The scoring system, which is part of the Hospital-Acquired Condition Reduction Program established by the Affordable Care Act, has been in place for three years. Hospitals are scored on a variety of parameters, using a 1 to 10 ranking for each one. Those numbers are then combined to produce a final HAC score, which also uses a 1 to 10 scale. The worst-performing quartile of hospitals — the 25 percent with the highest scores — are penalized by having their payments from Medicare and Medicaid cut by 1 percent.
For 2017, the penalties applied to all hospitals scoring 6.57 or higher. The Cherokee Indian Hospital scored 9.4 — the highest score in the state and the fifth-highest score in the nation.
However, the situation may not be as dire as the score indicates. The Cherokee hospital is a small facility that deals with small numbers of patients, so a handful of infections can easily result in a high score.
“A low-acuity facility like CIHA is not scored on services that it doesn’t provide,” the hospital said in a statement. “Thus the HAC score is essentially limited to a small number of infrequently occurring infectious disorders … Because of our small number of patients and low projection rate, when we do have an infection it appears that our infection rate is actually much larger than it is.”
In fact, Cherokee did not appear at all on the list of worst-performing hospitals in 2015 or 2016, the first two years that scores were published.
The Cherokee Hospital is a small facility, housing only 18 beds. Compare that to the 763 beds at Mission Hospital in Asheville, the 169 at Haywood Regional Medical Center, or the 86 at Harris Regional Hospital in Sylva.
The HAC score is composed of two domains. This year the Cherokee Hospital didn’t report anything for the first domain, called the patient safety indicator, because there were not enough patients who met the criteria, the hospital’s statement said.
The second domain is a composite score based on five common types of hospital-acquired infections. The 2017 data set shows a score for only one of those five parameters — infections caused by the bacterium Clostridium difficile, called C. diff. The hospital wound up with a score of 10 for that parameter, which heavily influenced its final score of 9.4. This is the first year that C. diff infections have been included in the scoring system — it, along with methicillin-resistant Staphylococcus aureus, known as MRSA, is a new parameter for 2017.
According to the hospital, small census size isn’t the hospital’s only challenge in maintaining low HAC scores.
“CIHA frequently admits patients who would otherwise be discharged from other facilities to home. We do this to provide more care, safety and support to patients and families after third-party payers cease to authorize payment for their stay at another facility,” the hospital’s statement reads. “As a result patients who would otherwise develop an infection at home after discharge, one that was actually acquired during their admission at other facilities, could manifest symptoms during their extended stay with us.”
In addition, the statement reads, the hospital sometimes chooses to keep patients longer than the stay covered by insurance if they lack the support at home they might need to recover safely. The longer a person is in the hospital, the higher the risk of acquiring an infection there.
“We weigh this against the risks of being vulnerable and disenfranchised,” the hospital’s statement said.
Julie Henry, vice president of communications for the N.C. Hospital Association, echoed the reality of the difficulties small hospitals like the one in Cherokee face when it comes to HAC scores.
Still, she said, Cherokee’s is “a high number” that deserves answers for why it’s as high as it is and what’s being done to improve in the future.
The scoring system has its issues, she said, but overall it’s positive as a tool for keeping hospitals accountable and forcing them to collect the data they need to get to the root of any issues that exist.
“The upshot of it is increased attention to hospital-acquired infections is a good thing for patients,” Henry said. “It’s good for providers too because it forces providers to collect the data so they can stay on top of what’s happening with their patients.”
The Cherokee Indian Hospital opened its brand new, $82 million facility in October 2015. However, the data reflected in the 2017 rankings were mostly gathered before the hospital moved to the new campus. The numbers in the most recent report are based on data from Jan. 1, 2014, to Dec. 31, 2015 — Henry expressed confidence in hospital CEO Casey Cooper’s ability to turn it around going forward.
“Casey Cooper is the data guy,” Henry said. “He is looking at data all the time. So I would be really surprised if something hasn’t changed. If their numbers are this high, I would be sure that he’s on top of it.”
The 2016 numbers do not show substantial change over 2014 and 2015. In both those years, the hospital reported two cases of C. diff but zero of MRSA or urinary infections due to catheters. In 2016, the hospital still saw zero cases of those last two but three cases of C. diff. However, two of the three counts were due to the same person having the infection two consecutive months.
Going forward, the hospital’s first step will be to take another look at its reporting system. A process failure in data reporting was detected and fixed in 2015, the statement said, so figures for 2013 and 2014 might not be completely accurate. The hospital plans to recalculate its scores using internal data to get a better idea of where it stands.
“Over the next year our focus will be to continue to manage the existing patient safety and infection controls systems and to improve the data reporting process,” the statement reads.
Due to its high score for 2017, the hospital will lose some funding for the current fiscal year. The exact amount is still being calculated, but it will be 1 percent of funding typically received from Medicare and Medicaid. These programs account for just under 35 percent of the hospital’s budget.
How they scored
Hospital name Number of beds HAC score
Cherokee Indian Hospital Authority 18 9.4
Harris Regional Hospital 86 5.58
Mission Hospital 763 5.36
Haywood Regional Medical Center 169 3.75
Scores in North Carolina ranged from 1.15 to 9.4. Nationwide, scores ranged from 1 to 9.85. For the 2017 fiscal year, hospitals with scores in the worst-performing quartile — 6.57 and above — were penalized with a 1 percent reduction in funding from Medicare and Medicaid.