By Kelly M. Pyrek
One of the imperatives for infection preventionists in the new year is continuing to comprehend the myriad forces shaping healthcare right now, as well as implementing strategies that assist their institution leadership in meeting healthcare reform-related mandates. Driving much of the recent paradigm shift is the Affordable Care Act, which includes a series of Medicare reforms. The law also includes provisions that are designed to improve the quality of care, develop and promote new models of care delivery, appropriately price services, modernize the U.S. health system, and fight waste, fraud and abuse. Since the legislation was signed into law on March 23, 2010, the Centers for Medicare & Medicaid Services (CMS) began work to implement many of the key cost saving provisions that will add more than $575 billion over the next decade to the Medicare Hospital Insurance Trust Fund, according to the CMS Office of the Actuary (OAct).
The passage of the Affordable Care Act came at a critical time 'when according to CMS, the U.S. spent more than16 percent of its Gross Domestic Product (GDP) on healthcare. Without reform, CMS says the nation’s already excessive healthcare spending would have reached unsustainable levels within the next few decades. The agency says further that "Perverse incentives in existing payment structures that reward providers for the volume of services delivered, rather than quality of those services, are a primary driver of healthcare costs. The combination of misaligned incentives and fragmented healthcare delivery have contributed to the U.S. having higher per capita and total healthcare spending than any other industrialized country, and also scoring among the lowest on key health indicators, such as infant mortality, obesity, and health system performance. The Affordable Care Act will change these incentives and strengthen Medicare."
Infection preventionists are well aware of the steps that CMS continues to take to address quality of care issues where evidence shows unnecessary spending and the opportunity to improve outcomes -- most notably in unnecessary hospital readmissions. The Affordable Care Act creates a “hospital readmissions reduction program,” which will help hospitals smooth transitions for patients and reward hospitals that are successful in reducing avoidable readmissions. Beyond improving the quality of care for Medicare beneficiaries with chronic conditions—who comprise over 80 percent of all Medicare enrollees—the CMS OAct projects that this provision, when fully implemented, will reduce Medicare costs by $8.2 billion from implementation through 2019. CMS continues to work with hospitals at the local level to reduce avoidable readmissions through it Quality Improvement Organizations, while developing regulations. Readmissions are also reported on Hospital Compare at www.hospitalcompare.gov, and the use of transparency has proven to help to improve reported measures.
With healthcare reform concentrating on boosting quality while cutting costs, infection preventionists can contribute to the process in their institutions, says Linda Greene, RN, MPS, CIC, manager of infection prevention at Highland Hospital in Rochester, N.Y. and a member of the board of directors of the Association of Professionals in Infection Control and Epidemiology (APIC). "Infection preventionists (IPs) play a vital role in facilitating the implementation of evidence-based practices. Clearly, practices that have a high degree of evidence are linked to improved outcomes and these outcomes equate to prevention of harm, decreased morbidity, mortality and of course, decreased cost for the organization. The concept of the 4Es from the patient safety literature provides a framework for implementation: engage, educate, execute and evaluate. IPs play a vital role in engaging physicians and front line staff by helping to create a shared vision which focuses on prevention of harm. IPs are vital to ongoing education, and can assist in implementation of evidence based practices. Finally, they are crucial in evaluation. Their analytical and problem solving skills can help turn data into information which can be used by care givers to improve their processes of care and ultimately patient outcomes."
Infection preventionists must also take to heart the provisions in the hospital value-based purchasing (VBP) program and be prepared for ongoing reduced payment for readmissions. Beginning in 2013, the Affordable Care Act (ACA) reduced by up to 1 percent inpatient payments based on each hospital's readmission rates for acute myocardial infarction, chronic heart failure and pneumonia. The readmission payment adjustment was applied to claims beginning Oct. 1, 2012. It also established a Medicare value-based purchasing program that ties 1 percent of payments to a hospital's performance on a set of quality measures. For the value-based purchasing program in 2015, CMS is finalizing its proposal to add three new measures, including the Medicare Spending per Beneficiary measure and two new outcomes measures -- Central Line-Associated Blood Stream Infection (CLABSI) measure and the Patient Safety Indicator (PSI-90) composite measure. (Premier 2012)
Medicare is using the payment penalty to provide a clear financial incentive to drive improvements in quality, and healthcare executives are paying attention, according to Premier Safety Institute, which explains that the program penalties, rising to 2 percent in 2014 and 3 percent in 2015, could have a serious impact on those hospitals who can least afford the penalties, those with the most vulnerable patient populations. (Premier, 2012). As Premier explains, "Because the CMS calculates penalties for readmissions using data from a prior three year period -- July 1, 2008 to June 30, 2011 -- it will be a while before we know exactly how effective all these programs are. It may not always be easy to identify those patients at highest risk for readmission for targeted interventions, however, successful programs focus on a combination of enhanced assessment and discharge planning for all patients before they leave the hospital. This planning takes into account a patient's social support structure, partnerships with post-acute and community care providers, scheduling post discharge follow-up, including phone calls and visits that include checking on the understanding and availability of prescription medications. Scheduled follow-up medical visits with providers, including availability of transportation and other services must also be addressed. One additional key element of success of these programs is to dispel the notion that hospital staff have minimal control over what the patient does nor does not do during their transition to the community and help them understand that engagement of all healthcare professionals in the key to success."
