CMS tests hospital infection survey
Expansion nationwide in October
It's 44 pages of questions about infection control procedures — from injections and hand hygiene to sharps safety and personal protective equipment — and it's coming to your hospital soon. The Centers for Medicare & Medicaid Service's "Acute Care Hospital Infection Control Tool for Surveyors" is being piloted in 10 states, Washington, DC, and Puerto Rico before being finalized this summer and released broadly in October. It is one of three new tools that hospitals can expect to be used. The other two relate to quality assurance and performance improvement, and discharge planning, says Daniel Schwartz, MD, chief medical officer of the survey and certification group at CMS.
The tool had its start about a year ago as a method to help hospitals assess not just their infection control procedures, but to figure out how adept they are at preventing infection in the first place. "This will help them observe the patients and procedures that have the highest risk of infection," says Schwartz.
He says that he and his team worked with the Centers for Disease Control and Prevention (CDC) to develop the tool. "They told us what they thought the most important infection control observations and questions were and from there we came up with a strategy." The goal was to ensure that surveyors were looking at issues like catheter and central-line insertions and spinal injections rather than spending a lot of time looking at pieces of paper explaining policies. Indeed, the overriding principle was for surveyors to spend "as little time as possible" looking at documents.
The questions the team developed are pretty high level, Schwartz says, and require the infection control officer to be able to describe his or her control program, and how problems are handled and integrated into hospital quality improvement and patient safety programs. "The other thing we did is that while we can't enforce some of the CDC guidelines, we include questions about them because they are important." So if the answers to some of the questions aren't optimal, that doesn't mean the facility is in trouble, but rather it shows them there is an opportunity to improve. "We don't have the authority to make hospitals comply with issues like oral hygiene or bed elevation, and we can't cite them for it," Schwartz says. "But some of these things are so important that we feel the questions should be in the tool anyway."
Each of the 12 pilot states and territories were required to use the tool in at least one hospital. The test facilities were chosen by doing a risk-adjusted 30-day readmission survey, with the hospitals in the bottom two quintiles targeted. Because the American Hospital Association was kept in the loop from the tool's inception, Schwartz says hospitals were not upset by it in the least. Indeed, everywhere the draft was sent it was copied, shared and pored over, he says.
The second iteration of the tool was completed in February, and training will begin on it in March. The pilot states will use it at least once and then provide further feedback before the final version is completed. The completed tool should be part of the survey process by October, he adds.
Schwartz is excited not just for the potential uses of the tool by surveyors, but because it could easily be used as a self-assessment for hospitals. "We know that infection control is a priority and is getting a lot of attention, and this is something that they can use," he says. "That was in the back of our mind as we developed it. That's why we put some of those questions in for things that we couldn't cite."
Clinical matters, antibiotic stewardship, and quality improvement all demand questions and consideration beyond what is citable, Schwartz says. "It's not just about following good infection control protocols, but about having internal systems that can help identify problems, analyze events, and help you put in place an action plan to improve performance. We think this tool can help achieve that."
For more information on this topic, contact Daniel Schwartz, MD, Chief Medical Officer, Survey and Certification Group, Centers for Medicare and Medicaid Services, Baltimore, MD. Telephone: (410) 786-1104.
It's 44 pages of questions about infection control procedures from injections and hand hygiene to sharps safety and personal protective equipment and it's coming to your hospital soon.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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