CMS draws generally favorable reviews as it hones infection control survey
IPs have 'more leverage, more pressure'
By Gary Evans, Executive Editor
The Centers for Medicare & Medicaid Services (CMS) continues to develop an infection control survey slated for use in the nation's hospitals later this year, using expert feedback and "pre-testing" results from the field to create a 42-page tool that assesses a wide breadth of program issues.
Now in a "pilot-testing" phase, the survey has the potential to be the most significant and far-reaching of a series of infection control initiatives undertaken by the CMS in the last few years as health care associated infections (HAIs) became a national issue. Created in partnership with the Centers for Disease Control and Prevention, the CMS survey has generally received favorable reviews for its design and attention to detail by infection preventionists contacted by Hospital Infection Control & Prevention. Indeed, some see it as a potential game-changer for infection prevention, particularly if CMS strengthens its ties to conditions of participation and ultimately links survey results directly to reimbursements. That would get the attention of senior hospital administrators and possibly empower infection prevention programs.
"It brings the force — the 'seriousness' — of CMS behind it," says Ruth Carrico, PhD, RN, CIC, an associate professor at the School of Public Health and Information Sciences at the University of Louisville, KY. "Some people may say well it's only an infection prevention risk assessment. But we're saying, `Seriously, this is important. It comes from CMS.' I think it will garner a lot of attention, and really I'm thrilled."
The CMS has created a survey tool for a broad assessment of infection prevention, using a "patient tracer" approach in some areas to focus on key issues and connections through the care process. The survey includes such areas as infection control program and resources, quality improvement programs, multidrug resistant organisms, antibiotic stewardship, employee health, hand hygiene, needle use, environmental services, cleaning and reprocessing equipment, and infection prevention in the surgical suite. Concerning the latter, two surgeons expressed doubt that a regulatory inspection approach will do much to address the complex issues that give rise to surgical site infections. (See box, below.)
Some have also questioned the inclusion of areas like antibiotic stewardship, which cannot be cited under current CMS regulations. For the most part, however, the pilot survey instructs inspectors to cite various sections of the CMS conditions for participation in infection control if deficiencies are discovered.
What hospital areas are CMS surveyors targeting? About all of them it appears A draft Centers for Medicare and Medicaid Services infection control survey slated for use in unannounced inspections of hospitals later this year includes the following major sections:
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"We are still trying to emphasize the basics. We are having surveyors spend more time at the bedside," says Daniel Schwartz, MD, MBA, chief medical officer of the CMS Survey and Certification Group in Baltimore, MD. "But there are some things that we want to emphasize that we know are not in the regulations – that we are not able to cite."
Indeed, as we recently reported, some infectious disease groups have even asked the CMS to begin regulating antibiotic stewardship to help reduce multidrug resistant organisms. While clarifying that the survey is not a "pay for performance" initiative — a move many see as inevitable — Schwartz also stressed that it is designed to be more than an educational tool.
"This is what the surveyors will eventually use as part of their survey process," he tells HIC. "As we are developing this tool we are also very cognizant that hospitals will want to take a look at this. We think it will be a good self-assessment for hospitals, and to that extent it is very educational. But after we finish the pilot phase and we put this out in its final form then we are going to be expecting CMS surveyors to use this tool to assess infection control compliance."
The latest version provided to HIC by CMS did not include the open-ended questions to IPs included in an earlier draft. That "instructions" portion was used in recent training of CMS inspectors, but was not included in the pilot survey going forward.
"We restructured it and put it together in a way that is perhaps easier for surveyors to use," Schwartz says.
The tool may continue to be refined as warranted based on the pilot testing, with the final product targeted to debut in all 50 states in October 2012. The CMS has developed similar surveys on discharge planning and quality assessment/performance improvement (QAPI). States are being asked to pilot at least one of the surveys in some of their hospitals in the coming months, he says. The CMS is expected to post all of the surveys on their websites in the near future, he adds.
