By Gary Evans, Senior Staff Writer
Once strongly criticized for failing to collaborate to prevent hospital infections, federal agencies are now working together to make a difference measured in patient lives and healthcare dollars.
Three agencies within the Department of Health and Human Services (HHS) recently reported that their collaborative efforts to reduce healthcare associated infections (HAIs) and other patient harms saved 87,000 lives and $20 billion from 2010 to 2014.
HAIs and other hospital-acquired conditions fell 17% during the period and 2.1 million patient harm events were prevented. The three HHS agencies primarily responsible for the dramatic improvements are the CDC, CMS, and the Agency for Healthcare Research and Quality (AHRQ).
In a general sense, AHRQ is funding research and creating tools for patient safety interventions, the CDC researches and translates best practices into clinical guidelines, and CMS uses its pay-for-performance regulatory power to provide financial incentives and penalties. Recently, principals from each of the three agencies outlined their progress and future challenges at a panel discussion held by the National Patient Safety Foundation.
“The collaboration across federal government is better than I [have] ever seen, honestly,” says Patrick Conway, MD, chief medical officer at CMS. “CMS traditionally may have not been seen as a collaborative entity and certainly we have a regulatory and payment role, but I think we are trying to have a culture of collaboration with others, with providers and patients in the healthcare system to drive improvement.”
Pay for performance
CMS has some 85% of payments now linked to quality or value, and almost a third of providers are in “alternative payment models” that reimburse via quality measures, he says.
“The vast majority of payments are in quality or value-based payments and we think that is driving the improvements that we all want,” Conway says. “In 2011 we had zero percent of Medicare in alternative payment models, where the provider is accountable for quality of care. Now we have 30%. It’s not just the frontline clinicians, but also the chief financial officers and others who are really understanding deeply that they need to make investments to generate these patient safety improvements — most importantly for patients, but also to benefit their bottom line.”
The aforementioned $20 billion estimated savings are disbursed over the healthcare system, reflecting cost avoided for adverse events for patients, payers, and providers.
“In the past, providers would just get paid for that extra care regardless of the reason, and since that’s changing the total costs of care becomes quite a bit more important,” says Jeff Brady, MD, MPH, director of the Center for Quality Improvement at AHRQ. “This is significant because efforts to improve patient safety are not only the right thing to do, they also have a compelling business case behind them.”
Though AHRQ is reporting success in the clinical translation of some of its interventions and toolkits (see related story later in this issue), all of the agencies agree that there is much more work to be done.
“We estimate that as many as 120 patient harms for every 1,000 hospital discharges still occur,” Brady says. “So while the country has made a meaningful dent in this problem overall, it is still a really big problem and more needs to be done.”
Turning point
And from a historical perspective, it must be noted that the origins of this HHS collaboration do not go back to a moment of calm consensus. The event that brought them together — the turning point in the infection prevention aspects and perhaps the patient safety movement as a whole — was a 2008 Government Accountability Office (GAO) report1 that called out HHS for a lack of leadership. Citing the ongoing epidemic of HAIs and the lack of coordination, data sharing, and collaboration, the report concluded that the various federal agencies were locked in their respective silos due to a failure of leadership at HHS. “Without such leadership, the department is unlikely to be able to effectively leverage its various methods to have a significant effect on the suffering and death caused by HAIs,” the GAO concluded.
The scathing reported set off a flurry of initiatives, including the HHS national action plan to prevent HAIs. With clear-cut goals and metrics, HHS became more transparent in its actions. CMS moved more strongly into pay-for-performance strategies that often codify CDC guidelines and decline payment for preventable patient harms. The ongoing CMS Partnership for Patients (PfP) was established in 2011, bringing leaders of hospitals, clinicians, patient advocates, and government agencies together in an effort to make healthcare safer and less costly. CMS is now working with some 3,700 hospitals representing 80% of patient admissions across the country in the PfP program. The Hospital Engagement Networks in this system are focusing on core areas of harm including catheter-associated urinary tract infections (CAUTIs) and central line-associated bloodstream infections (CLABSIs) beyond the intensive care unit. Other areas of interest and growing emphasis are Clostridium difficile reduction; antibiotic stewardship; creating a hospital culture of safety including healthcare workers; and getting patients and families engaged in their care.
“We are committed to collaboration in this work for the long term,” Conway said. “We need to invest in the quality and safety infrastructure to [continue to] improve and have transparency — certainly through [CMS] Hospital Compare, but also through other mechanisms as well.”
Likewise, the CDC is emphasizing more patient and family involvement to reduce errors and practices that may cause HAIs, says Arjun Srinivasan, MD, associate director for HAI prevention in the CDC’s Division of Healthcare Quality Promotion.
“I think we need to do a lot more to engage patients and their family members to prevent harm,” he says. “This is something that has really been transformational at CDC. We have been working a lot with a number of different patient advocacy groups and consumer groups. We are getting their input regularly on what we can do to provide patients with the information that they need in order to become much more active partners in prevention. We think this is critical.”
