Data collection and analysis is public health’s most valuable  renewable resource- which is why we’ve made data analysis such a high priority.  Yesterday, the Office of the Inspector General for HHS published a document that highlights the fact that disciplined data analyses can identify key factors that result in poor outcomes- giving us the information we need to intervene and improve results. 

Yesterday’s report is entitled Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries, and it examines “adverse events” that occurred in skilled nursing facilities nationwide between 2008 and 2012.  “Adverse events” are basically events related to medication, ongoing resident care, or infections. 

The study found that about 22% (of Medicare beneficiaries) had an “adverse event” while at a skilled nursing facility.  Of course, not all of these were preventable, but the study found that almost 60% of the adverse (and temporary harm) events were preventable. The report attributes much of the preventable harm to substandard treatment, inadequate resident monitoring, or a delay in administering necessary care. 

Part of our core mission as an agency is to protect public health and safety by addressing quality of care issues in our licensed healthcare institutions.  As part of that mission, we license and inspect 147 skilled nursing facilities statewide.  The facilities range in size from as few as 10 to as many as 200 patients. 

Today’s study will be a valuable as a tool for us because it’ll help us focus our inspections and facility surveys on areas where we can have the biggest impact on improving care and outcomes.  Over the coming weeks, our skilled nursing survey team will be diving into the details of the report so we can become more familiar with the areas that we should focus on while we’re in the field- including updating our focused reviews of nursing home practices to identify and reduce adverse events. 

Additionally, the Affordable Care Act requires nursing homes to develop Quality Assurance and Performance Improvement (QAPI) programs to address quality problems and improve facility performance. Our survey teams will be including an assessment of adverse event identification and reduction in our evaluations of Arizona’s skilled nursing facilities QAPI plans with a focus on the elements of care identified in today’s report.