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Where the Rubber Meets the Road

SB 739. Where the Rubber Meets the Road. Jan ’08 version (2) presented: (insert your chapter, current date here) Sue Chen RN, MPH, CIC HAI Program Coordinator California Dept of Public Health Sue.Chen@cdph.ca.gov. Objectives. SB 739 in context History of mandatory reporting

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Where the Rubber Meets the Road

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  1. SB 739 Where the Rubber Meets the Road Jan ’08 version (2) presented: (insert your chapter, current date here) Sue Chen RN, MPH, CIC HAI Program Coordinator California Dept of Public Health Sue.Chen@cdph.ca.gov

  2. Objectives • SB 739 in context • History of mandatory reporting • Making the business case • Review of SB 739 requirements • Your role in implementation of SB 739(devil is in the details) • Introduction to NHSN • Sequence of events/specific activities • Updates from HAI-AC to CDPH • Say “amen” and escape

  3. Number of nosocomial pathogens, according to infection site, identified in the hospital-wide component of the NNISprogram from January 1990 to March 1996 HAIs- The Big Four • Urinary tract infections • (catheter-associated) • Surgical site • Infections • Bloodstream infections • (central line-associated) • Pneumonia • (ventilator-associated)

  4. Healthcare-Associated Infections – Numbers and Costs * From Klevens et al..Public Health Rep. 2007;122:160-6 +12% of U.S.

  5. Cost of HAI vs. Infection ControlDuke Infection Control Outreach Network • 28 community hospitals (30-616 beds) $25,072 for VAP – $23,242 per CLA BSI $10,443 per SSI – $758 per CAUTI • Ave cost of infections $594,683/year • Ave annual budget for IC $129,000 • Decreasing HAIs by 25% would save $148,667 per hospital Anderson et al. Underresourced Hospital Infection Control and Prevention Programs: Penny Wise, Pound Foolish. Infect Control Hosp Epidemiol 2007; 28:767-773

  6. Who Pays? • Patients with HAI are disproportionally Medicare but only 50% Medicare-paid

  7. Glimpse of the Future: From Centers for Medicare & Medicaid Services Effective October 1, 2008, hospitals will no longer receive higher payments for the additional costs of treatment associated with following HAIs* • Catheter-associated urinary tract infections • Vascular catheter-associated infections • Surgical site infection: mediastinitis after coronary artery bypass graft surgery * Unless condition is present upon admission

  8. History of Reporting of HAIs • Florence Nightengale: descriptive epidemiology during Crimean War documented causes of mortality* • National Nosocomial Infections Surveillance (NNIS) • Epidemiology of HAIs, describe antimicrobial resistance, enable inter-hospital comparisons • Study on the Efficacy of Nosocomial Infection Control (SENIC) Study – 1970s *Gill C, Gill G. Nightengale in Scutari: Her Legacy Reexamined. CID 2005:40.

  9. Public Reporting – Background • The quality and safety of healthcare in the U.S. needs to improve • Public reporting is one of a number of quality improvement methodologies adopted • Public reporting of health care performance information is intended to: • Provide information to enable consumers to obtain safer care • Stimulate and provide basis for quality improvement by reporting providers

  10. Public Reporting – Slide 2 • Indicators for public reporting can be: • Outcomes (e.g. mortality, infections) • Processes (e.g. aspirin for MI, antibiotic within 4 hours of admission for community-acquired pneumonia, appropriate antibiotic prophylaxis prior to surgery) • Public reporting for myocardial infarction, coronary bypass graft surgery (CABG), and community-acquired pneumonia has been in place >10 years • Reductions in the rate of death associated with CABG in New York and Pennsylvania have been attributed, in part, to public reporting

  11. Trend over time in bloodstream infections associated w/ catheters in pediatric ICU Nov 1998: use of maximal barrier precautions July 1999: use of antibiotic-impregnated catheters March 2000: annual hand washing campaigns April 2003: move to new unit with private rooms May 2003: introduction of skin disinfection with chlorhexidine U Arkansas Children’s Hospital Bhutta et. al., BMJ 2007;334:362-5

  12. Leapfrog Report – 9/18/07 • 87% hospitals (n=1256) do not take all recommended steps to prevent HAIs • 35.6% do not always follow hand hygiene practices • 30.7% vaccinate staff against flu http://www.leapfroggroup.org/

  13. Consumer’s Union Focus on obtaining data on HAIs so consumer can make an informed choice; also pressures hospitals to improve • legislation for mandatory reporting • active surveillance cultures for MRSA “Rep. Tim Murphy (PA) is sponsoring the "Healthy Hospitals Act of 2007" (HR1174). The bill will make you safer during a hospital stay by requiring public disclosure of hospital-acquired infection rates. If hospitals must tell you about their infections, they will work harder to reduce them.” “Please ask your representative to co-sponsor this bill!”

