the specifics of that relationship. We do not know whether it is that COVID patients are at higher risk. We do not know whether it’s that patient mix generally changed for reasons that we mentioned. We don’t know whether it was a distraction because of the surge, so it’s very hard to risk adjust for that situation. I think the same could be true for patient experience measures and the impact of changes in visitor policies, for example. The environment where there’s more PPE can have an effect on patients as well, and so it’s very hard to model. I would say, even if you look at some of this data and see it did not change much during COVID, you’d have to ask the question of did the hospital actually have an opportunity to be significantly improving during that period of time and that improvement with hidden by the change?

Dr. Ken Sands (11:39):

So in summary, I think we have a year of special cause variation that is going to be very hard to disentangle and understand. The options from here are to try to investigate what those factors are so that there can be some way to understand that period of time, or continue to treat the period of time with COVID population separately and discount that, and that’s not entirely accomplished by the 2022 announcement.

Dr. Ken Sands (12:10):

We know that future years still have the potential to include the period of time of 2020. And I would say that even now, thankfully, the COVID numbers are significantly down, but our hospitals are far from back to baseline in terms of continuing to have very special practices around visitor policy, around use of masking, around ability to interact with patients the way they used to occur previously. So there’s still a lot of unknowns, and I think that this needs to be an ongoing conversation with CMS in order to judge hospital performance appropriately.

Chip Kahn (12:47):

You know, Ken, just as an aside, one of the issues that you brought up where you were getting different kinds of results was the area related to infections. I think there’s some data that I’ve heard, and you can maybe fill us in on, that provides a sort of an example of a unique aspect of COVID infections that first wasn’t expected and needs to be delved into?

Dr. Ken Sands (13:10):

What I can just tell you is what we’ve seen is that for some HAIs, we’ve seen almost a linear relationship between the percent of hospital admissions that are COVID admissions and the risk of HAIs. Again, we don’t know whether that is the COVID patients having a higher risk of HAIs per se, or whether it’s a broader phenomenon in the hospital.

Dr. Ken Sands (13:36):

Interestingly, we’ve observed that our rates of the C. difficile infections and other specific HAI have actually gone down, and that has also been reported in the literature, and that may be for any number of reasons. It might be that COVID patients are a lower risk, for some reason. It might be the impact of PPE making it harder to transmit that infection within a facility, or it might be something entirely different.

Chip Kahn (14:04):

Ken, let’s go back to one of the other issues you raised in your previous answer, and we’ve pointed to in the Health Affairs blog, this topic of sort of sequencing. Many of the measurements that are key in the book of measurements, in a sense, that CMS has really depend on numerous years or multiple years of data, not just single years. How will this affect the data that hospitals and patients depend on? And what can CMS do, you think, to mitigate in this area where you just can’t take one year out because you’ve got these series of years?

Dr. Ken Sands (14:42):

You know, I think that there is a number of techniques that they could assess. One could be to deemphasize a certain period of time in how they calculations or deemphasize certain measures. That is one approach is an underweighting, if you will. I think that they could use the data that they have to further try and understand the relationship between care of COVID patients and some of these performance metrics and try and create a more level playing field. That will be a fairly significant endeavor to try and understand that impact.

Dr. Ken Sands (15:24):

But it feels to me those are the choices. The choices are to either attempt to better understand the way that COVID impacts these measures, or say we can’t achieve that understanding and, therefore, we have to at least underweight that period of time, if it cannot be entirely ignored.

Chip Kahn (15:46):

Ken, this conversation has been so helpful. The issues around COVID are so complex and frankly unprecedented, I think, in terms of even our modern healthcare in the United States. We really appreciate everything you have done for the patients of HCA Healthcare over the last more than a year, and your sharing your perspective today was so helpful, I’m sure, to our audience.

Dr. Ken Sands (16:11):

Well, thank you, Chip, for inviting me, and it’s been a pleasure to be with you.

Speaker 1 (16:20):

Thanks for listening to Hospitals In Focus from the Federation of American Hospitals. Learn more at fah.org. Follow the federation on social media at FAH Hospitals, and follow Chip at Chip Khan. Please rate, review and subscribe to Hospitals In Focus. Join us next time for more in-depth conversations with healthcare leaders.

Kenneth E. F. Sands, MD, MPH is HCA Healthcare’s Chief Epidemiologist. Since joining CSG in January 2017, Dr. Sands has led enterprise-wide initiatives including health services research, infection prevention, and patient safety.

Before his HCA Healthcare tenure began, Dr. Sands served as an Associate Professor of Medicine, at Harvard Medical School, as well as Chief Quality Officer and member of the Division of General Medicine at Beth Israel Deaconess Medical Center (BIDMC).

Dr. Sands has been active in medical education, co-founding both the first dedicated rotation in quality improvement for residents at a Harvard teaching hospital and the two-year Harvard Medical School Fellowship in Quality and Safety. He has served on the Board of Directors for the Risk Management Foundation, which oversees risk prevention and patient safety activities for CRICO, the risk retention group for the Harvard teaching hospitals.

Dr. Sands has led a number of activities in Massachusetts to advance malpractice litigation reform, including acting as principal investigator of an AHRQ-funded study to evaluate readiness for disclosure models in Massachusetts, and co-founder of the Massachusetts Alliance for Communication and Resolution following Medical Injury (MACRMI).

Dr. Sands is a graduate of Dartmouth Medical School and holds a Master’s Degree in Public Health from Harvard University where he completed fellowship training in Infectious Disease. A respected researcher, Dr. Sands co-founded the Center for Healthcare Delivery Science at BIDMC; Sands’ recent research has focused on use of technology to improve prediction of risk of harm and to improve patient engagement, and the expansion of measurement of patient harm to include measures of the patient experience.

Dr. Sands has been married for 29 years to Joan, and they have two children: Trevor (27) and Kristen (25). Both Joan and Ken enjoy golf, tennis, and travel.