Patients should stay informed about their care and be aware of basic protective practices like hand hygiene when hospitalized or visiting.
“I think the most important thing that patients can do is to speak up when you see something that doesn’t seem quite right, whether it is the care that you’re being provided or you are seeing for a family member,” Srinivasan says. “It all comes down to being informed and having the courage to speak up when see something that doesn’t strike you as being quite right.”
A larger portion of HAIs were once viewed as an evitable consequence of providing care to very sick patients, but they are now viewed in a larger context as a system failure.
“We don’t view these as someone’s fault,” he said. “We are not looking to blame someone for an HAI. Nor do we view them as the inevitable price of medical care. What we believe is that HAIs represent failures of a system. By making strategic improvements to these systems we believe we can prevent these infections and the data supports that assertion.”
Indeed, healthcare delivery was not specifically designed for safety as it evolved into the complex system we see currently, Brady notes. Complexity of care, flawed systems, and poor communication are still daily challenges to patient safety. Citing a common error that could set off a cascade of subsequent problems, 5% of patients are misdiagnosed annually, he adds.
Most HAIs preventable
Despite these barriers, the CDC mindset is that only a small percentage of HAIs are unpreventable based on current medical knowledge, Srinivasan says.
“Those need to be the focus of our research strategies,” he says. “We know that HAIs are all too common, they are costly, and they are deadly. Most of all, they are preventable. We know that many of these HAIs are preventable and the fraction that is preventable is far more than we thought in the past.”
Currently, some 1 million HAIs occur annually, setting off additional costs that total a staggering $30 billion. The CDC estimates that one of every 25 admitted patients will acquire an infection due to their medical care. That is certainly a problem, but still progress compared to the previous commonly used ratio: a HAI for every 20 patients.
Though healthcare-associated infections are being reduced nationally — most notably a 50% decrease in CLABSIs between 2008 and 2014 — one in seven catheter- and procedure-related infections are still caused by antibiotic-resistant pathogens, the CDC reports.2,3 In addition, there was a 17% decrease in surgical site infections (SSIs) between 2008 and 2014 for 10 key procedures. However, one in seven remaining SSIs are caused by antibiotic-resistant bacteria, and CAUTIs and Clostridium difficile are still proving very difficult to reduce. (See related story in this issue.)
“We are seeing some success in preventing HAIs,” Srinivasan says. “But it’s important to emphasize that the progress that we are seeing is not uniform. In some areas we are making substantial progress and in other areas we are not making any progress at all. Importantly — in addition to being not uniform — the progress is not nearly as significant as we would like it to be. We want to see many more of these infections prevented.”
REFERENCES
- Government Accountability Office. Health-Care-Associated Infections in Hospitals: Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on These Infections. GAO-08-283: Apr 16, 2008.
- CDC. Making Health Care Safer: Protect patients from antibiotic resistance. March 3, 2016. Available at: 1.usa.gov/1TT1N7B.
- CDC. Healthcare-associated Infections (HAI) Progress Report. March 2016: http://1.usa.gov/21bDcdo.
CDC reports HAI progress, pitfalls
Healthcare-associated infections are proving to be a stubborn and resilient adversary, but many are being driven down through the national efforts of infection preventionists and the CDC.
The CDC’s latest HAI Progress Report1 cites significant reductions reported at the national level in 2014 for nearly all infections when compared to the baseline data. Central line-associated bloodstream infections (CLABSIs) and abdominal hysterectomy surgical site infections (SSIs) showed the greatest reductions. Some progress was also shown in reducing hospital-onset MRSA bacteremia and hospital-onset Clostridium difficile infections. The previous two reports showed an increase in catheter-associated urinary tract infections (CAUTIs) from the prior year, signaling a strong need for additional prevention efforts that did result in a decrease from 2013 to 2014.
Among national acute care hospitals, the report found:
- A 50% decrease in CLABSI between 2008 and 2014.
- No change in overall CAUTI between 2009 and 2014. However, there was progress in non-ICU settings between 2009 and 2014, progress in all settings between 2013 and 2014, and even more progress in all settings toward the end of 2014.
- A 17% decrease in SSIs related to the 10 select procedures tracked in previous reports. This included a 17% decrease in abdominal hysterectomy SSI between 2008 and 2014 and a 2% decrease in colon surgery SSI for the same period.
- An 8% decrease in C. difficile infections between 2011 and 2014.
- A 13% decrease in MRSA bacteremia between 2011 and 2014.
- The report includes a national snapshot of HAIs in long-term acute care hospitals (LTACHs) and inpatient rehabilitation facilities (IRFs).
- LTACHs: 9% decrease in CLABSIs and an 11% decrease in CAUTI between 2013 and 2014.
- IRFs: 14% decrease in CAUTIs between 2013 and 2014.
REFERENCE
- CDC. Healthcare-associated Infections (HAI) Progress Report. March 2016: http://1.usa.gov/21bDcdo
Once criticized for not collaborating to prevent hospital infections, federal agencies now work together to make a difference measured in patient lives and healthcare dollars.
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