National Patient Safety Goal on HAIs to be phased in by January: Are you ready?

Consultants highlight where hospitals are falling short

"What [Goal 7] is doing is... reminding us that more Americans are dying of these infections than breast cancer, motor vehicle incidents, and HIV infection combined in this country," says Stephen Weber, MD, associate professor in the section of infectious diseases and chief health care epidemiologist at the University of Chicago Medical Center and consultant with Joint Commission Resources.

An expensive, and often fatal, scourge to hospitals, health care workers, and patients, "these infections" include multidrug-resistant organisms (MDROs) such as Staphylococcus aureus (MRSA), Clostridium difficile (CDI), vancomycin-resistant Enterococci (VRE), as well as central-line associated bloodstream and surgical-site infections. And hospitals are dealing with them on two fronts: as "never events" for which the Centers for Medicare & Medicaid Services will not reimburse when they are acquired after admission to the hospital and as a Joint Commission National Patient Safety Goal.

Goal 7 on reducing health care-associated infections is pegged to be phased in, with all elements implemented, by Jan. 1. It touches on goals in areas from infection control, environment of care, and human resources, as well as issues including hand hygiene and contact precautions. "The things that are demanded or insisted upon are, what I think, pretty core elements of any sensible infection control program. [They're] saying: Are we educating our staff about these matters? Are we keeping tabs on what these numbers actually look like? Are we communicating these risks and, in essence, their part in prevention to patients and family members?" Weber says.

"When you look at it with a very narrow view, one could say, 'Boy, what a pain to have this added on to our other work.' I prefer to think of it a little more broadly and just say, this really gives an organization an opportunity to take one particular problem, here as it relates to infection control, and really map it through the entire organization — everything from communication to education to information systems support — to really see that it's hard-wired instead of just another reactive leap for an accreditation standard."

How does your infrastructure stand? Weber and fellow Joint Commission Resources consultant Barbara Soule, RN, MPA, CIC, practice leader, infection prevention and control, spoke with Hospital Peer Review about where hospitals should focus in order to be ready come 2010 and to build a lasting foundation for preventing health care-associated infections.

Checklist for readiness

"I think there's wide variation in what hospitals are struggling with and where they are in their process," says Soule, but she has noticed some common themes.

Conduct thorough risk assessments.

"I don't think everyone is currently performing thorough risk assessments for multidrug-resistant organisms and how they're acquired or transmitted in that organization," Soule says. For each infection type, the goal requires "periodic risk assessments."

For MDROs, for example, she suggests annual assessments, which obviously doesn't prohibit a hospital from conducting them more often, especially if things change. "What I see mostly, for instance, with MDROs, is the risk assessment looks at the pathogen, looks at the organisms to see if there's a high or low prevalence. But what I don't often see is a look at the other aspects that could prevent MDROs from occurring or might actually contribute to them occurring."

She says organizations should ask themselves if they are educating all the necessary staff — medical, nursing, support, and environmental services. And they should ask themselves how well staff are following appropriate isolation precautions. Are those precautions part of a policy, and is the policy always being monitored?

Your risk assessment should clarify what issues you need to measure, Weber says. "[Y]our leadership, whether their primary role is in clinical quality or that administrative infrastructure that supports quality, needs to really know when it comes to infection control that the way their dollars are being spent, and the way their resources are being expended, that it makes sense given the particular challenges of the organization," he says.

Monitor environmental hygiene.

"I suggest that [hospitals] do monitor and see if people are truly following the policies, and that's for all the different professional groups that might go into a patient's room. Another issue we feel can contribute to MDRO transmission is the environmental contamination with these organisms," she says.

Monitor cleaning procedures, particularly in areas where patients and staff come in contact, around patient beds, and where patients go for examinations. She says some of the organisms the goal covers can live for months if areas aren't appropriately cleaned.

Provide staff education according to the requirements of the goal.

Hospitals should make sure they are providing education in accordance with the goal. This involves any staff who would be involved with the issue. Education must take place at the time of hire and annually thereafter. Education also must be offered when a staff member changes position — for instance, becoming involved with central line insertion where before he or she was not.

"Not only does an organization need to provide the education," Soule says, "they need to evaluate it to see if learning has taken place."

Surveyors will want to see records of education that has been performed. "They might pull a person's HR personnel record, say a new nurse in the ICU or a new staff physician who's been working in the ED, and see if there's documentation of education," Soule says.

While education for staff must be presented, evaluated, and documented, education for the patient and his or her family can just be documented in the chart, she says. For central lines, family and patients must be educated when a central line is placed.

Use evidence-based guidelines or best practices.