There are a number of programs designed to help hospitals avoid readmissions. One of CMS' innovative healthcare improvement models, the Partnership for Patients, is designed to achieve a reduction of preventable hospital-acquired conditions by 40 percent and readmissions by 20 percent by 2013. The Premier Hospital Engagement Network (HEN), one of the largest of the 26 CMS HENs with more than 450 hospitals, is collaborating to reduce harm, including preventable readmissions. Another CMS initiative, Reducing Avoidable Hospitalizations Among Nursing Facility Residents, is a grant-funded program that is part of CMS' Community-based Care Transitions Program (CCTP) to support community organization to more effectively manage post discharge care. This initiative supports the Partnership for Patients goal of reducing hospital readmission rates and focuses on high risk Medicare beneficiaries. The Agency for Healthcare Research and Quality (AHRQ)'s Project RED (re-engineering hospital discharge) is also helping hospitals reduce readmissions by re-engineering the hospital workflow process by using a nurse discharge advocate that reinforces action steps to improve the discharge process and decrease hospital readmissions.
For the hospital-acquired condition (HAC) payment policy for FY 2013, CMS added Surgical Site Infection (SSI) Following Cardiac Implanta-ble Electronic Device (CIED) Procedures and Pneumothorax with Venous Catheterization to the HAC payment provision for FY 2013. SSI following CIED was added to the existing SSI category, rather than exist as its own category as CMS proposed. CMS also added diagnosis codes 999.32 (Bloodstream infection due to central venous catheter) and 999.33 (Local infection due to central venous catheter) to the existing Vascular Catheter-Associated Infection HAC category for FY 2013.
These HACs have been the collective radar of government agencies and clinicians alike. The Affordable Care Act imposes payment penalties on the 25 percent of hospitals whose rates of hospital acquired conditions like bedsores, complications from extended use of catheters, and injuries caused by falls, are the highest. OAct projects that this provision will reduce Medicare costs by $3.2 billion over 10 years. The positive effects of these provisions have the ability to extend to all payors and consumers that hospitals serve, and will ultimately improve the overall quality of care provided in hospitals. CMS has issued new quality reporting mechanisms to make such conditions more transparent to patients and providers.
Regarding these hospital inpatient quality reporting (IQR) proposed measures, for FY 2015 payment determination under the IQR program, CMS is reducing the total number of measures from the current 72 measures to 59 measures. The performance measures for FY 2014-2016 include:
- Adding three claims-based readmissions measures:
• Hospital-Level 30-Day All-Cause Risk-Standardized Readmission Rate (RSRR) Following Elective Total Hip Arthroplasty (THA) and Total Knee Arthroplasty
• Hip/Knee Risk Complication S: for Hip/Knee complication Hip/Knee Complication: Hospital-Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and Total Knee Arthroplasty
- Adding a three-part care transition measure to HCAPHS survey along with two questions for the "about you section" – admission through the emergency department and overall emotional and mental health
- Adding one chart abstracted measure on Elective Delivery
- Adding (for FY 2016) one structural measure (Use of Safe Surgery Checklist) for a total of 60 measures
- Retiring 17 measures:
◦ One chart abstracted, SCIP-VTE-1, as the measures process is included in SCIP-VTE-2 "Surgery patients who received appropriate VTE prophylaxis within 24 hours of pre/post surgery"
◦ Eight hospital-acquired conditions
◦ Five Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs)
◦ Three AHRQ Inpatient Quality Indicators (IQIs)
One more mandate that infection preventionists must bear in mind addresses healthcare personnel influenza vaccination. Although payment determination for healthcare personnel influenza vaccination measure will not begin until FY 2015, data submission via CDC's NHSN began on Jan. 1, 2013.
Gina Pugliese, RN, MS, FSHEA, vice president of the Premier Safety Institute, says that the recent emphasis on quality improvement con-tained in healthcare reform is an opportunity for infection preventionists to build on what they already know, bringing new skills to their existing clinical skillset.
