Mandatory HAI Reporting

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Mandatory HAI Reporting

• HB 197

Barbara W. Bradley, MS, RN, CIC Chief, Bureau of
Infectious Disease Control Ohio Department of
Health
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Enactment of House Bill 197

• HB 197 became law in November 2006
• Requires Ohio hospitals to report performance
  measure data to the Ohio Department of Health for
  the purpose of public reporting
• Some measures are required to be selected from
  several national organizations
• Centers for Medicare and Medicaid Services (CMS)
• The Joint Commission on the Accreditation of
  Healthcare Organizations (JCAHO)
• National Quality Forum (NQF)
• Agency for Healthcare Research and Quality (AHRQ)

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Creation of Advisory Council

• By statute, a Hospital Measures Advisory Council
  was created and consists of
• Director of Health, Council Chair
• Two members of the Ohio House of Representatives
• Two members of the Ohio Senate
• Superintendent of Insurance
• Executive Director of the Commission on Minority
  Health
• Representative from each of the following Health
  Insurers, Small and Large Employers, Organized
  Labor, Physicians in General Practice, Physicians
  Specializing in Public Health, Childrens
  Hospitals, Hospitals, Health Care Consumers and
  Health Services Researchers

4
Creation of other Groups

• Each member of the Hospital Measures Advisory
  Council was required to appoint a data expert
  (Data Expert Group)
• An Infection Control Group was also required to
  provide information about infection measures
• The Advisory Council created Pediatric and
  Perinatal workgroups
• These group looked at measures specific to these
  populations

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Process for Measure Selection

• The Data Expert Group met monthly to review each
  measure created by the organizations mentioned in
  the law
• The Data Expert Group created a set of criteria
  that would serve as guidelines for selection
• The specifications for each measure were examined
  and it was determined whether or not it met the
  majority of the criteria

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Measure Selection Criteria

• Importance
• Do the measures reflect unequivocally important
  aspects of patient care?
• Preventability
• Can a poor score be prevented through proper
  care?
• Is excess variation in the data accounted for by
  factors unrelated to hospital quality?
• Genuine quality improvement
• Can a hospitals rate be improved without
  improving quality?
• Data integrity
• Can a hospital accurately collect the data from
  its records?
• Does the measure adequately measure the construct
  it attempts to measure?

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Measure Selection Criteria (cont.)

• Usefulness of data to the public
• Is the measure of use to consumers?
• Is the measure comprehensible to consumers?
• Do hospitals have a sufficient case load to
  accurately report quality?
• Burden
• Does calculating the measure place undue burden
  on hospitals?
• Evidence-based
• Is there scientific research demonstrating the
  accuracy and importance of the measure?
• Variance
• Is there sufficient variability in performance
  among hospitals to allow for comparison?
• National Quality Forum endorsement
• Is the measure endorsed by the National Quality
  Forum?

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Next Steps

• Adopt rules reflecting recommended measures
• Six to nine month process
• Public comment period
• Public hearing
• Reporting of new measures to begin no earlier
  than October 2009
• Development of the consumer website
• To be operational by January 2010

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Hospital Infection Reporting

• Infection Control Group
• Many members from Directors Advisory Committee
  for Emerging Pathogens
• Hospital Infection Control Professionals/Infection
  Preventionists included
• Infectious Disease Physicians included

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Background of Hospital Infection Reporting

• APIC was conceived in 1972 in recognition of the
  need for an organized, systematic approach to the
  "control" of infections acquired as a result of
  hospitalization. (apic.org)
• Hospital reporting of infections into the CDC
  National Nosocomial Infection Surveillance System
  (NNIS) has been going on since the early 1970s.

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Background (continued)

• The NNIS database was used to
• Describe the epidemiology of Healthcare
  Associated Infections (HAI)
• Describe antimicrobial resistance associated with
  HAIs
• Produce aggregated HAI rates suitable for
  interhospital comparison.

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Background (continued)

• The National Healthcare Safety Network (NHSN) was
  launched in 2005 as a new electronic surveillance
  system
• One of the enhanced features of this surveillance
  system is that while maintaining data security,
  integrity, and confidentiality, NHSN has the
  capacity for healthcare facilities to share data
  in a timely manner
• Between a facility and public health agencies
• Between facilities (e.g., multihospital system)

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NHSN - Purpose

• Collect data from a sample of healthcare
  facilities in the United States to permit valid
  estimation of the magnitude of adverse events
  among patients and healthcare personnel.
• Collect data from a sample of healthcare
  facilities in the United States to permit valid
  estimation of the adherence to practices known to
  be associated with prevention of HAIs.
• Analyze and report collected data to permit
  recognition of trends.

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NHSN Purpose (continued)

• Provide facilities with risk-adjusted data that
  can be used for interfacility comparisons and
  local quality improvement activities.
• Assist facilities in developing surveillance and
  analysis methods that permit timely recognition
  of patient and healthcare personnel safety
  problems and prompt intervention with appropriate
  measures.
• Conduct collaborative research studies with NHSN
  member facilities (e.g., describe the
  epidemiology of emerging HAI and pathogens,
  assess the importance of potential risk factors,
  further characterize HAI pathogens and their
  mechanisms of resistance, and evaluate
  alternative surveillance and prevention
  strategies).

