One-third of the nation’s states already have laws requiring mandatory public reporting of hospital-associated infection data. Fifteen more states are considering bills in this area, as is the U.S. government. The Association for Professionals in Infection Control and Epidemiology (APIC) and other infection control advocacy groups have their work cut out for them in seeking common standards in these well intended, but often incongruent, legislative efforts. How will hospitals be affected? Read on.
Q We’ve seen a broad push by states to introduce and enact legislation on mandatory reporting of health care-associated infections (HAI). What forces are behind this movement and where is it headed?
A One of the ultimate aims is to increase transparency in the reporting of HAIs to consumers, the public and to payers. I believe the main forces who started this were consumer advocacy organizations such as the Consumer Union. In 2002 and 2003, it lobbied each state legislature to promote legislation for mandatory public reporting of HAIs.
Health plan purchasers want the data so they can rank their hospitals and see who has the best quality. The next biggest driver is the Centers for Medicare & Medicaid Services (CMS). It announced its intention to have public reporting of HAIs. And the last driver, and probably the one that people see the most, is the media. In the last six or seven years or so, there has been a lot of media attention focused on HAIs.
Q And there are financial implications for hospitals with CMS’ initiatives, correct?
A Yes. CMS is moving toward pay-for-performance. If a hospital does not report on specific quality measures, they get a reduced payment for their Medicare reimbursement.
Q How many states have enacted legislation on mandatory reporting of HAIs and how many states have introduced bills in this area?
A Right now, 17 states have requirements. Of those, 15 states have enacted legislation and two states—Pennsylvania and Maine—addressed mandatory reporting of HAIs through the regulatory process. They basically started enforcing the rules they already had in place.
Q To what extent are states that have laws on the books grouping peer hospital data to try to give consumers at least somewhat of an apples-to-apples comparison?
A That’s one of the problems because each law is different. In each state the authority on collecting and reporting the data has been given to various agencies.
In some states it’s the agency that’s responsible for monitoring hospital quality and in other states it’s the health department. In addition, many states require different infection process measures be recorded. So right now we have a real mishmash of 17 different requirements.
Q Will these legislative efforts give consumers valuable information? What areas of confusion may arise from the data?
A For now, we really don’t know if consumers are going to find this information valuable. Only one state at this point—Pennsylvania—has released hospital-specific data.
I conducted a literature review and found some articles have shown that there is some evidence that public reporting on HAIs will increase quality, not so much by leading consumers to certain hospitals, but by leading hospitals to put a little more emphasis on their quality improvement programs.
There are a few articles, though, that talk about some unintended consequences of reporting. One article reported on a single-state study on cardiac surgery and mortality. This study found that because the state’s data is publicly reported, some physicians are hesitant to work on patients who are very sick for fear that their quality data will reflect that.
Q What needs to be done to ensure the public develops a meaningful understanding of HAIs and the various risk factors in vulnerable populations?
A Both consumers and health care providers need a lot of education about the fact that an HAI can lead to adverse outcomes. Consumers and health care workers also need to know that many of these HAIs are preventable.
One really good thing to come out of the whole push to make this information public is that providers are focusing on the fact that more infections than we first thought are preventable.
For many years we figured that one-third of these infections were preventable. Since then there have been a lot of quality improvement projects showing that we can prevent an even greater percentage of these infections.
Q What are some of the key similarities and chief differences among the state laws that have been enacted on mandatory reporting of HAIs?
A There are more differences than similarities. In fact, each state now has requirements for reporting slightly different measures.
Some states focus on outcome measures such as central line-associated infections and ventilator-associated pneumonia, while other reporting systems concentrate on process measures, such as measuring compliance of health care worker vaccination against influenza.
Most of the states that have specified which infections to monitor seem to be focusing on central line-associated bloodstream infections. And this is an infection that’s relatively easy to detect and to monitor. This has been a quality monitor for many years in many hospitals. It’s one of the indicators that’s used in the CDC National Nosocomial Infections System, which has morphed into the National Healthcare Safety Network. Some states, however, have not even specified what they want to monitor.
In my state, Maryland, they have set up an expert panel to look at how this is going to be done and who is going to do it and what they’re going to look at. Many states are doing this.
