Reducing Healthcare-Associated Infections

1. ReducingHealthcare-Associated Infections

2. Presentation Overview Introduction DHHS overview CDC initiatives CMS role in HAI reduction AHRQ HAI portfolio Discussion

3. Participants Don Wright, MD, MPH Principal Deputy Assistant Secretary for Health, Office of Public Health & Science L Clifford McDonald, MD Chief, Prevention and Response Branch, Division of Healthcare Quality Promotion, CDC Barry M Straube, MD CMS Chief Medical Officer, & Director, Office of Clinical Standards & Quality, CMS William B Munier, MD, MBA Director, Center for Quality Improvement & Patient Safety, AHRQ

4. DHHS Overview

5. HHS Efforts to PreventHealthcare-Associated Infections Don Wright, M.D. M.P.H. Principal Deputy Assistant Secretary for Health AHRQ Annual Conference Rockville, MD Monday, September 14, 2009

6. Presentation Overview HHS Action Plan: Development and Implementation State Action Plans: States Adopt National Plan Recovery Act Funds: Targeting HAIs Future Direction in Reducing HAIs: Tier 2 Healthy People 2020 Questions

7. Healthcare-Associated Infections (HAIs) What are they? Bloodstream infections, urinary tract infections, pneumonia, surgical site infections The Problem 1.7 million HAIs in hospitals�unknown burden in other healthcare settings 99,000 deaths per year $28-33 billion in added healthcare costs HAI Prevention Implementing what we know for prevention can lead to up to a 70% or more reduction in HAIs

8. HHS Action Plan to Prevent Healthcare-Associated Infections Development and Implementation

10. GAO Report:Recommendations for HHS Improve central coordination of HHS-supported prevention and surveillance strategies Identify priorities among CDC guidelines to: Promote implementation of high priority practices Establish greater consistency and compatibility of HAI-related data across HHS systems to: Increase reliable national estimates of HAIs

11. HHS Steering Committee for the Prevention of HAI Charge: Develop an Action Plan to reduce, prevent, and ultimately eliminate HAIs Plan will: Establish national goals for reducing HAIs Include short- and long-term benchmarks Outline opportunities for collaboration with external stakeholders Coordinate and leverage HHS resources to accelerate and maximize impact

12. Tier One Priorities HAI Priority Areas Catheter-Associated Urinary Tract Infection Central Line-Associated Blood Stream Infection Surgical Site Infection Ventilator-Associated Pneumonia MRSA Clostridium difficile Implementation Focus Hospitals

13. Steering Committee Working Group Structure

14. Stakeholder & Public Engagement Hold five stakeholder/public engagement meetings Washington, DC � Tuesday, June 30 (National Level) Denver, CO � Saturday, July 25 (Regional/State Level) Chicago, IL � Thursday, July 30 (Regional/State Level) Seattle, WA � Thursday, Aug 27 (Regional/State Level) Chicago, IL � Tuesday, Sept 22 (Regional/State Level) Engage professional and public stakeholders in the HHS Action Plan Request input on priorities and strategies

15. State Action Plans

16. State Action Plans State plans will: Be consistent with the HHS Action Plan Contain measurable 5-year goals and interim milestones for preventing HAIs

17. State Action Plans Fiscal Year 2009 Omnibus Appropriations Act: Requires states receiving Preventive Health and Health Services (PHHS) Block Grant funds to certify that they will submit a plan to the Secretary of HHS not later than January 1, 2010 Authorizes CDC to withhold 25% of states allocated funds until this certification is submitted All states have submitted a certification Be reviewed by the Secretary of HHS with a report submitted to Congress by June 1, 2010 Technical assistance sessions and calls will be planned to assist states in plan development CDC has created a template to assist states in plan development

18. American Reinvestment and Recovery Act Funds Preventing Healthcare-Associated Infections

19. Building State Programsto Prevent HAIs Project Description: Create and expand state-based HAI prevention collaboratives Build a public health HAI workforce in states Enhance states abilities to assess where HAIs are occurring Agency Lead: CDC Collaborating Agencies: AHRQ and CMS Funds Source & Amount: American Reinvestment and Recovery Act Funds ($40 million) CDC HAI Recovery Act Website www.cdc.gov/nhsn/ra

20. New Ambulatory Surgery Center Infection Instrument Project Description: Nationwide application of a new infection control survey instrument (designed by CMS & CDC) Use of new tracer methodology Use of multiple-person teams for ASCs over a certain size or complexity Greater inspection frequency than the current 10-year average inspection frequency (Goal = 3 years) Funds Source & Amount: 2-year funding with ARRA grant dollars of $1 million in FY09 and the remaining $9 million in FY10

