The pace of healthcare reform over the past few years has been relentless, with plenty of new information and government programs that the design community has had to understand in order to better serve providers and patients. And now there’s another new federal healthcare initiative to consider: the Centers for Medicare & Medicaid Services’ (CMS) Hospital-Acquired Condition Reduction Program, a reimbursement initiative that went into effect on Oct. 1 and is tied to quality outcomes and mandated by the Affordable Care Act.

In order for the healthcare design community to better navigate this next reform hurdle and offer tools that will help providers be successful, it’s important to understand hospital-acquired conditions (HACs) and the legislation and regulations designed to reduce them.

Defining HACs
Fifteen years ago, the Institute of Medicine published the report “To Err is Human,” which revealed that almost 100,000 Americans die each year because of medical errors that occur in hospitals. As awful as these statistics are, most patient safety experts believe that this data under represents what have been termed “never events,” or those medical errors that are unambiguous, serious, and usually preventable. In 1999, the National Quality Forum (NQF), a not-for-profit, nonpartisan, membership-based organization that works to catalyze improvements in healthcare, was founded and eventually created a list of 27 serious reportable events (SRE). Using a consensus process, NQF defined each event that results in patient injury or death (for example, a medication error, surgery performed on the wrong site or the wrong patient, or severe pressure ulcers acquired after admission). The group specified the metrics that would be used to identify and measure each SRE. It’s this work that informed informs the legislation and regulations that now target HACs.

Never events and healthcare-associated infections (HAIs) fall under the HAC umbrella, as does patient falls with injury. A systems-based approach is often used to eliminate HACs. In 2013, the Institute of Medicine and National Academy of Engineering published a paper, “Bringing a Systems Approach to Care,” in which the authors recommend “considering the multiple elements involved in caring for patients and the multiple factors influencing health.” Understanding the individual components of healthcare, how they operate, and how they interact can help organizations promote better care by integrating people, processes, policies, and place.

The built environment is an often unrecognized element, but in this approach, designers have an important role to play by offering evidence-based environmental features that help reduce harm. To do so effectively, designers will need to understand what’s being targeted for improvement and how CMS reimbursements are affected.

The law
The first direct tie between patient harm and reimbursement began on Oct. 1, 2008, when CMS stopped paying hospitals for the increased cost of care tied to a variety of HACs, including care for patients who fall and were injured or who developed certain types of HAIs. Prior to this legislation, if a patient was admitted for colon surgery, for example, and then fell and broke a hip during the post-operative phase, not only would the hospital have been reimbursed for the care associated with the surgery, but that reimbursement would have been at a higher rate to cover the care for the hip fracture. The 2005 Deficit Reduction Act was the first enacted legislation to link reimbursement to HACs, though experts didn’t think the penalties were significant enough to incentivize real change.

But in 2010, the most comprehensive healthcare reform legislation in half a century, the Patient Protection and Affordable Care Act (ACA), was signed into law, touching just about every aspect of healthcare delivery. One overarching goal is to improve the quality and performance of the healthcare system through the implementation of a variety of Medicare initiatives, including three pay-for-performance programs, which together this year can result in a cut of up to 5.5 percent of a hospital’s Medicare payment. Two programs were introduced on Oct. 1, 2012, the Hospital Readmissions Reduction Program and the Hospital Value Based Purchasing Program (HVBP). These programs fundamentally shift reimbursement practices from volume-based, fee-for-service payments to reimbursement based on the quality of care delivered. Through HVBP, hospitals are rewarded or penalized based on the quality of care they provide their patients and their ability to keep patients healthy, evaluated though an approved set of measures and dimensions.

On Oct. 1, the HAC reduction program was added as the third component of the pay-for-performance initiatives. In this first year, three HAC measures, catheter-associated urinary tract infections (CAUTI), central line-associated blood stream infections (CLABSI), and a composite patient safety indicator (PSI) measure are included. PSIs are measures adopted by the Agency for Health Care Research and Quality (AHRQ), which enable the identification of adverse events that occur during healthcare delivery. The PSI-90 composite represents an aggregation measure of eight patient safety problems, such as hip fractures and central venous-catheter related blood stream infections that frequently occur during hospitalizations. For each HAC, research suggests that environmental features play a role.

