Meeting the Challenge of Mandatory HAI Reporting Marcy Maxwell RN, BSN, CICDignity Health

March 6, 2012

Objectives

•Provide broad overview of forces leading to development of current requirements•Review current HAI reporting mandates for

California and CMS •Share Dignity’s Health success in meeting

surgical procedure reporting

Institute Of Medicine 1999

•Preventable medical errors in hospitals exceed attributable deaths to such feared threats as motor-vehicle wrecks, breast cancer, and AIDS. •Identify and learn from errors by developing a

nationwide public mandatory reporting system and by encouraging health care organizations and practitioners to develop and participate in voluntary reporting systems. •State governments will be required to collect

standardized information about adverse medical events that result in death and serious harm.

Institute for Healthcare Improvement 2004

•"Some Is Not a Number, Soon Is Not a Time”• Campaign with specific commitment to

produce measurable results in quality within a time certain, on a national scale, including –Reliable use of central venous line bundles

–Surgical site infection prophylaxis

–Reliable use of ventilator associated pneumonia bundles

Reporting Policy Fundamentals

•Must report via National Healthcare Safety Network (NHSN) – database developed and maintained by the CDC•Use of standardized definitions to allow

meaningful comparison•Hospital data publicly reported •Rates of infections will be used for CMS

reimbursement- 2012 reporting linked to 2014 payments

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CMS- Req’t Began

CMS- Locations

CDPH- Req’t Began

CDPH- Locations

CLIP - - 2008 ICU/NICU

MRSA -BSI 2013 All 2009 All

VRE- BSI - 2009 All

CDI 2013 All 2009 All

CLABSI 2011 ICU/NICU/PICU 2010 All

Surgical Procedures

2012 2 procedures 2011 29 procedures

CAUTI 2012 ICU/PICU - -

State and National Requirements are not the same!

•Submit process measure data to CDPH utilizing CDC definitions•Report central line bloodstream infection

rates •Report central line insertion practices (CLIP)•Influenza vaccination rates of patients and

employees

SB 739- 2008

•MRSA screening on admission and discharge•All cases of health-care-associated MRSA bloodstream

infection, clostridium difficile infection, and VRE bloodstream infection and number of inpatient days •All central line associated bloodstream infections and the

total central line days •All health care associated surgical site infections of deep

or organ space surgical sites, health care associated infections of orthopedic surgical sites, cardiac surgical sites, and gastrointestinal surgical sites •( or so CDPH thought!....)

Nile’s Law 2009

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•The California Hospital Association (CHA) has filed a lawsuit against the California Department of Public Health (CDPH) to stop the implementation of new public reporting requirements for surgical site infections (SSI). The lawsuit was filed Thursday, May 26, 2011.

•At issue are SSI public reporting requirements mandated by the CDPH in the state’s revised All Facilities Letter (AFL) No. 11-32 which was released on April 26, 2011. As stated in the AFL, the CDPH now requires hospitals to collect and report data on 29 different surgical procedures and any resulting SSIs to the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN

California Hospital Association Files Lawsuit to Halt New Surgical Site Infection Reporting Requirements

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•29 NHSN codes, approx. 200 ICD-9 codes•Requires detailed information on each

procedure- minimum 15 data elements•Must report via NHSN•Data publicly reported and used for CMS

reimbursement•2012 reporting linked to 2014 payments

SSI Denominator Requirements- 2011

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Resistance is Futile!

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Dignity Health Response•Development of the SSIR- Surgical Site Infection Reporting

application–Web-based application

–Identifies reportable procedures based on ICD-9 codes

–Up to half of required data elements available from registration, ADT data

–For facilities with surgery systems, flat file is run monthly and uploaded into SSIR; merged with registration data by medical record number, date of procedure.

•When all records completed, file is saved, uploaded to NHSN.

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SSIR

The SSIR has significantly reduced manual data entry by IPs, while accurately identifying reportable procedures.

•Goal set in 1999 to create a nationwide public mandatory reporting system using standardized definitions has been realized.•Financial (dis)incentives, public reporting and

consumer interest have increased the visibility of infection prevention. •There has been a significant shift in attitude re: HAI

prevention, good for patient safety.•Automated systems for meeting data requirements

are possible.

Summary- The Good News

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•Time spent meeting reporting requirements comes at the expense of other infection prevention activities. •Too early in the process to determine the effect of

reporting on rates of HAI.•Insufficient to simply report infections, the purpose

is to prevent/reduce infections and increase patient safety.•Basic hand hygiene and environmental sanitation

remains the key to reducing HAIs.

On-Going Challenges

Thank You