By MarianMcDonald, RN, MSN, CIC
Four states, Pennsylvania, Illinois,Missouri, and Florida, already have laws in place which require mandatory publicreporting of healthcare-associated infections (HAIs), and the Californialegislature passed such a bill last year, only to have it vetoed by thegovernor. This year, 32 states have bills moving through the legislature, andsome 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 consumersgrowing desire for reliable information to allow them to make informed choicesregarding their source of healthcare. In several states, the legislation was already introducedbefore we in the field even became aware of it. The challenge for us is thatthis legislation is being written by people who are not knowledgeable aboutinfection control and do not understand the difficulties of providing statisticswhich are accurate, meaningful and readily understood by the lay public. Ourchallenge will be to participate in this process to provide statistics whichwill meet those goals.
Many of us do not have experience with the legislativeprocess, 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 practicewhich 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 theappearance that there is something terrible to hide. It is important for us tobe clear that we have nothing to gain by hiding anything. We should keep in mind that the people writing thislegislation 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 thismovement rather than trying to work against them. If we wish to influence thedevelopment of the legislation, it is often necessary to be a supporter. InCalifornia in 2004, we were not allowed to have input unless we supported thebill. It is critical that the legislation passed into law be written with a goodunderstanding of standardized definitions, methods and risk-adjustment. Peopleoutside our field usually have no experience with those concepts, so it will beup to us to help them understand why they are so critical to providing usefuland valid data. These laws are very likely to be passed with or without ourinput, so we have nothing to gain by opposing them.
Finally, the reason that many of us have opposed thislegislation is that there is no way we can possibly take on one more thing. Weare already way too busy doing what we already have to do. However, if amandatory reporting law is passed in your state, this may be the opportunity foryou to finally get more attention from your leadership. One of the things CU is considering reporting is the number ofinfection control practitioners (ICPs) for each facility. Remember that anythingwe pay attention to tends to improve (the Hawthorne effect), and this may be ouropportunity to gain from the new attention. If it helps us to do a better jobprotecting our patients, it can only be a good thing!
So, if you have decided that you do need to participate ininfluencing this legislation, how do you get started? This is a project whichwill require teamwork, collaboration and shared learning, and your localAssociation for Professionals in Infection Control and Epidemiology (APIC)chapter is the natural place to start. It is very important to collaborate withall of the APIC chapters in your state so you can speak with a unified voice andwork in an organized way with legislators. The legislative representatives forall APIC chapters should make contact if they have not already done so. Pulltogether a working group of interested folks who will actually do the work ofthis process, probably no more than a dozen people per state. Having awell-coordinated process is critical. If you live in the district of asponsoring legislator, you may have a key role as their constituent.
Next, get copies of all the bills for your state and readthem. Reading legislation is probably not your favorite activity,but remember that we will have to do what any legislation that passes says, soit is worth the trouble to read the bills before they pass. If the complexlanguage throws you, use a highlighter to mark the subject and verb of eachsentence.
Then have a constituent, if possible, get acquainted with theoffice staff of the legislator who sponsors each bill. If your state has morethan one bill being considered, you may want to have one APIC member be the maincontact person for each legislators office, so that there is only one voicespeaking for APIC in each office. When you call, first mention the number of thebill you are interested in and ask to speak with the staff person in charge ofthat bill. When you have the right staff person, make careful note of theirname, because your relationship with that key person may very well determine thesuccess or failure of your effort to influence the bill. Introduce yourself,mention if you are a constituent, and tell them who you are representing. Tellthem briefly about APIC, and be very careful to respect their time. Let themknow that APIC is interested in working with them to develop a bill which willprovide accurate and useful data for consumers.
Ask them who is working with them on the bill and who helpedto write it. You may find that CU or a labor organization is involved. Keepeverything very positive and collegial, whatever you may be thinking. Ask them what the next step for the bill is, which may be acommittee hearing. Be sure to note the name of the committee and the date of themeeting, because you may need to take action before that date. Finally, be sure that you have correct contact information forthat staff person and that they have your contact information. Thank them fortheir help.
Back in your working group, determine your next priority.Factors to consider include how soon the bills will be heard in committee, howmuch 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 ofmultiple bills a possibility? This can require sensitive negotiation with thesponsoring legislators.
Work on one bill at a time. Several people should read eachbill and then discuss what it says, because different people will pick updifferent points and problems. Make notes as you discuss the bill, especiallythe parts you dont like, then write language you do like to replace them. Yes, you are actually writing proposed legislation! This isnot easy, but it is a lot easier working with a group.
Keep in touch with national APIC on the progress in yourstate. Denise Graham in the national office is working with all thestates, 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 adocument on Guidance on Public Reporting of Healthcare-Associated Infections. It can be reviewed athttp://www.cdc.gov/ncidod/hip/PublicReportingGuide.pdf. The Missouri bill maybe the best of the bills already passed, and you can view it at http://www.senate.mo.gov/04info/billtext/tat/sb1279.htm. Finally, youmay want to check out the CU model bill atwww.stophospitalinfections.org. Weshould know what other folks are doing to learn from their positions, whether weagree with them or not.
Ask your legislative staff person how you can have input intothe bill, and tell them you would like to provide alternative wording. Rememberthat the people you are working with in the legislators office are notexperienced in infection control, and be very careful to avoid insulting theirintelligence. Your job is to get language into the bill which can result inaccurate and comparable data (with all the risk adjustment we know that implies)without appearing to obstruct the process. You may need to testify at committeehearings for the bill; be well prepared when you do, and take a colleague withyou 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 preparedand have a copy of your points to leave with the staff member who will be takingnotes.
You may be surprised how much you can change a bill frombeginning to end. Last year in California, we were very unhappy with our billwhen we first read it, but by the time the state Legislature passed it, we feltwe could live with it. Work closely with the staff person in charge of eachbill. Always be pleasant, organized, well prepared, and credible. You really caninfluence this process.
The possibility of having 50 different state standardspresents a number of problems. It will complicate educating ourselves torespond. It will make it much more difficult to develop the informationtechnology needed to provide the data to support reporting. It will createsignificant problems for hospital systems that cross state lines. It will also mean that data cannot be compared from one stateto another. APIC supports having a single national standard and the federalgovernment is willing to work to develop one, but CU is not willing to wait, sowe cannot wait either. We must participate in the development of our stateregulations, 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 ourstate leaders about what we are already doing.
Remember that the goal of the legislators and of CU is thesame as our goal to protect patients from preventable infections. This newattention may allow us to do a lot more than we have been able to do in the pastto protect our patients.
Marian McDonald, RN, MSN, CIC, is a consultant in infectioncontrol and serves as 2005 president of the California APIC CoordinatingCouncil. Her contact information is available via www.cacc.net.