  14. Experience with Legislated Mandatory Public Reporting • Pennsylvania • Have been reporting data since 2004 • Areas for improvement • Use of administrative data • Law of Unintended Consequences • Pittsburg Regional Healthcare Initiative • Found error-prone systems that did not focus on the patient at the point of care. • “Healthcare must focus on delivering perfect healthcare to every patient.”

  15. Response to Public Reporting: Consumers Don’t Seem to Care….. Source: CHCF sponsored survey of Californians, 2004

  16. Quality of Care - Heart Attack But Hospitals Do… Numberof hospitals

  17. California Ancient History* • Little Hoover Commission report April 10, 2003: recommended increased capacity to fight HAIs • HAI-AWG met from July ‘05-Feb ’07 • Recommendations for Reducing Morbidity and Mortality in California: Final Report to CDPH December 31, 2005 • Result was SB 739 signed into law September 28, 2006 * For those w/ attention deficit or CRS

  18. SB 739 Mandates • Implement an HAI surveillance program • Electronic database: NHSN • By July 1, 2007 • Appoint an HAI Advisory Committee • Hospitals must implement respiratory hygiene/cough etiquette program, employee flu vaccine program, disaster plan w/ pandemic flu component in conjunction w/ local health dept • Educate health facility evaluators in HAI

  19. Mandates cont’d On or after Jan 1, 2008: • Revise infection control-related portions of Title 22 • GAC shall implement and annually report process measures which are to be made public within 6 months • Central line insertion practices • Influenza vaccination of HC personnel and high risk patients • Surgical antimicrobial prophylaxis

  20. Current Tasks and Further Directions – Slide 1 • Facilities must enroll in NHSN; soft deadline Jan 31, 2008 • Be prepared to join CDPH group and give CDPH permission to see appropriate data elements Specific directions will be forthcoming from CDPH with details and start dates for mandated reporting.

  21. Slide 2 • Use CLIP practice module to get process in place for data collection • Be prepared to report vaccination rates for 2007-08 flu season (model is TJC requirements) • Respond to SCIP questionnaire by Jan 15. SCIP data will be required to be reported through CMS/Lumetra

  22. Update on HAI_AC Recommendations • Central Line Insertion Practice (CLIP) • Influenza vaccine for • Employees • High risk patients • Antimicrobial prophylaxis (SCIP) • Legal • Reporting of healthcare-associated MRSA infections

  23. HAI-AC: Central Line Insertion Practices (CLIP) • Option 1: fill out all asterisked data points on CLIP form • In ICUs x 6 months • Option 2: fill out 6 areas AND do outcome module for those units AND • Document daily assessment of line necessity by a clinician.

  24. HAI-AC: Influenza Vaccination for Employees • Publicly report influenza vaccination/ declination rates for employees for ’07-’08 season • Differentiates between employees and healthcare workers • Non-employee HCW should be offered vaccine; a rate for this not mandated at this time • Forms may only be obtained Sept-Mar

  25. HAI-AC: Surgical Care Improvement Project (SCIP) • Will be reported through CMS/Lumetra • Facilities currently reporting data will not have more work • Facilities not currently reporting must work w/ Lumetra to establish reporting pathway or • If facility does not perform surgeries, no reporting will be required. • CDPH will begin downloading CMS data at a to-be-announced date.

  26. National Healthcare Safety Network (NHSN)for State Reporting Heavily* Plagiarized by CDPH from CSTE 2007 Annual Conference presentation June 2007 R. Monina Klevens, DDS, MPH Division for Healthcare Quality Promotion National Center for Infectious Diseases * Heavily is not an infestation

  27. What is NHSN? • National voluntary, confidential system for monitoring events associated with health care • Initial focus on infections in patients and healthcare personnel • Expanding to include noninfectious events (such as process measures) • Accessed through a secure, web-based interface • Open to all US healthcare entities at no charge • Enrollment opened June 4th, 2007

  28. NHSN is a Partnership! NHSN participation was never designed or intended to be the sole responsibility of Infection Control.

  29. Am J Infect Control 2007;35:290-310

  30. Device-associated • Procedure-associated • Medication-associated modules

  31. Percentage of Hospitals in AHA Survey Enrolled* in NHSN *613 facilities Status as of June 18, 2007

  32. Characteristics of NHSN Surveillance Methodology • Active, patient-based, prospective, priority-directed collection of data • Results in risk-adjusted incidence rates; will allow comparison between yourself or group against national average. • Intended to be used as a quality improvement tool to be of mutual benefit to facilities and NHSN; goal to eventually link processes with outcomes

  33. Authority and Confidentiality for NHSN • Public Health Service Act (42 USC 242b, 242k, and 242m(d)) • Confidentiality Protection • Sections 304, 306, and 308(d) of the PHS Act “The information contained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306, and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)).”

