HIC Exclusive: A Q&A with the CMS
'HAIs will continue to be a top agenda'
In response to repeated requests for interviews and information, the Centers for Medicare Services (CMS) agreed to take written questions by Hospital Infection Control & Prevention and circulate them within the agency for answers. Here are the questions by Gary Evans, Senior Managing Editor, and the written responses we received from CMS:
HIC: The perception in the hospital infection control community is that CMS has really stepped up its emphasis on prevention of health care associated infections (HAIs) in recent years. We have so-called pay for performance or value based purchasing increasingly driving infection prevention efforts in hospitals, long term care and ambulatory care. Is it fair to say that HAIs have taken on a greater importance at CMS and can you report any results from the efforts you have undertaken?
CMS: HAI reduction and prevention is a key CMS priority as evidenced by the lead roles CMS has undertaken in quality improvement strategies, payment incentive and HAI prevention collaborative programs. Reporting HAI infection rates increases transparency and helps to drive improvement in this area through feedback and awareness of hospital performance.
The Hospital Inpatient Quality Reporting Program, previously known as Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) program is one such initiative designed to enhance the delivery of healthcare quality data including hospital HAI rates to our Nation's consumers. This program identifies quality care measures for Medicare participating hospitals which are established through a yearly rulemaking process. Hospitals that successfully report these measures are eligible for the 2% market payment update reimbursed by Medicare annually. Several of these quality measures relate to HAI prevention efforts including the Surgical Care Improvement Project (SCIP). This set of processes when embedded in operative protocol, are designed to reduce surgical morbidity and mortality from complications such as perioperative surgical infection.
In addition, the final rule for the FY2011 inpatient prospective payment system was released in July of 2010 and adds the requirement for Medicare participating hospitals to report their data on central-line associated bloodstream infections (CLABSIs) and surgical-site infections (SSIs) as part of the Hospital Inpatient Quality Reporting Program. Our most recent report shows that in FY 2010, 97% of Medicare IPPS hospitals successfully reported data making them eligible for the annual payment update. Historically, between 94% and 99% [of institutions] have successfully reported data since the program's inception in FY 2005.
HIC: Can cutting back reimbursements translate to higher quality in terms of reduced infections?
CMS: In addition to payment incentive programs, CMS has led multiple quality improvement initiatives geared toward HAI reduction and prevention. Quality Improvement Organizations (QIO) are entities contracted by CMS to identify, develop and actively engage healthcare facilities and providers in strategies that improve healthcare quality and its delivery. These QIOs contract with Medicare in 3-year cycles.
Currently underway in the 9th SOW [Statement of Work] which began in August 2008, are two national projects; the first involving improving compliance with the SCIP measure(s) in surgical patients and the second involving reducing methicillin-resistant Staphylococcus aureus (MRSA) transmission rates in Medicare beneficiaries. The MRSA project involves a CMS collaborative with the CDC in which hospitals recruited to work with QIOs report their data into the National Healthcare Safety Network (NHSN), the infection surveillance database operated by the CDC. That interagency partnership continues with two additional subnational projects currently in place, working to reduce the transmission rates of catheter-associated urinary tract infections (CAUTI) and Clostridium difficile infections (CDI) in Medicare beneficiaries.
CMS plays a lead role in the Health and Human Services (HHS) Action Plan for the Reduction and Prevention of HAIs. Programs which expand the reach of HAI prevention efforts to outpatient settings such as Ambulatory Surgical Care centers and End-Stage Renal Disease or dialysis facilities are projected in line with this widespread departmental initiative. Therefore, we are already seeing an increase in HAI prevention efforts and fully expect to see a continuation of this trend.
HIC: From a CMS perspective, what is driving your interest in HAIs and is it likely to increase?
CMS: The incentive or main driver for this Agency as well as for this Department to reduce HAIs is the recognition that it is the right of all patients to receive the best quality healthcare that we can deliver in the safest way and environment as possible. This forms the foundation for not only our work to reduce HAIs, but is the basic premise behind all QI efforts as we work to embed a culture of quality and safety throughout our healthcare system. As such, initiatives that reduce and prevent adverse events like HAIs will continue to be a top agenda [priority] for CMS and for the HHS as a whole.
HIC: Speakers at infection meetings are citing CMS language that specifically holds health care leadership accountable for ensuring adequate support for infection control programs. How are you getting this HAI prevention message to health care administration and what kind of reactions are you getting?