Tie to CMS funding coming?
The CMS is expected to eventually tie the survey process more directly to reimbursement and financial incentives, experts tell HIC.
"I think it is going to have to be," says Carrico. An IP for some 20 years before a move into academia, she recently won the prestigious Carole DeMille Achievement Award from the Association for Professionals in Infection Control and Epidemiology. Increasing CMS regulation is likely because HAIs have such a devastating impact on individual patients and the health care system as a whole, she says. Moreover, as the scope of the CMS document makes it abundantly clear, it takes an organization-wide effort to prevent HAIs.
"For example, I don't think you can really have a good medication administration program without having a good infection prevention and control program," she says. "Issues like safe injection practices, medication preparation are tied together. It really shows that infection control is a program — not just an initiative or a department. It has to really be embraced organization wide."
In that sense, the CMS survey reflects and quantifies to some extent the increasingly broad job description of the IP.
"You can't possibly 'own' infection prevention and perform all of these activities," she says. "Our job is to find the best people, the right people to do all of these different components. It really helps take our job to a very different level, a place where we know our [career future] lies."
That said, having detailed requirements for antibiotic stewardship — citable or not — in an infection control document, is a little disconcerting to some. The perception is that medicine and pharmacy would have to be directly involved in this aspect of a CMS inspection, but it's an unsettling section of an otherwise strong CMS effort, says Patti Grant, RN, BSN, MS, CIC an infection preventionist in Addison, TX.
"Where it is assigned is where the responsibility lies," Grant says. "I'm just saying that before this is finalized this section should really be strongly considered for movement to another area — to a discipline that actually has control over antibiotic use through prescriptions."
While noting that the list of requirements may be "a little overwhelming" for IPs, Connie Steed RN, BSN, CIC, stresses the importance of taking a collaborative approach from the onset.
"The IP should not be doing this alone," says Steed, manager of infection control at the Greenville (SC) Hospital System. "It should be collaborative in nature. It is not just IPs that are responsible for these programs. It's a pretty extensive survey, as I look at, but a good program has all of this. It shouldn't be that they have to go out and create a bunch of new stuff. If they do — then they need to. Because everything that CMS has here are key components of a program."
Having alerted administration about the CMS initiative, Steed is preparing to break down the requirements and begin meeting with key staff as the CMS moves toward a final version of the survey.
Use survey tool for risk assessment
As a starting point, the CMS survey can be used as part of annual risks assessments already done as a Joint Commission requirement, several IPs noted.
"The key is to look at this with the same type of multidisciplinary approach that you use when you perform a risk assessment," Carrico says. "Who are the right people who need to be involved in all of these different areas? You've got to get together on the same page. We are not talking about having the `illusion' of compliance. We need to have hard compliance with these requirements."
A member of the CDC's Healthcare Infection Control Practices Advisory Committee (HICPAC), Carrico says the panel has been briefed and is advising on the project but the CMS has clear ownership.
"This is a CMS document," she says. "I hope that one of the results is that it really gets the attention of those who are responsible for resource allocation."
That has not always been the case with other CMS programs targeted at infection control. A recent analysis of CMS policies linked to reimbursement cuts for certain HAIs in 2008 found that only 15% of IPs reported increased funding for infection control as a result of the CMS policy.1 A few IPs actually had budgets cut, though the majority (77%) reported stable funding levels. Respondents reported faster removal of urinary (71%) and central venous (50%) catheters as a result of the CMS policy, but the study also found some questionable testing policies on admission and "resource shifting" away from HAIs not targeted by the CMS policies.
"The positive impact has been on hospital leadership and awareness of the importance of infection prevention, which I think really helped a lot of the IPs in terms of how the `C-suite' feels about the importance of their mission," says Grace Lee, MD, MPH, lead author of the study and associate medical director of infection control at Children's Hospital in Boston. "That was extremely helpful. It also really enhanced efforts in surveillance education and prevention on the HAIs targeted by CMS policies. They did report improvements as a consequence of a policy such as removing urinary catheters as soon as possible in order to minimize the risk for CAUTIs."