  34. Strengths – Built on NNIS Experience • NNIS System is a model for patient safety1,2 • High quality data can be used for performance improvement. Reductions in national infection rates have been achieved. • Scientific credibility: Definitions and methods adopted internationally • Timely: data can be immediately downloaded • Aggregate comparisons by unit or procedure across states ensure greater numbers 1Leape LL. Reporting of adverse events. NEJM 2002;347:1633-8. 2Burke JP. Infection control—a problem for patient safety. NEJM 2003; 348:651-6.

  35. Registration Process:Follow the Balloons and Arrows Accept Rules of Behavior NHSN sends email w/ instructions for digital certificate You read and follow directions – carefully; complete modules NHSN sends further instructions You read and follow directions – carefully; sign away first born Etc. Etc. Etc. (From Facility Administrator Enrollment Guide)

  36. Process for Hospitals to Register • http://www.cdc.gov/ncidod/dhqp/nhsn_members.html • Accept rules of behavior • Part of registration is to complete 8 modules (~2 hrs each) • On R side of page NHSN Resources, click on Training, then “Archived Training”, follow stepwise directions • Name a facility administrator [person with all rights to all data for your facility]

  37. Registration Process Cont’d • Obtain (and don’t lose) digital certificate • If firewalls prevent access, own IT dept must clear site • Fill out online form and survey • Name group/groups • Send to NHSN • CDC will activate facility • Facility must join CDPH group, give rights to see mandated data

  38. Summary of NHSN Rules • Every month, the facility must submit a surveillance plan • Facility must report data to NHSN 6 of every 12 calendar months within 30 days of end of reporting period • Failure to adhere to reporting can result in loss of member status • Loss of member status puts facility at odds w/ mandates of SB 739 • All data fields marked w/ an asterisk must be filled out for record to be counted if in plan

  39. I certify that I completed the required training to participate in the National Healthcare Safety Network Registration Nirvana? Name of participant Name of facility Dates of training:

  40. How CDPH Accesses Data in NHSN • Groups: e.g., healthcare corporations, State Health Departments • A facility “nominates” CDPH • Facilities join the group and confer some/all rights to data • Facilities within the group cannot see each other’s data • Group sees data from all facilities as granted • After joining, a facility can use any NHSN module (ex: outcome measure) they choose; data not visible to CDPH except w/ permission

  41. Limitations • Primary experience with voluntary, confidential reporting • Validation methods in development • Labor intensive • And deadlines for data reporting • No special protocols for small hospitals • Not tied to utilization or billing data directly (DRGs, ICD9/10, etc.) • Must follow NHSN rules

  42. Support for States & Users • Collaboration with APIC/CACC, CSTE, SHEA, IDSA • NHSN State Users Group • Conference calls monthly/Webboard to share materials, including users newsletter • Training for all members • Webinars • Interactive distance learning • nhsn.cdc.gov

  43. What and When States Using NHSN are Reporting PA CA VA WA NY VT SC CO TN OK* DE Jan 2007 2008 * Undefined measures

  44. Anticipated Additions • Process modules for CLIP and immunizations (for both employees and patients) to be released – Feb ‘08 • Introduction of 23 modules of interactive computer training (20-30 min ea) – Jan ‘08 • In addition to original modules • Number required will depend on ‘rights’ conferred • Goal to set up CEUS for module completion • Will contain post-test to document knowledge; minimal score of 80% to pass

  45. What CDPH would like to see • Formulation of a model for reporting of “never events” for nationwide use • Downloading capacity from 3rd party vendors directly into NHSN • Discussion between CMS, CDPH, and NHSN for direct download of SCIP data already reported to CMS Disclaimer: While willing, CDC lacks personnel and monetary resources to develop these capacities at this time.

  46. Challenges • What are the evidence-based reporting best practices? • Balance use of existing data with accuracy and ownership • How to gain necessary resources for implementation of reporting? • State and hospital levels • More efficient methods • How will reporting impact quality of care? • Integrity of processes will drive decrease in infection rates • Provider and consumer behavior

  47. Questions? Answers Cheap

  48. Acknowledgements • Jon Rosenberg • Centers for Disease Prevention and Control • New York State • Audiences for refining the program

  49. Infectious Diseases Experts Applaud Bill Against "Bad Bugs" With extensively drug-resistant tuberculosis, life-threatening drug-resistant respiratory and skin infections, and other “bad bugs” routinely making headlines, infectious diseases physicians are applauding Rep. Jim Matheson (D-UT) and Rep. Michael Ferguson (R-NJ) for introducing H.R. 3697, Strategies To Address Antimicrobial Resistance (STAAR) Act  

  50. S.2278 Durbin Bill/H.R. 4214CHAI* Reduction Act of 2007 • Establish best practices guidelines for IC plans to treat and control CHAI in GAC • Hospitals to begin reporting through NHSN within 90 days • CDC to be given authority to make rules • Institute pay for performance • Public awareness and education • Ongoing interagency workgroup *Community-Associated and Healthcare-Associated Infections

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