GAO report lays blame for infections on HHS
GAO report lays blame for infections on HHS
Putting neither light nor heat on hospitals
The onus for much of the "needless suffering and death" caused by health care-acquired infections (HAIs) was recently ascribed to a failure of leadership by the Department of Health and Human Services (HHS) in a scathing report by the U.S. Government Accountability Office (GAO).
"Without such leadership, the department is unlikely to be able to effectively leverage its various methods to have a significant effect on the suffering and death caused by HAIs," the GAO states in a report that was released as evidence in an April 16, 2008, Congressional hearing.
Such leverage would include both the Centers for Disease Control and Prevention and the Center for Medicare & Medicaid Services (CMS). In order to help reduce HAIs in hospitals, the GAO called for the Secretary of HHS to:
- Identify priorities among CDC's recommended practices and determine how to promote implementation of the prioritized practices, including whether to incorporate selected practices into CMS' Conditions of Participation for hospitals.
- Establish greater consistency and compatibility of the data collected across HHS on HAIs to increase information available about HAIs, including reliable national estimates of the major types.
The upshot is that hospitals escaped blame for the problem to some extent, but may end up with less money in the future to solve it. (The GAO cites the ongoing action by CMS to reduce payment for certain infections by October 2008.)
"We identified two possible reasons for the lack of effective actions to control HAIs to date," the GAO concluded. "First, although CDC's guidelines are an important source for its recommended practices on how to reduce HAIs, the large number of recommended practices and lack of department-level prioritization have hindered efforts to promote their implementation. The guidelines we reviewed contain almost 1,200 recommended practices for hospitals, including over 500 that are strongly recommended. [That is] a large number for a hospital trying to implement them."
A few of the CDC guidelines are required by CMS' or accrediting organizations' standards or their standards interpretations, but it is not reasonable to expect CMS or accrediting organizations to require additional practices without some prioritization, the GAO noted.
In addition, the HHS has not effectively used the HAI-related data it has collected through multiple databases across the department to provide a complete picture about the extent of the problem. "Limitations in the databases, such as nonrepresentative samples, hinder HHS' ability to produce reliable national estimates on the frequency of different types of HAIs. [C]urrently collected data on HAIs are not being combined to maximize their utility," the GAO found. "For example, data on surgical infection rates and data on surgical processes of care are collected for some of the same patients in two different data bases that are not linked."
The result of all this, the GAO seems to be saying, is that the HHS is putting neither light nor heat on hospitals, creating a confusing array of unprioritized practices and then applying little pressure for anyone to adopt them. While the report lets hospitals slide a bit in the accountability department, the GAO argues convincingly that more focused "influence" over hospitals could yield better results.
"HHS has multiple methods to influence hospitals to take more aggressive action to control or prevent HAIs, including issuing guidelines with recommended practices, requiring hospitals to comply with certain standards, releasing data to expand information about the nature of the problem, and soon, using hospital payment methods to encourage the reduction of HAIs," the GAO concludes. "Prioritization of CDC's many recommended practices can help guide their implementation, and better use of currently collected data on HAIs could help HHS — and hospitals themselves — monitor efforts to reduce HAIs."
Unenviable position
Drawing the unenviable position of defending the HHS was Don Wright, MD, MPH, principal deputy assistant secretary for health at the agency.
"Though there has been significant progress in several areas, HHS recognizes more work and leadership is necessary to enhance patient safety in this regard," he said. ". . . The reduction of health care-associated infections to enhance patient safety and reduce unnecessary costs is a top priority for HHS. Through prevention activities, surveillance, and data monitoring initiatives, value-based purchasing, and guidelines to facilitate quality improvement research, the department is tackling this public health challenge in many different ways. There are many examples of interagency collaboration in this area throughout the department. HHS looks forward to working with all stakeholders — public and private — in meeting its shared responsibility to reduce health care-associated infections."