Though it's something of a work in progress, the CMS is aligning its regulations with quality improvement strategies and infection prevention recommendations like those issued by the CDC.
"I think that is the goal. CMS wants to align quality with financial reimbursement," Lee says. "They are making steps in that direction, but I don't know when that will officially be triggered."
Other observers concur. "That is the way I read the writing on the wall," says William Schaffner, MD, chairman of the department of preventive medicine at Vanderbilt University School of Medicine in Nashville. "This [CMS survey] is impressive for both its breadth and depth — the precision with which it raises and addresses the details of infection control. I think it can only enhance the role of infection control in an institution, but that will take various forms. They will have more leverage, but it will put more pressure on infection control. And as we know, it doesn't necessarily mean that infection control will get more resources."
Whither the Joint Commission?
There has been some question about whether the Joint Commission, which accredits organizations under its "deemed status" from the CMS, will adopt all or part of the survey tool for its own inspections.
"This is much more detailed than any Joint Commission survey or any state survey that we have undergone at Vanderbilt," Schaffner says. "This will be a more trenchant review, and I would imagine that if Joint Commission and individual states take this on there is going to be an awful lot of training of surveyors. It will take more time for the Joint Commission surveyors to do the infection control part than in the past."
In response to a request for comment from HIC, the Joint Commission released the following statement via email: "The Joint Commission is aware of this important infection control activity by the CMS and has been working with them to refine the infection prevention tool as well as the other surveyor tools that they are developing. While CMS is still in the process of developing these new tools, The Joint Commission believes that its current requirements align closely with each of the tools and their specific areas of focus."
The CMS was under considerable pressure to act on HAI prevention after several key developments in recent years. For example, all of the agencies in the Department of Health and Human Services (HHS) were called on the carpet after a scathing 2008 federal report cited a lack of HHS leadership and coordination to reduce "needless suffering and death" caused by HAIs.2
That same year a hepatitis C virus outbreak at a Las Vegas endoscopy clinic resulted in a massive follow-up and testing effort for tens of thousands of patients. As we reported at the time, CMS inspectors had actually been to the clinic in question, but apparently were not adequately trained in assessing needle safety practices. As a result, the CDC worked with the CMS to develop an infection control survey tool for ambulatory care, forming a partnership that eventually led to the development of the current hospital survey. The collaboration with CDC is likely to continue in other areas, as the CMS puts its regulatory power behind the CDC's voluntary guidelines.
"The tools would have to be tweaked for the various services that are provided and the specific locations, but I think that is certainly a major possibility," says Carolyn Gould, MD, a medical epidemiologist in the CDC Division of Healthcare Quality Promotion. Gould has been a key liaison with the CMS in creating the infection control survey.
The tool is still subject to revision, she says, noting that she has heard some of the quibbles and questions about both what is in the survey — and what is not. For example, though generally praising the scope of the effort, Schaffner questioned why there is no mention of the Tdap, MMR and varicella vaccines in the employee health section. Though the survey is presumably not designed to be all inclusive, "if you don't put it on the exam, students won't study for it," he observed.
It may come down to a question of regulatory authority, but Gould says "we may add additional elements to reflect more vaccinations. Whether those are going to be citable or not is up to CMS. But I think as HICPAC continues to review this and we get feedback from the states we are probably going to be adjusting it and that may be one of the things we add."
References
- Lee GM, Hartmann CW, Graham D, et al. Perceived impact of the Medicare policy to adjust payment for health care-associated infections. Am Jrl Infect Cont 2012; 40:314-319.
- Government Accountability Office: Health-Care-Associated infections in Hospitals: Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on these Infections. 2008; GAO-08-673T. Available at http://ow.ly/72O4u
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