Never Events and Hospital Acquired Conditions

The AAFP strongly supports efforts to implement the best evidence-based guidelines to improve health care, including the ultimate goal of eliminating National Quality Forum (NQF) Never Events (NE) and Centers for Medicare and Medicaid Services (CMS) identified Hospital Acquired Conditions (HAC). While there is preliminary evidence that ideal systems of care can reduce or- in select cases- eliminate many of these events, there are substantial gaps in current evidence, systems of care, and scalable practices to conclude that all such outcomes are reasonably preventable. Moreover, there is little evidence linking payment denial with improved outcomes.

Therefore, the AAFP supports incentives for performance improvement including the implementation of robust systems to reduce reasonably preventable conditions. The Academy recommends the development of standard definitions for NE and HAC along with non-punitive reporting frameworks, such as the Patient Safety Organizations sponsored by the Agency for Healthcare Research and Quality. In addition, the Academy recommends further research to delineate evidence-based practices that address such conditions in an actionable and scalable fashion for both inpatient and ambulatory settings. (2010 COD)