21. Future Direction

22. HHS Commitment to Reducing Healthcare-Associated Infections Tier 2

23. Tier Two Priorities Ambulatory Surgical Centers Dialysis Centers

24. Growth in Outpatient Care Shift in healthcare delivery from acute care settings to ambulatory care, long term care and free standing specialty care sites Infection control oversight often lacking Approximately 1.2 billion outpatient visits / year Number of Dialysis Centers 2008: 4,950 (72% increase since 1996) Number of Ambulatory Surgical Centers 2008: 5,100 (240% increase since 1996) 2007: more that 6 million surgeries performed in ASC and paid by Medicare

25. Surgical Procedures Movingto Outpatient Setting

26. Healthy People 2020:Defining the Nation�s Health Objectives

27. Healthy People:What is it Now? A comprehensive set of national ten-year health objectives A framework for public health priorities and actions Guided health policy decisions for 3 decades www.healthypeople.gov

28. Healthy People 2020 � Phase IINew Topic Areas Access to Health Services Adolescent Health Children�s Health Genomics Global Health Older Adults Healthcare-Associated Infections Quality of Life Social Determinants of Health Blood Disorders and Blood Safety Healthy Places Preparedness

29. Points of Contact & Links HHS Action Plan to Prevent Healthcare-Associated Infections & Stakeholder Meeting Information www.hhs.gov/ophs/initiatives/hai

30. CDC Initiatives

31. CDC Approach to Eliminating Healthcare-associated Infections L. Clifford McDonald, MD, FACP Chief, Prevention and Response Branch Division of Healthcare Quality Promotion Centers for Disease Control and Prevention

32. Patient Safety within CDC�s Division of Healthcare Quality Promotion (DHQP)

33. CDC�s Role in HAI Elimination Provide technical support to states, local health agencies, and healthcare facilities Field investigations, consultations, training Define the scope of the problem and impact of interventions National Healthcare Safety Network (NHSN) Population-based surveillance systems Identify best practices Work with partners to promote prevention Complement other HHS agencies and support state/local health departments

35. DHQP Field Investigations of Healthcare Associated Outbreaks, United States, 2004-2009

36. Epidemic Clostridium difficile Infections:Detection, Understanding, Surveillance, and Prevention

38. 33 outbreaks in 15 states Outpatient clinics, n=12 Dialysis centers, n=6 Long term care, n=15 Tip of the iceberg?Tip of the iceberg?

40. Injection Safety Campaign

41. Collaboration with CMS Improve infection control in survey and certification process for ASCs Advise on the adoption of infectious �Hospital Acquired Conditions� for reduced reimbursement Part of the Deficit Reduction Act (DRA) Collaborate on HAI reduction through QIOs MRSA in the 9th Scope of Work Pilot for the 10th Scope of Work Hospital Compare Role for NHSN

42. Surveillance

43. National Healthcare Safety Network (NHSN) Voluntary, secure, internet-based surveillance system Includes information about infections, microorganisms, and practices for HAI prevention Over 2200 hospitals from 50 States currently report to NHSN; 21 States mandate the use of NHSN for HAI reporting

44. States Mandating NHSN for Reporting (as of August 2009)

45. NHSN eSurveillance Moving Towards the Future

46. NHSN Data for Action Data for local action Outcomes, adherence, analysis Compare trends and benchmark Data for regional/state action Data for national metrics from HHS plan

47. HICPACThe Healthcare Infection Control Practices Advisory Committee Guideline production Revised, systematic rapid-cycle evidence analysis Urgent infection prevention recommendations for emerging threats (e.g., SARS) June 2008, HHS Charge to HICPAC in response to findings of the GAO investigation: Prioritization of recommendations from HICPAC guidelines Identification of major infection prevention strategies for Department-wide promotion

48. From Guidelines to Checklist

49. Following CDC Guidelines Reduces Healthcare-associated Infections in States-Examples of Success: Pennsylvania, Michigan

50. Hospitals Participating in NHSN are Preventing MRSA Bloodstream Infections

51. Prevent Infection

52. Prevent Transmission

54. CDC�s MRSA Prevention Initiatives

55. CDC and AHRQ collaborating to prevent MRSA/HAIs AHRQ receiving supplemental funds for MRSA/HAI research CDC and AHRQ are collaborating on MRSA/HAI prevention research in a healthcare system, including acute care hospitals and long-term facilities CDC provides technical expertise into what research questions need answering CDC will put research results into action, and use results to: Update existing recommendations as appropriate Advise prevention implementation campaigns on how best to prevent HAIs