Wright emphasized ongoing activities at various HHS agencies, including the CDC. While numerous, CDC infection control guidelines are prioritized according to the quality of evidence available to support them, he said. CDC guidelines are translated into practice in several ways, and have served as the basis for national health care quality initiatives such as the Institute for Healthcare Improvement's 100,000 Lives Campaign and the CMS Surgical Care Improvement Project, which bundles together these guidelines to create best practices to reduce health care-associated infections, he stressed. In addition, the CDC collaborated with the Pittsburgh Regional Healthcare Initiative to prevent central line-associated bloodstream infections, among intensive care unit patients in southwestern Pennsylvania, which resulted in a 68% decline in bloodstream infection rates over a four-year period.
For its part, the Agency for Healthcare Research and Quality (AHRQ) funded the Keystone Initiative in Michigan that resulted in a 70% decline of central line-associated bloodstream infections when CDC guidelines were fully implemented, he said. CMS is moving ahead with value-based purchasing that will include HAIs, he added. "Currently, CMS is seeking legislative authority to implement a value-based purchasing program for Medicare inpatient hospital payments that ties 5% of hospital payments to the hospital's actual performance," Wright testified. "Payments would be based on improving a hospital's quality of care as well as achieving absolute levels of quality of care."
In a related development, CMS has targeted three HAIs for reduced reimbursement, including catheter-associated urinary tract infections, vascular catheter-associated infections, and mediastinitis after coronary artery bypass graft surgery. "Beginning Oct. 1, 2008, Medicare cannot assign these selected conditions to a higher-paying DRG unless they were present on admission," Wright said. "In addition, CMS is seeking public comment on additional hospital-acquired conditions, which will include several health care-associated infections."
In other testimony at the hearing, Leah Binder, CEO of The Leapfrog Group, said the group's annual voluntary hospital survey found last year that 87% of hospitals did not take all of the recommended steps to prevent "avoidable infections." Leapfrog is a member-supported nonprofit organization representing a consortium of major companies and other private and public purchasers of health care benefits for more than 37 million Americans nationwide.
"Despite the overwhelming impact of these preventable infections on U.S. citizens, eradication has not been prioritized to the same extent as these other issues," Binder said. "It is long past time for bold action and real, focused leadership to address hospital-acquired infections — it is a public health emergency, and scores of lives are lost while we delay implementing well-understood preventions. Hospital-acquired infections are emblematic of a larger problem in our health care system: We do not align financial incentives with patient well-being."
Instead, government and private sector payers have traditionally structured payment to hospitals to compensate individual protocols and procedures no matter how those procedures turn out, she emphasized. "We pay for this surgery, that medication, this X-ray without tying payment to quality outcomes," she said. "Even with DRGs we pay for bundles of procedures regardless of quality, and until recently, we pay even if they are performed mistakenly and jeopardize the patient's life and health. Indeed, medical errors result in increased payments to hospitals to cover the additional treatment needed to remedy the error."
On average, HAIs add some $15,000 to the patient's hospital bill, amounting to more than $30 billion a year, Binder said. "We must assume that money is concentrated at hospitals with the worst record for hospital-acquired infections. This perverse payment system impedes the implementation of critical quality processes. We as purchasers in both the public and private sectors must continue working together to rapidly realign incentives to encourage systemic change in the delivery of care and to reward good outcomes."
Though the country is moving to integrate public and private sector strategies to influence transparency and value-based payment reform, "progress is unacceptably slow," she said. ". . . Unfortunately, many of the components of Secretary Leavitt's vision are not being prioritized within HHS to effectively generate change."
(Editor's note: The GAO report: "Health-Care-Associated infections in Hospitals: Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on these Infections" is available at http://oversight.house.gov.)
The onus for much of the "needless suffering and death" caused by health care-acquired infections (HAIs) was recently ascribed to a failure of leadership by the Department of Health and Human Services (HHS) in a scathing report by the U.S. Government Accountability Office (GAO).Subscribe Now for Access
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