Q Given that about one-third of the states have HAI reporting legislation in place, where do you think we’re headed now? Is federal legislation next?
A Right now there are 15 states that have proposed some kind of regulation in the 2007 legislative session. At the federal level, several things are going on. First, several bills have been introduced in the 2007-2008 congressional session.
The Healthy Hospitals Act of 2007 (HR 1174) was introduced in February 2007. This is aimed at amending the Social Security Act by requiring public reporting of HAIs by hospitals and ambulatory surgical centers.
This bill would permit the secretary of Health & Human Services to establish a pilot program to provide incentives to hospitals and surgical centers to reduce and eliminate HAIs. It looks as though this may be aimed toward pay-for-performance.
Two other bills target the Veterans Affairs (VA) hospitals. They are both called the VA Hospital Quality Report Card Act— HR 1448, which was introduced in the House this past March, and resolution 692, which was introduced in Senate in February. Both acts would establish a hospital quality report card initiative to report on health care quality in VA hospitals.
The U.S. government’s General Accounting Office is inquiring and investigating mandatory reporting and has approached several professional organizations on a fact-finding mission. We’ll have to see where that goes.
Q What are APIC’s concerns about some aspects of these legislative efforts, and has APIC sought amendments to any of these legislative proposals?
A APIC is concerned about the potential for having 50 different requirements as each state addresses and enacts legislation or other requirements. This makes it difficult to standardize anything.
APIC has not sought specific amendments to state legislation, but we worked with the Society for Healthcare Epidemiologists of America (SHEA) on model legislation for legislators and health care professionals to use and we have these guidelines on our Web site at www.apic.org.
Q What do perioperative nurses and infection control specialists, in particular, need to know about this legislative trend and public reporting of HAIs? What can they do to provide input when laws are introduced?
A It’s very important for the perioperative nurses and infection control professionals and anyone who has a stake in this to collaborate to monitor at both the local or state and federal level so that they can assist each other and their hospitals in meeting the requirements. And even prior to the requirements it is important that infection control professionals and nurses try to help mold them because the legislators don’t really know the hospital system.
It’s pretty new to most of them and I know that many professional organizations have conducted a lot of educational sessions for legislators. We have to remember not to lose track of the most important goal, and that’s to reduce HAI rates. If perioperative specialists and the ICPs work together to reduce the risks and implement best practices to prevent the occurrence of HAIs, then everybody will benefit and the hospital will be able to meet the requirements.
Q What resources are available to assist hospital professionals who will be involved in the public reporting of HAIs?
A Several organizations have worked together to develop resources, and on the APIC Web site you’ll find talking points and a legislative position paper. SHEA also has a position paper on what its members can do to participate in this process (www.shea-online.org). Also, the Healthcare Infection Control Practices Advisory Committee, which advises the CDC, has come up with a guidance report and recommendations on public reporting of HAIs (www.cdc.gov).
Q What needs to change within the hospital culture to bring significant reductions in HAIs?
A We need to change the culture so that we strive to reduce HAIs to as close to zero as we can as opposed to thinking that only 33 percent of HAIs are preventable. We may not be able to achieve zero for all, but we know can get pretty close to zero with some infections. This is a key focal point for APIC and SHEA.
Q As you look at the various legislative efforts on HAIs, are you generally optimistic or pessimistic and how would you characterize the situation?
A I’m optimistic and pleased to see that a lot more interest and effort is going into preventing HAIs. I’ve been involved in infection prevention since 1980 and many times it’s difficult to get done what you know needs to be done. This increased emphasis really is making it easier to get hospital administrators and health care facility leaders to listen more.
What a lot of people don’t realize is that in the 1990s many hospitals started targeting specific infections, trying to collaborate so they could reduce the rates. The hospital I was working with in 1996 in Baltimore targeted central line-associated infections and we used what is now called the IHI (Institute for Healthcare Improvement) bundle and we reduced our infection rate in this area by 66 percent.
A lot of hospitals have been following those guidelines since the mid-1990s. It just never got any publicity until the IHI jumped on it and really promoted it. That was a real benefit.
The downside is that at this point we really don’t know where this is going in terms of giving consumers good information. That still remains to be seen.
This article first appeared in the June 2007 issue of Materials Management in Health Care.
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