"If you go back to 1999 and the Institute of Medicine (IOM)'s report, 'To Err is Human,' it mentions infection prevention only briefly in the big-ger picture but once people recognized that quality and safety includes infection prevention, it changed the game," Pugliese says. "Infection preventionists must learn about quality and safety because it's a part of infection prevention -- they must learn strategies for conducting surveillance, incorporating best practices, monitoring for compliance, establishing competencies, and looking at outcomes across a variety of issues, including infections. As more and more challenges related to data mining are placed upon them, it's taking them further away from the bedside. It also requires them to examine their programs and ensure there are adequate resources, not only for themselves, but resources to implement practices all along the front line."
Greene concurs that meeting the many mandates of healthcare reform requires IPs to constantly hone and build their skills. "IPs need a complex blend of skills. Clearly, technical skills related to epidemiology and disease transmission continue to be important especially in light of challenging diseases. However, IPs also need to understand the business and regulatory side of healthcare . Equally important are leadership skills. Whether the IP is a sole practitioner or has oversight for a large program, he/she must have the power to influence others. This requires strong leadership skills . Finally, in order to assure that evidence based practices are part of the routine delivery of care, there should be a basic understanding of principles such as human factors engineering, lean sigma, etc.
Pugliese encourages infection preventionists to use quality improvement as a way to system-check their infection prevention processes. "For example, If your institution has a policy that urinary catheters are no longer indicated, do you actually implement that all the way to the front line? There was a fabulous study published in the November issue of the American Journal of Infection Control by Ascension Health that consisted of a survey of their hospitals. The study showed that if you look at the policies in place and then look at actual practices, there is a disconnect between policies and how many are actually monitoring for compliance, or feeding information to their staff, or conducting root cause analysis when there is a glitch, or doing a competency assessment to make sure people actually know how to do what you are trying to accomplish. There's still some room for improvement, even in a health system like Ascension Health which has been so focused on quality. I thought it was a very eye-opening study, one that takes me back to the original SENIC study which actually put people on the ground in hospitals to look at their processes."
Indeed, the Ascension Health study found that identifying gaps in infection prevention practices may yield opportunities for improved patient safety. Ascension, a non-profit healthcare system with hospitals and related healthcare facilities in 23 states and the District of Columbia, conducted a 96-question survey of 71 of its member hospitals to evaluate infection control processes for catheter-associated urinary tract infections (CAUTI), central line-associated bloodstream infections (CLABSI), ventilator-associated pneumonia (VAP), and surgical-site infections (SSI). The survey questions addressed policies for placement and maintenance of devices, surgical procedures, evaluation of healthcare workers’ competencies, and outcomes evaluation. The effort was undertaken as part of Ascension Health’s participation as a Hospital Engagement Network in the Department of Health and Human Services (HHS) Centers for Medicare and Medicaid Services (CMS) Partnership for Patients program, a federally funded effort to help improve the quality, safety and affordability of healthcare for all Americans with the goal to decrease preventable hospital acquired conditions by 40 percent and decrease hospital readmissions by 20 percent.
According to the survey results, the majority of hospitals had infection prevention policies in place for the use of devices, surgery, hand hygiene, and multidrug-resistant organisms. However, only (28 out of 71 or 39.4 percent) reported having policies relating to antimicrobial stewardship, such as antimicrobial restrictions. Appropriate use of antibiotics is necessary to prevent antibiotic resistance. Also, practices to reduce device risk varied between hospitals. For example, the use of bladder scanners to assess for urinary retention was more available in medium and large hospitals compared to smaller ones. In addition, while more than three-quarters of hospitals had a nurse-driven protocol for determining need for a urinary catheter, only a minority of nurses (26.8 percent) and patient care technicians (11.3 percent) received annual training on how to properly place and maintain urinary catheters.
To reduce the risk of CLABSI, 94.4 percent of hospitals reported using an insertion checklist. However, according to the survey, only 59.2 percent used the checklist more than 90 percent of the time and only 40.8 percent provided annual training for nurses on placing and maintaining venous catheters. Very few hospitals used electronic reminders to help nurses (8.5 percent) and physicians (1.4 percent) evaluate catheter need.
Hospitals evaluated outcomes for CAUTI, CLABSI, VAP, and SSI, with root cause analysis predominantly occurring for cases of CLABSI and VAP. Surgeon-specific SSI rates were calculated and discussed with the surgeons in only two-thirds of the hospitals, a tool that may be important in helping surgeons prioritize infection prevention efforts.
“We suggest that individual hospitals evaluate their policies, processes, and practices prior to implementing interventions to establish a baseline for comparative purposes, to reduce infection, and base their action on the gaps identified,” state the authors. “We believe that identifying the gaps and addressing them as a system will help lead to marked improvements in safety for our patients.”