56. CDC Works with Healthcare Facilities and States Technical and direct support (e.g. field investigations and consultation) Data for action (e.g., NHSN, emerging infections program) Training and tools Funding with accountability (e.g., epidemiology and laboratory capacity)

57. CDC Successfully Collaborates with States to Prevent Healthcare-associated Infections Focused on incrementally building infrastructure needed for BSI and other future prevention initiatives (e.g. C. difficile) Communications to share best practices Culture of accountability CEO to support staff levels involved Site visits, monthly reporting Adopted bundles of practices New York: CDC guidelines basis for prevention implementation initiatives Greater New York Hospital Association prevention initiative Collaborative partnership with 46 hospitals

58. Preventing Healthcare-associated Infections� the Time is NOW Problem is critical and costly but preventable Interventions can have an immediate national impact Interventions can be cost savings Ongoing efforts are needed to address changes in healthcare

59. Keys for the Elimination of Healthcare-associated Infections Collect data and disseminate results Communication with consumers Evaluate how we�re doing Full adherence to best practices Recognize excellence Identify and respond to emerging threats Improve science for prevention through research

60. Public Health Continuum

61. Increasing Needs for Public Health Approach Across the Continuum of Care

62. INFECTION PREVENTION IS EVERYONE�S RESPONSIBILITY! http://www.cdc.gov/ncidod/dhqp/

63. Save the DateFifth DecennialInternational Conference onHealthcare AssociatedInfectionsMarch 18-22, 2010Hyatt Regency AtlantaAtlanta, Georgiahttp://www.decennial2010.com

64. CMS Role in HAI Reduction

65. Healthcare Acquired Infections:CMS Driving Improvement Barry M. Straube, M.D. CMS Chief Medical Officer Director, Office of Clinical Standards & Quality Centers for Medicare & Medicaid Services (CMS)

66. Ensuring Quality & Value:CMS Strategies �Traditional Quality Improvement� Transparency: Public Reporting & Data Sharing Incentives: Financial: Value-Based Purchasing Non-financial Regulatory vehicles Demonstrations, pilots, research Leveraging efforts with other HHS components, state/federal agencies & private sector

67. Traditional QI Prioritization of potential topics Evidence-based metrics and interventions Accountability: Administrative & financial Attribution of interventions to outcomes Scientific evaluation of outcomes as well as cost-benefit analysis of each initiative Continue, build, retire or new direction?

68. Traditional QI QIO Program: 9th SOW August 1, 2008 � July 31, 2011 Four themes: Patient Safety Prevention Care Transitions Beneficiary Protection Cross-cutting issues HIT adoption and use Health Disparities Value in Healthcare

69. Traditional QI QIO Program 9th SOW HAIs under patient safety theme Reduction of MRSA infections in 440 hospitals nationwide CDC National Healthcare Safety Network (NHSN) AHRQ TeamSTEPPS methodology Pilot programs: ? 10th SOW inclusion C. difficile infection reduction Urinary tract catheter infection reduction

70. Traditional QI ESRD Network Program QI activities Individual ESRD Networks have included activities to address infections in vascular access as well as other infection control issues, including facility-acquired infections (dialysis facilities and some hospitals) Collaboration with other HHS agencies, other state/federal agencies, private sector organizations

71. Transparency Hospital Compare Website as prototype 27 quality process measures (all patients) 6 quality outcomes measures (Medicare only) HCAHPS survey for experience of care (all) Medicare payment and volume (Medicare only) Several infection-related quality measures Influenza and pneumonia vaccinations Therapeutic and prophylactic antibiotics Pre-op hair removal, blood cultures, etc.