CMS: In November 2007, revisions were made to the Interpretive Guidance regulating 42 CFR 482.42 Hospital Condition of Participation (CoP): Infection Control. The changes to this CoP reflect emerging advancements in infection control knowledge and processes. This guidance further defines and expands the role of hospital leadership, including the CEO, Medical Staff and Director of Nursing, in the process of integrating an infection control quality assessment and performance improvement program hospital-wide as well as making leadership accountable for applying corrective action to identified deficiencies and/or lapses in infection control.
Leadership is essential as they often determine fiscal and staffing resources as well as set the priority for this work within their organization. These principles are echoed, not only throughout the accreditation or CMS survey process for hospitals but also throughout Agency-sponsored QI operations. The QIOs are especially responsive to the need for leadership engagement in QI strategy. One of the main principles of the QIOs when working with a hospital or healthcare system on HAI QI and other such initiatives is to ensure complete engagement of that system's CEO, Board of Directors and/or Medical Staff in every stage of that improvement effort.
CMS sponsors multiple meetings throughout each year with representatives from all 53 QIOs who work so diligently on engaging system leadership. While barriers to this engagement are present especially in more closed organizational cultures, CMS has received multiple positive responses from leadership through the QIOs. This occurs especially when they are able to examine their quality measure data and put it in context with not only how their healthcare system is performing, but how they are performing as compared with their colleagues and other organizations at the local, state and national level.
The desire to bring their healthcare system up to certain quality benchmarks serves as a great motivator and one of the more successful strategies in gaining not only leadership buy-in, but also in achieving system-wide spread and sustainability,
HIC: Is the CMS specifically advising its inspectors to look for infection control issues?
CMS: We introduced a surveyor tool for assessing infection control practices in Medicare-certified ambulatory surgical centers (ASCs) in May 2009, which all states began using routinely for ASC surveys in October 2009. Although we do not currently have a comparable tool for use in hospital inspections, in many states the same surveyors may conduct both hospital and ASC inspections and may also be utilizing the same approach to assessing infection control practices in hospitals as well.
HIC: What are the basic conditions that could prompt a CMS visit and what power of enforcement do you have?
CMS: State survey agencies working on behalf of CMS periodically reinspect all certified providers and suppliers to assess their compliance with the applicable Medicare health and safety standards. The frequency of these inspections depends on the type of health care facility and the availability of federal funding for these State survey activities.
More focused surveys are also conducted in response to complaints alleging serious violations of Medicare requirements. In addition, certain types of providers/suppliers, including hospitals, have the option of demonstrating their compliance with Medicare health and safety standards through accreditation by a CMS-approved accreditation program rather than through inspection by State surveyors on behalf of CMS. These accreditation programs must demonstrate to CMS that their standards meet or exceed the Medicare standards, and that they have comparable inspection processes. They are also expected to conduct reinspections of their accredited facilities at least every 3 years. Approximately 80% of hospitals participate via accreditation.
However, States conduct surveys of these accredited facilities when directed to do so by CMS. CMS authorizes such surveys either in response to complaints alleging serious violations, or to conduct full surveys (i.e., the inspection assesses compliance with all of the applicable standards) of a representative sample of accredited facilities, in order to evaluate the accreditation organizations' survey processes. If such a complaint survey reveals serious deficiencies, the facility is temporarily placed under the jurisdiction of the State survey agency, which conducts a follow-up full survey. CMS' enforcement authorities vary by type of provider and supplier, but in the case of hospitals, if a State inspection finds a serious violation of the Medicare health and safety standards (on a full survey for accredited facilities, or on a complaint or full survey for non-accredited facilities) the hospital is given a limited period of time to come into compliance or face termination of its Medicare provider agreement.
HIC: Do you have enough inspectors to really enforce your infection prevention requirements?
CMS: In the area of ASC inspections we have increased the resources available to States to support more frequent surveys of this type of facility. As previously indicated, since a large majority of hospitals participate in Medicare via accreditation, they are not inspected by the States on a routine schedule. States do conduct over 5,000 hospital complaint investigations per year, but the nature of the complaint determines whether the requirements related to infection control will be assessed.
Editor's note: The CMS audit tool for ambulatory care is available at: http://totalsol.vo.llnwd.net/o29/data/1080/infection_control_surveyor_worksheet.pdf.
In response to repeated requests for interviews and information, the Centers for Medicare Services (CMS) agreed to take written questions by Hospital Infection Control & Prevention and circulate them within the agency for answers.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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