Meeting the Challenge
of Mandatory HAI
Reporting
Marcy Maxwell RN, BSN, CIC
Dignity 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 motorvehicle 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
State and National Requirements are not the same!
CMS- Req’t
Began
CMSLocations
CDPH- Req’t
Began
CDPHLocations
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
-
6
SB 739- 2008
• 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
Nile’s Law 2009
• 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!....)
California Hospital Association Files Lawsuit to Halt
New Surgical Site Infection Reporting Requirements
• 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. 1132 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
9
SSI Denominator Requirements- 2011
• 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
10
Resistance is
Futile!
11
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.
13
Summary- The Good News
• 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.
On-Going Challenges
• 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.
15
Thank You