Maximizing reimbursement by design
Design teams can make important evidence-based design contributions to help reduce the targeted HACs and, as a result, reduce patient harm and help owners improve reimbursement results. For example, most HAIs, like CAUTI and CLABSI, are transmitted by caregivers who have contact with contaminated patients and surfaces. Often, without washing their hands, they’ll go on to touch other patients or objects (door knobs, light switches, bed rails, over-bed tables), contaminating each surface. When others touch the same surfaces, the offending pathogens are spread. Designers can facilitate hand hygiene through the placement of highly visible and accessible sinks and alcohol-gel dispensers to improve hand-washing compliance. In addition, in the selection of materials and design of surfaces, it’s important to enable the proper cleaning protocols for high-touch areas.

Reducing the number of hip fractures that occur during a hospitalization is among the AHRQ safety problems targeted in the PSI composite measure. These fractures typically occur when a patient falls, which for most patients happens when they move from the bed to the bathroom without assistance. There are many design considerations that can reduce the incidence of patient falls, such as appropriate clearances around the bed and equipment to better enable patient mobility, barrier-free access to the bathr
oom, flooring design (no bumps or slick spots) and the selection of furniture (sturdy and stable, no sharp edges).

There are other reimbursement-related outcomes where the design of the built environment may help. Many hospitals have included ceiling-mounted lifts to improve patient handling and movement, but lifts can also play an important role in frequent patient repositioning, necessary to help avoid two HACs, decubitus ulcers and deep vein thrombosis. Family zones that enable loved ones to be present and help with the transition home may help to reduce readmissions rates, which account for 18 percent of all admissions.

Partners in HAC reduction
Maximizing reimbursements requires using every tool available to solve targeted outcomes, including the design and maintenance of a facility. With each design feature considered, the team should ask what evidence is available concerning the feature’s ability to prevent HACs. To help adopt this focus, design firms should consider the following six steps:

  1. Familiarize yourself with healthcare reform programs that target healthcare outcomes, especially those that the evidence shows can be impacted by design (see
  2. Consult CHD’s Knowledge Repository as a source of evidence and outcomes linked to specific design features (
  3. Visit CMS’ Hospital Compare website to view a particular hospital’s and its competitors’ profiles for key outcome results ( ).
  4. Find out if the hospital is a member of CMS’ Partnership for Patients Program and the details of their initiatives ( See below for more information.
  5. Share the data that demonstrates the impact of your previous designs on other clients’ outcome measures when responding to RFPs.
  6. Partner with your client to evaluate the impact of design decisions on key healthcare outcomes at various times after occupancy.

You can learn about what the best hospitals are doing to reduce HACs by visiting CMS’s Partnership for Patients Program website. Twenty-six Hospital Engagement Networks (HENs) have been established to identify best-practice solutions and disseminate their results. According to the latest CMS data, 3,700 hospitals have signed-up as HEN partners.

Enormous change and opportunity
Quality outcomes are now directly tied to healthcare reimbursement. Design teams must ensure that they understand both the challenges facing providers as they pertain to various ACA programs and the evidence that identifies features that can help reduce HACs, specifically. To do so successfully, speaking the language of the provider is important, and understanding these programs can help frame future discussions. Healthcare organizations require every tool available to successfully reduce patient harm, and the design of the built environment is often an unconsidered tool in this battle.


Eileen Malone, RN, MSN, MS, EDAC is senior partner at Mercury Healthcare Consulting LLC (Alexandria, Va.). She can be reached at . Ellen Taylor, AIA, MBA, EDAC, is director of research at The Center for Health Design (Concord, Calif.). She can be reached at


SIDEBAR: Learn more
To read more on what some hospitals are doing to reduce HACs, visit CMS’s Partnership for Patients Program website ( a public-private partnership with a goal to reduce HACs by 40 percent and readmissions by 20 percent. Twenty-six Hospital Engagement Networks (HENs) have been established to identify best-practice solutions and disseminate their results. According to the latest CMS data, 3,700 hospitals have signed up as HEN partners.

The partnership’s goals including reducing readmission rates by 20 percent and reducing HACs by 40 percent, including:

  • Adverse drug events (medication errors)
  • Associated urinary tract infections (catheter)
  • Central line-associated blood stream infections
  • Injuries from falls and immobility
  • Surgical site infections
  • Venous thromboembolism
  • Ventilator-associated pneumonia
  • Pressure ulcers
  • Obstetrical adverse events