72. Transparency Additional reporting of HAI measures Considering for future Hospital Compare updates Requires NQF endorsement and Hospital Quality Alliance and other stakeholder input Expand to other provider sites, starting with: Ambulatory surgery centers Dialysis facilities Link to transitions of care and episodes of care

73. Transparency The White House, the Secretary and HHS have prioritized the concept of HHS making its data available to all healthcare stakeholders http://www.data.gov development and expansion CMS has now added the concept that as part of its public health agency role, collecting, reporting and making healthcare data available is a core competency/mission

74. Incentives Value-based Purchasing (VBP) Hospital VBP Report to Congress (Nov 2007) Physician VBP RTC due May 2010 ESRD Quality Incentive Program to be implemented by January 1, 2012 All other settings with plans Healthcare Reform debate may define better HAI focus may be included in all

75. Incentives: Hospital Acquired Conditions DRA Section 5001(c) authorized this approach Beginning October 1, 2007, IPPS hospitals were required to submit data on their claims for payment indicating whether diagnoses were present on admission (POA) Beginning October 1, 2008, CMS stopped assigning a case to a higher DRG based on the occurrence of one of the selected conditions, if that condition was acquired during the hospitalization

76. Incentives: HACs By statute CMS had to select conditions that are: High cost, high volume, or both Assigned to a higher paying DRG when present as a secondary diagnosis Reasonably preventable through the application of evidence-based guidelines CMS and CDC convened an internal workgroup to select the HACs

77. Incentives: HACs Almost all HACs might have indirect relationship to potential HAIs HACs clearly linked to HAIs Catheter-associated UTI Vascular catheter associated infection Surgical site infections Mediastinitis after CABG Certain orthopedic surgeries Bariatric surgery for obesity

78. Incentives: HACs HAC payment policies currently relate to outlier payments under Medicare Part A Could consider expansion of payment to more than the outlier portion In some cases can supplement payment policy restrictions with Coverage Policy via National Coverage Decisions (NCDs) Affects not only Part A (hospitals), but Part B (physicians, clinicians, suppliers, etc.)

79. Conditions of Participation COPs are minimum health and safety standards set by CMS for facilities that may receive Medicare payments Current Infection Control COPs generally address reduction of HAIs Expansion possibilities for COPs Require facilities to incorporate specific standards of practice or guidelines set by the Secretary Require that infection control be part of the QAPI program

80. Conditions of Participation Infection control regulations already strengthened Conditions for Coverage for ESRD facilities (April 15, 2008) CfC for Ambulatory Surgery Centers (ASCs) (November 18, 2008) Other current considerations Omnibus COP/CfC Rule for HAIs Individual setting strengthening of current regs

81. Survey & Certification All U.S. healthcare facilities certified by Medicare are expected to be in compliance with all current regulations, as well as applicable state laws S&C process uses interpretive guidelines to assess compliance with regulations Focus on HAIs can be prioritized Surveyor training has included HAI emphasis Web-based training & surveyor tools being developed Interpretive guidelines for 2010 to include QAPI opportunities for hospitals

82. Other Demonstrations, pilots, research ARRA funding and other funding sources should also focus on HAIs as they fall under: Comparative Effectiveness Research Prevention, Wellness, Patient Safety CMS will incorporate HAI topics into its demos, when appropriate Cross Agency HHS collaboration (a priority for all issues from the Secretary), as well as with other federal/state agencies, private sector

83. Contact Information Barry M. Straube, M.D. CMS Chief Medical Officer, & Director, Office of Clinical Standards & Quality Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, MD 21244 Email: Barry.Straube@cms.hhs.gov Phone: (410) 786-6841

84. AHRQ HAI Portfolio

85. Overview Background Current Initiatives Future Directions

86. Background General AHRQ approach Keystone ICU Project � 2003 First major AHRQ HAI project: $454,000 Enormously successful in reducing central line infections in ICUs in Michigan Barriers and Challenges for Preventing HAIs in 34 Hospitals Initiative � 2007 5 ACTION networks: $2 million

87. MRSA � 2008 $5 million in appropriated funds Coordinated with CDC & CMS Funded 7 projects, e.g., Implementation of MRSA-reducing practices Contribution of community & LTC to rising occurrence of MRSA in hospital patients Rapid-cycle state and national estimates Understanding MRSA reservoirs

88. MRSA & CUSP � 2009 $17 million in appropriated funds $8 million for MRSA => 7 MRSA projects $9 million for CUSP => 6 CUSP projects Included projects also directed at: C. difficile KPC-producing organisms Urinary tract infections Surgical site infections Antibiotic usage Hemodialysis

89. AHRQ HAI Investments

90. Current Efforts Roll-out of CLABSI initiative in all 50 states, in cooperation with private sector Commencement of numerous new projects addressing effective implementation of known techniques & research on better methods of prevention of HAIs by organism & by infection site

91. Future Plans Maintain alignment with DHHS Continue rollout of CLABSI nationwide Promote best practices & research findings via proven techniques Align HAI efforts with those of Patient Safety Organizations (PSOs), which are collecting data on adverse events using AHRQ�s �Common Formats�

93. Your questions?