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Healthcare payers are exploring a wide variety of Pay for Performance programs to lower costs and hopefully improve quality and patient safety. Different patient characteristics affecting clinical outcomes are not always easily or reliably captured, so most measures are based on surrogates, typically on compliance with evidence-based care guidelines Very few measures address actual clinical outcomes. In practice, even protocol compliance is difficult to measure and hundreds of pages of administrative guidelines can accompany even the simplest measurements. Withholding reimbursement for so-called Never Events is an attractive intervention because of its perceived face-validity as a simple, fair, effective, and easy to administer intervention. The key elements needed to assure that these perceptions of Non-Payment for Never Events meet reality are proper definition of Never Events, comprehensive documentation and coding of conditions present on admission, and ongoing assessment of both processes and outcomes. Additions and deletions of officially designated Never Events should be expected. As with any change initiative, planning, education, and consensus-building must occur, even for something as “obvious” as Non-Payment for Never Events.

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