Pugliese says infection preventionists should be part of the healthcare institution's multidisciplinary team working that addresses risk man-agement issues from a quality and infection prevention perspective, which can hopefully shift some of the burden and free up the IP to address implementation at the front line. "This applies not only to healthcare workers but to the education of patients, especially with the focus on preventing readmissions," she says. "Certainly preventing readmissions is everyone's responsibility but it really comes down to what are your processes for educating patients -- if you are talking C. diff, not only do you have the transmission issue and prevention efforts but you have antibiotic use -- a recent study showed that only 39 percent of facilities had a policy for antimicrobial stewardship and antibiotic restrictions -- which means we have hospitals that have huge gaps in antimicrobial control, and therefore more challenging control of C diff, admissions with C. diff and readmissions in general."
Many infection prevention experts believe that technology can help practitioners meet an intensifying demand for clinical and infection data.
"Electronic surveillance really is the future," says Pugliese. "The Centers for Disease Control and Prevention (CDC) is trying to do as much as it can to bring all of the healthcare organizations up to speed and get them on its National Healthcare Safety Network (NHSN) for reporting purposes, because you can really capture the surveillance information off your data you already have in the medical record. Paper surveillance and manual data entry is a labor-intensive process and unfortunately a small percentage of hospitals are doing things electronically -- it's important that they move toward electronic surveillance going forward."
Greene says she believes that information technology (IT) can help cushion the blow of competing demands on IPs' time and resources. "One of the most pressing issues is the number of competing priorities which are resource dependent," she says. "The increasing demands for more public reporting coupled with the need to drive change, provide real time feedback and communication, engage healthcare workers, and decrease the rate of challenging HAIs such as C. diff can be overwhelming. This is especially challenging given the fact that some of the NHSN measures will soon be moving from pay for reporting to pay for performance. In order to prepare, we need to be acutely aware of what the reporting requirements are, how the data will be reported and understand the metrics associated with the reporting. We also need to engage other stakeholders in this process and utilize available resources to ease the data collection burden. The electronic health record can provide important information to ease the burden of data collection especially denominator data. Clearly, we need to engage and leverage our IT resources."
Pugliese cautions IPs to balance meeting healthcare reform mandates with frontline work. "I believe that we've gotten side-tracked in some ways by all of the data collection that we have to do and keeping up with all of the new processes that have taken us away from the prevention side. And how can we continue to lose funding and have hospital reimbursements cut without it impacting what we do when we can't staff the areas that need to be staffed, for example. So it requires the IP to examine where the challenges are in their organization and make recommendations as to how many staff members and what resources they need to reduce infection and patient safety risk. If you look at the Ascension Health study, for example, 78 percent had policies for urinary catheter placement and maintenance, and 77 percent had nurse-driven evaluations of the need -- that means the doctors in many of those hospitals have to decide when the catheter comes out. Additionally, just 27 percent had annual competency reviews of catheter placement and maintenance, so there are big gaps in CAUTI prevention. Ascension has house-wide surveillance of CAUTI and that's a significant accomplishment, but I'm not sure the vast majority of hospitals are ready for that. It's going to be a huge change in the way many hospitals are conducting surveillance. In many hospitals they are focusing on MDROS and other things, so going house-wide for catheter infections, and keeping up with everything else, will be tough."
No matter the challenges, Pugliese and Greene both agree that there's never been a better time for the spotlight to be on infection prevention as part of the wider quest for quality and safety.
"I think the attention being given to infection prevention, with so much emphasis on public reporting and with value-based purchasing, has really brought not only attention and resources, but also collaboration to the IPs that they might not have had before. It's critical to approach challenges as part of a multidisciplinary team, with everyone coming together to look at a problem across the different disciplines. You may have the right policies but are your processes in alignment, and do you have gaps between policy and practice? The only way to succeed is to close that gap in the organization, reduce infections, and reduce the risk to your hospital's reimbursement."
As Greene notes, "There are many challenges- more requirements for mandatory reporting measures, assuring that measures are meaningful, valid and reliable, the growing number of vulnerable elderly patients and the need to increase our efforts across the continuum of care. However, we are presented enormous opportunities to collaborate with other disciplines, to influence others and to truly play an important role in infection prevention. We have the opportunity to shape the future of infection prevention."
Centers for Medicare and Medicaid Services. Affordable Care Act Update: Implementing Medicare Cost Savings. Accessible at: http://www.cms.gov/apps/docs/aca-update-implementing-medicare-costs-savings.pdf
Premier Safety Institute. SafetyShare newsletter. Oct. 1, 2012.
Premier Safety Institute. Safety Share newsletter. CMS FY 2013 IPPS performance measures. Sept. 4, 2012