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Avera Health Quality Report

Hospital Acquired Conditions

Hospital Acquired Conditions

The Patient Protection and Affordable Care Act (ACA) established the Hospital Acquired Condition Reduction Program to encourage hospitals to reduce HACs. HACs are a group of reasonably preventable conditions that patients did not have upon admission to a hospital, but which developed during the hospital stay. Hospital performance under the HAC Reduction Program is determined based on a hospital’s Total HAC Score, which can range from 1 to 10.

The higher a hospital’s Total HAC Score, the worse the hospital performed under the HAC Reduction Program. Hospitals are given an opportunity to review their data and request a recalculation of their scores if they believe an error in the score calculation has occurred. 

Table 1


Readmission Reduction Program

Section 3025 of the Affordable Care Act added section 1886(q) to the Social Security Act establishing the Hospital Readmissions Reduction Program, which requires CMS to reduce payments to IPPS hospitals with excess readmissions, effective for discharges beginning on October 1, 2012.

Program Details

  • For FY 2017, CMS includes hospital discharges that occurred from July 1, 2012 through June 30, 2015. The measures include Medicare Fee-For-Service beneficiaries who were admitted for inpatient care with a principal diagnosis of any of the following: 
    • Acute Myocardial Infarction (AMI)
    • Heart Failure (HF) 
    • Pneumonia (PN)
    • Chronic Obstructive Pulmonary Disease (COPD)
    • Total hip and/or knee arthroplasty (THA/TKA) 
    • Coronary Artery Bypass Graft (CABG) surgery
  • These reports include a summary of the hospital’s results along with a national readmission rate, detailed discharge-level data, and risk factor information. 
  • The review and corrections period began June 1st, 2016 and ended June 30th, 2016. 
  • The excess readmission ratios in BOLD have a ratio greater than 1.0000 and tentatively will receive a payment reduction which would affect payments starting October 1, 2016.
Table 2

Value Based Purchasing

Value Based Purchasing

Hospital Value-Based Purchasing (VBP) is part of the Centers for Medicare & Medicaid Services’ (CMS’) long-standing effort to link Medicare’s payment system to a value-based system to improve healthcare quality, including the quality of care provided in the inpatient hospital setting.

The program attaches value-based purchasing to the payment system that accounts for the largest share of Medicare spending, affecting payment for inpatient stays in over 3,500 hospitals across the country.

Participating hospitals are paid for inpatient acute care services based on the quality of care, not just quantity of the services they provide. Congress authorized Inpatient Hospital VBP in Section 3001(a) of the Affordable Care Act. The program uses the hospital quality data reporting infrastructure developed for the Hospital Inpatient Quality Reporting (IQR) Program, which was authorized by Section 501(b) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003

Table 3


Avera Patient Experience Report

“I was really nervous about the procedure in general, and they put my mind at ease. I had nothing, but confidence in them, and their ability to take really good care of me, and respect my privacy at the same time, and my entire stay after my surgery. There were many nurses and techs that took care of me through the night, but they were all outstanding. They came in and helped when I needed it. They allowed me time to rest in between. They provided me alternative options to pain relief rather than just always taking the medication which means you're really happy as well. They have been amazing from the beginning of my journey until now. I'm thankful for all of them. They were outstanding!”

This is one of thousands of messages of thanks that are sent to the caring staff at Avera facilities every year. Each person at Avera is committed to living out The Avera Way – “Guided by Christian values, we commit to consistently deliver an excellent experience to every person at every encounter.”

Patient experience in overall satisfaction in the areas of Inpatient, Outpatient, Outpatient Surgery and Emergency Department are indicated in the graphs below. In four of the last five quarters, Avera ranked in the top quartile for overall patient satisfaction in the acute care setting when compared to the HealthStream national database. In every quarter of the last eight quarters, Avera Emergency Departments ranked above the top 20th percentile in overall patient satisfaction! And in Outpatient and Outpatient Surgery services, patients gave Avera the highest marks for overall satisfaction between 80% – 90% of the time.

Overall Satisfaction

Overall Satisfaction

Overall Satisfaction

Overall Satisfaction

Live Better. Live Balanced. Avera.

Avera is a health ministry rooted in the Gospel. Our mission is to make a positive impact in the lives and health of persons and communities by providing quality services guided by Christian values.

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