Mandatory Reporting of HAIs: What is Your Role?
By Marian McDonald, RN, MSN, CIC
Four states, Pennsylvania, Illinois, Missouri, and Florida, already have laws in place which require mandatory public reporting of healthcare-associated infections (HAIs), and the California legislature passed such a bill last year, only to have it vetoed by the governor. This year, 32 states have bills moving through the legislature, and some of those states have several bills active at the same time.
This movement was not initiated by the healthcare industry, but is being driven largely by Consumers Union (CU) as a nationwide initiative. The fact that is has resonated so widely across the nation reflects consumers growing desire for reliable information to allow them to make informed choices regarding their source of healthcare. In several states, the legislation was already introduced before we in the field even became aware of it. The challenge for us is that this legislation is being written by people who are not knowledgeable about infection control and do not understand the difficulties of providing statistics which are accurate, meaningful and readily understood by the lay public. Our challenge will be to participate in this process to provide statistics which will meet those goals.
Many of us do not have experience with the legislative process, and this is an excellent time to learn. Choosing not to participate is, in effect, saying that you are willing to abide by regulations on your practice which you did not help to create.
Simply opposing these new laws is probably not a good choice, for a number of reasons. First, if we seem to be hiding something, it gives the appearance that there is something terrible to hide. It is important for us to be clear that we have nothing to gain by hiding anything. We should keep in mind that the people writing this legislation want to reduce the risk of HAIs to the public, which is our goal, too. We will probably come out ahead by joining forces with those behind this movement rather than trying to work against them. If we wish to influence the development of the legislation, it is often necessary to be a supporter. In California in 2004, we were not allowed to have input unless we supported the bill. It is critical that the legislation passed into law be written with a good understanding of standardized definitions, methods and risk-adjustment. People outside our field usually have no experience with those concepts, so it will be up to us to help them understand why they are so critical to providing useful and valid data. These laws are very likely to be passed with or without our input, so we have nothing to gain by opposing them.
Finally, the reason that many of us have opposed this legislation is that there is no way we can possibly take on one more thing. We are already way too busy doing what we already have to do. However, if a mandatory reporting law is passed in your state, this may be the opportunity for you to finally get more attention from your leadership. One of the things CU is considering reporting is the number of infection control practitioners (ICPs) for each facility. Remember that anything we pay attention to tends to improve (the Hawthorne effect), and this may be our opportunity to gain from the new attention. If it helps us to do a better job protecting our patients, it can only be a good thing!
So, if you have decided that you do need to participate in influencing this legislation, how do you get started? This is a project which will require teamwork, collaboration and shared learning, and your local Association for Professionals in Infection Control and Epidemiology (APIC) chapter is the natural place to start. It is very important to collaborate with all of the APIC chapters in your state so you can speak with a unified voice and work in an organized way with legislators. The legislative representatives for all APIC chapters should make contact if they have not already done so. Pull together a working group of interested folks who will actually do the work of this process, probably no more than a dozen people per state. Having a well-coordinated process is critical. If you live in the district of a sponsoring legislator, you may have a key role as their constituent.
Next, get copies of all the bills for your state and read them. Reading legislation is probably not your favorite activity, but remember that we will have to do what any legislation that passes says, so it is worth the trouble to read the bills before they pass. If the complex language throws you, use a highlighter to mark the subject and verb of each sentence.
Then have a constituent, if possible, get acquainted with the office staff of the legislator who sponsors each bill. If your state has more than one bill being considered, you may want to have one APIC member be the main contact person for each legislators office, so that there is only one voice speaking for APIC in each office. When you call, first mention the number of the bill you are interested in and ask to speak with the staff person in charge of that bill. When you have the right staff person, make careful note of their name, because your relationship with that key person may very well determine the success or failure of your effort to influence the bill. Introduce yourself, mention if you are a constituent, and tell them who you are representing. Tell them briefly about APIC, and be very careful to respect their time. Let them know that APIC is interested in working with them to develop a bill which will provide accurate and useful data for consumers.
Ask them who is working with them on the bill and who helped to write it. You may find that CU or a labor organization is involved. Keep everything very positive and collegial, whatever you may be thinking. Ask them what the next step for the bill is, which may be a committee hearing. Be sure to note the name of the committee and the date of the meeting, because you may need to take action before that date. Finally, be sure that you have correct contact information for that staff person and that they have your contact information. Thank them for their help.
Back in your working group, determine your next priority. Factors to consider include how soon the bills will be heard in committee, how much work they need, how many bills are moving, which are most likely to pass, and how much energy the group has to invest. Be sure to keep the big picture in mind. Is consolidation of multiple bills a possibility? This can require sensitive negotiation with the sponsoring legislators.
Work on one bill at a time. Several people should read each bill and then discuss what it says, because different people will pick up different points and problems. Make notes as you discuss the bill, especially the parts you dont like, then write language you do like to replace them. Yes, you are actually writing proposed legislation! This is not easy, but it is a lot easier working with a group.
Keep in touch with national APIC on the progress in your state. Denise Graham in the national office is working with all the states, and assisting with language and strategy. The Healthcare Infection Control Practices Advisory Committee (HICPAC) of the Centers for Disease Control and Prevention (CDC) has published a document on Guidance on Public Reporting of Healthcare-Associated Infections. It can be reviewed at http://www.cdc.gov/ncidod/hip/PublicReportingGuide.pdf. The Missouri bill may be the best of the bills already passed, and you can view it at http://www.senate.mo.gov/04info/billtext/tat/sb1279.htm. Finally, you may want to check out the CU model bill at www.stophospitalinfections.org. We should know what other folks are doing to learn from their positions, whether we agree with them or not.
Ask your legislative staff person how you can have input into the bill, and tell them you would like to provide alternative wording. Remember that the people you are working with in the legislators office are not experienced in infection control, and be very careful to avoid insulting their intelligence. Your job is to get language into the bill which can result in accurate and comparable data (with all the risk adjustment we know that implies) without appearing to obstruct the process. You may need to testify at committee hearings for the bill; be well prepared when you do, and take a colleague with you if you can.
You may want to meet with your legislator at some point, mostly to thank him or her for their work to protect patients from infection. Your meeting may last only five minutes, so be well prepared and have a copy of your points to leave with the staff member who will be taking notes.
You may be surprised how much you can change a bill from beginning to end. Last year in California, we were very unhappy with our bill when we first read it, but by the time the state Legislature passed it, we felt we could live with it. Work closely with the staff person in charge of each bill. Always be pleasant, organized, well prepared, and credible. You really can influence this process.
The possibility of having 50 different state standards presents a number of problems. It will complicate educating ourselves to respond. It will make it much more difficult to develop the information technology needed to provide the data to support reporting. It will create significant problems for hospital systems that cross state lines. It will also mean that data cannot be compared from one state to another. APIC supports having a single national standard and the federal government is willing to work to develop one, but CU is not willing to wait, so we cannot wait either. We must participate in the development of our state regulations, even if they are only a stage along the way to a national standard. At the very least, we will be developing valuable contacts as we educate our state leaders about what we are already doing.
Remember that the goal of the legislators and of CU is the same as our goal to protect patients from preventable infections. This new attention may allow us to do a lot more than we have been able to do in the past to protect our patients.
Marian McDonald, RN, MSN, CIC, is a consultant in infection control and serves as 2005 president of the California APIC Coordinating Council. Her contact information is available via www.cacc.net.