Another requirement, she says, is using evidence-based guidelines or best practices for all three types of infection. "An organization would want to monitor whether they're actually complying, for example, with the Centers for Disease Control and Prevention [CDC] guidelines or, if they're not, why they aren't, and do they have a justifiable reason that they can assure that they're providing the same level of patient safety by doing something different."

She points facilities to guidelines from both the CDC and the "Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals" published by The Society for Healthcare Epidemiology of America, the Infectious Diseases Society of America, the American Hospital Association, The Joint Commission, and the Association for Professionals in Infection Control and Epidemiology. (You can download the the compendium at

Communicate data across the hospital.

Another challenge for hospitals is getting information about incidences of all health care-acquired infections "to all the different stakeholders. We would like to see them get that information all the way up to the board of directors or the governing body of the organization; that group is responsible for the care provided in the organization," Soule says.

Those data, she says, should be provided in an easy-to-digest way and in appropriate formats to accommodate different learning styles.

Monitor outcomes using evidence-based metrics and conduct surveillance.

For MDROs, the goal requires hospitals to implement a surveillance program based on the findings of their risk assessment.

"I'm always worried when someone says, 'Well, we don't have a really strong surveillance system for a resistant organism or C. difficile because we don't have a big problem with that,'" Weber says. "And I guess what that immediately brings to mind is, 'Well, how can you say you don't have a big problem with it if you're not even following it or mapping it?' I don't think anyone on the administration side, when it comes to budget time would say, 'Well, we don't really need to look at our expenditures or revenues because we're basically doing OK.' That wouldn't pass muster in the board room. So I'm not sure why the standard on the issue related to patient safety or quality of care would be approached any less rigorously."

He adds that "active surveillance, as it's now known, is not some magic wand that you just start doing and MRSA goes away. You need to make a commitment to all the business interactive surveillance, which is people following precautions in order for it to have a benefit."

Soule points hospitals to CDC guidelines on metrics for monitoring outcomes. "There's an excellent paper on this by Cohen et al.1 It's all on metrics for measuring MDROs. It really goes into ways you can measure for MDROs. For central line, the CDC guideline is pretty old; there's a new one that's under review now. But in the compendium of strategies, they give recommendations for metrics for measurement for those areas," she says.

You should be able to show you're using a specific metric, one that makes sense, and then that you collect data, and that you act on those data in constant surveillance.

Consider carefully what data to collect.

Soule says there is still a wide variation in what data hospitals are collecting. In the compendium, she says there are suggestions for process and outcome measures. "I think the first thing to do is a risk assessment, and that helps the organization focus on what data it needs to collect. Because you don't want to be just collecting all kinds of data that you don't need or that can't use," Weber says. Then design your surveillance plan based on the organizational challenges found in the risk assessment.

Improve hand hygiene compliance.

As Weber says, the goal touches on so many fundamental elements of safety, one of which is hand hygiene. Speaking of the low compliance numbers surrounding hand hygiene, Weber says, "I think it's the most awful shortcoming in patient safety and hospital quality, at least for the last half century and I guess going back before that. To go to national meetings that I have of infection control folks and have a leading authority in the field get up and say, 'Wake up folks, we'll never get to 100% [compliance on hand hygiene].' It seems preposterous to me that we're giving up on this.

"It's remarkable how we've shied away from the idea of giving individual and direct feedback," he says. At the University of Chicago, they are looking at strategies to automatically detect hand hygiene adherence, one of which is radiofrequency identifier tags.

"And I'll tell you, our viewpoint is to provide individual feedback. It's remarkable that some of the groups that are doing similar work are saying, 'Well, we would never detect down to the individual health care worker level. We'd never want to get involved in that privacy issue.' I think that's just silly. When I orient the medical students, I say, 'If you came into a patient room and you saw the dean of students punching the patient in the face, would you say anything about it?' And I think everybody would," he says.

Assign responsibility.

Soule says you should assign responsibility for oversight and coordination of the goals and document that in minutes from the infection control committee or group such as quality and patient safety or senior leadership. For instance, she says at the unit level, there should be an assigned physician, nurse, and then another person who is the driver for quality.

It's certainly a hospitalwide effort she says and neither an infection control's nor a quality department's sole responsibility. "The effort has to be broader [than the infection control and quality departments], because none of those groups put their hands on patients or perform the procedures that put patients at risk," Soule says. "They are the ones who can help guide and coordinate, but if there's no cooperation or buy-in from the nursing staff, the surgery staff, so forth, then it won't work." In the end, she says, it's the people giving care who have to say, "We're going to make this happen."


  1. Cohen AL, et al. Infect Control Hosp Epidemiol. "Recommendations for metrics for multidrug-resistant organisms in healthcare settings: SHEA/HICPAC Position paper" Oct 2008;29:901-913.