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Process Within Hospitals for Reporting

• Outbreaks in hospitals in Ohio are reportable to
  LHD/ODH based on Class C Reportable Infectious
  Diseases
• 24 outbreaks in hospitals have been reported
  since between 2002 and 2007
• Infection Preventionist (IP) identifies infection
  based on reports from hospital staff,
  microbiology reports, personal observations
• IP conducts investigation with standard case
  definitions provided by infectious disease
  control manual/ NNIS/NHSN

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Process Within Hospitals for Reporting (contd)

• Identified infections are addressed with the
  hospital staff and attending physician
• A line listing is prepared and the data is
  characterized by person, place and time
• Outbreaks and infection rates are shared with the
  Infection Control Committee
• JCAHO reviews infection control data when
  hospitals are accredited

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Professional Organizations

• Multiple professional organizations are involved
  in mandatory reporting of HAIs across the U.S.
• Association for Professionals in Infection
  Control and Epidemiology (APIC)
• Society for Healthcare Epidemiology of America
  (SHEA)
• Infectious Disease Society of America/Ohio
  (IDSA/IDSO)
• Veterans Administration (VA)
• Center for Medicare and Medicaid Services (CMS)
• National Quality Forum (NQF)
• Joint Commission on Accreditation of Healthcare
  Organizations (JCAHO)
• AHRQ

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What has ODH been doing?

• Bureau of Infectious Disease Control, Bureau of
  Health Surveillance Information and the State
  Epidemiologist have been collaborating on this
  issue for about 3 years
• Directors Advisory Committee on Emerging
  Pathogens convened on this issue
• National APIC conferences bringing together IPs
  from across U.S.
• ODH staff traveled to Pennsylvania to visit and
  learn about Pennsylvania system

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More of what ODH has been doing

• Monitoring legislation in Ohio and across the
  U.S.
• Hearing from and monitoring actions of consumer
  groups
• Made C. difficile reportable in 2006 mandatory
  reporting case definitions data analysis
  education
• Participating with LHDs in investigations of HAIs
• Training staff across the state in infection
  control and epidemiology

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Available Measures

• What do hospital IPs collect now?
• Catheter-Associated Bloodstream Infections
  (CA-BSI)
• Surgical Site Infections (SSI)
• Ventilator-Associated Pneumonia (VAP)
• Catheter-Associated Urinary Tract Infections
  (CA-UTI)
• Multiple other infections available for
  monitoring from NNIS/NHSN system

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What offers the best transition to mandatory
reporting for hospitals?

• Use data that is already being collected
• Use a standardized data collection system
• Provide reporting to meet the statutes
  requirement
• Provide reports that are easily understood by
  healthcare professionals
• Provide reports that are easily understood by the
  general public

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What are the anticipated needs?

• Public education
• Provider education
• Electronic system with easy access
• Staff to provide education and technical
  assistance

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Statutory Reporting Guidelines

• April 1st and October 1st of each year
• Data that reflects performance over a
  twelve-month period
• Use the specifications and risk adjustment
  methodology recommended by the entity that
  developed or endorsed the measure

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Statutory Reporting Guidelines

• The data collected must include measures from
• The Centers for Medicare and Medicaid Services
• The Joint Commission on the Accreditation of
  Healthcare Organizations
• The National Quality Forum
• The Agency for Healthcare Research and Quality
• The data collected may include other measures
  that the Hospital Measures Advisory Council
  recommends to the Director

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CMS Infection Measures

• Surgical Care Improvement Project (SCIP) is a
  national quality partnership of organizations
  (CMS, JCAHO, NQF)
• There are 9 SCIP procedural measures intended to
  improve the safety of surgical care through the
  reduction of postoperative complications
• Five measures are currently required for CMS
  reimbursement and by the end of 2008 others will
  be required pending NQF endorsement.

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AHRQ Infection Measures

• Agency for Healthcare Research and Quality (AHRQ)
  currently has two infection control measures
• Selected infections due to medical care
• This measure is intended to flag cases of
  infection due to medical care, primarily those
  related to intravenous (IV) lines and catheters.
• Post-operative sepsis
• This measure is intended to flag cases of
  nosocomial postoperative sepsis.
• These measures are not currently nationally
  collected

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NQF Infection Measures

• NQF endorses a variety of measures from multiple
  National organizations including
• CMS and JCAHO
• CDC
• IHI (Institute for Healthcare Improvement)
• Vermont Oxford Network
• NQFs healthcare-associated infections consider
  infections in 4 clinical areas and 2 specialty
  areas

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Statutory Guidelines

• Data reported must be made available to the
  public
• The public must be able to compare hospitals
  performance in meeting the measures

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Infection Control Group

• A group of
• Health care consumers
• Nurses
• Experts in infection prevention and control
• Provide information about infection control
  issues to the council as needed for the council
  to perform its duties

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Proposed Charge

• To assess and recommend existing hospital
  associated infection measures that could be used
  to provide meaningful information to consumers.

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What is happening nationally?
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Questions?