CMS planning infection control inspections of U.S. hospitals

Is `pay for prevention' on the horizon?

By Gary Evans, Executive Editor

The Centers for Medicare and Medicaid Services (CMS) — the single largest payer for health care in the United States — is creating a hospital inspection program focused specifically on infection control, Hospital Infection Control & Prevention has learned.

"We have a problem in this country with far too many infections and too many deaths due to infections in hospitals," said Daniel Schwartz, MD, MBA, chief medical officer of the Survey and Certification Group at the CMS. "So what can we do to fix this? I don't think it's necessarily CMS alone that is going to fix this, but a hospital should be able to detect when they have a problem — they should have systems in place to recognize and fix those problems."

It doesn't take a great leap of imagination to see this fledging survey concept eventually morphing into CMS "pay for performance" requirements, though the program is being pitched initially as a non-punitive collaborative that can help hospitals improve quality. In the boldest move yet in its dramatically expanding oversight of infection prevention, the CMS is planning to train a cadre of inspectors to assess basic infection control measures and follow single hospitalized patients using a "tracer" concept similar to that used by Joint Commission (TJC) surveyors. The CMS program was discussed recently in Atlanta at a meeting of the Centers for Disease Control and Prevention's Healthcare Infection Control Practices Advisory Committee (HICPAC).

"Obviously, if we are writing regs and you are writing guidelines, we really want to be on the same page," Schwartz told the HICPAC panel. "We want this to have a major impact on infection control and help reduce health care associated infections."

There is a clear precedent for partnership. In the wake of continuing hepatitis outbreaks in ambulatory care settings — most of them linked to improper use of needles and medication vials — the CMS worked with the CDC to create an infection control checklist to use for inspecting outpatient facilities. (See HIC Dec. 2008; related story p. 76) Though such flagrant needle practices are rarely found in hospitals, CMS inspectors would likely look for such breaches while assessing basics principles like hand hygiene, barrier precautions, instrument processing and the like.

As discussed at the CDC meeting, the CMS will create a hospital infection prevention survey that will be reviewed by HICPAC, other key stakeholders and possibly opened for public comment. The survey will be "pre-tested" in selected participating hospitals, with an emphasis on using it as a self-assessment tool to improve infection control practices. In that sense, the CMS appears to be trying to launch this inspection process without incurring a lot of pushback from hospitals. For their part, infection preventionists are viewed as an important part of the process and could leverage the CMS involvement into upgraded program resources.

"We want to go into the hospitals and use [the survey] to see what works and what doesn't, get feedback and really make it better," Schwartz told HIC. "In the end we want everybody to be kind of happy with it. We want it to be, obviously, something the surveyors find to be useful and we want it to be an assessment opportunity for the hospitals. We want them to be comfortable that if they do these things, not only will they do well on the surveys but they might be able to [prevent more HAIs]."

Codifying CDC guidelines

With the death of 100,000 people annually due to HAIs, critics have been saying for years that the CMS should use its considerable influence on the hospital bottom-line to put some teeth in the CDC's voluntary infection control guidelines. However, Schwartz rejected that analogy in an interview with HIC, saying the CMS was charged to create the hospital inspection program as part of the newly formed Partnership with Patients. This recently announced federal, state and private collaborative will focus on improving patient safety by reducing healthcare associated infections (HAIs) and other hospital-acquired conditions.

"[In terms of the] state of the art in the field I can't think of a better organization, and one that has a better reputation in infection control than the CDC,' he told HIC. "it really helps to have this working arrangement with them so that was our starting point [for this survey]. We have thought about doing something like this anyway because we have been dealing with [ambulatory surgery centers] and we have conversations [with the CDC] all the time about infection control issues."

Whatever the program's origin, the future result — possibly within the next year — could see CMS inspectors making fairly thorough visits to hospitals. "This will probably involve two surveyors over two days to do the assessment," Schwartz told HICPAC. "We are hoping to make this an easy to use tool that is highly effective."

While CMS usually comes into hospitals only to respond to specific complaints, the scale of the program discussed at the meeting would be much more ambitious in terms of oversight and routine inspection. "When CMS goes into hospitals most of the time the reason is a compliance investigation and we do maybe 4,000 to 5,000 of those — but that's a very limited survey," he said.

The hospital survey initiative certainly reflects the influence of new CMS chief Don Berwick, MD, a longtime health care quality and transparency advocate. Under Berwick, the CMS has continued to step up fiscal pressure on hospitals to adopt quality measures and best practices to reduce HAIs. In an interview prior to his CMS appointment in July 2010, Berwick said he hopes the public "gets a bit outraged and mobilized as voters," he said. "[They should] ask why we pay systems the amount of money we are and not have them adopt the best practices."

In that regard, liaison HICPAC member Lisa McGiffert, senior policy analyst on health issues at the Consumers Union, expressed strong support for the CMS initiative.

"This [survey] tool is very important," she said. "I do agree [it can be used] for hospitals to have help in improving care, but I think ultimately it's [CMS'] responsibility that the environment is safe for patients. You are not there just to help the hospitals."

In particular, McGiffert urged the CMS to ensure that hospitals are tracking and reporting all infections, something that has been questioned as more and more states mandate rate data.

"We do touch on that in the interview portion of it," said Carolyn Gould, MD, a CDC medical epidemiologist who is collaborating on the CMS project. "There are a lot of questions related to the infection prevention program and resources, and that includes surveillance."

How will CMS address diverse settings?

While generally open to the concept, several HICPAC members pointed out the wide differences in types of hospitals and the possible detrimental impact of such inspections on smaller hospitals with scarce resources. Schwartz said the CMS is not developing a "one-size fits all" tool, but in any case the basic infection control principles apply across the continuum.

"If you put a tracer on almost any patient and procedure the surveyor is going to be looking at hand hygiene, injection safety [and] basic infection control at the bedside," he told the CDC panel.

The Joint Commission's experience with the tracer technique in the survey process indicates that the CMS will have to be prepared to conduct ongoing training of inspectors, noted HICPAC liaison member Robert Wise, MD, vice president of the division of standards and survey methods at TJC.

"We have been at this [patient tracer] for about seven years," he told Schwartz during the HICPAC discussion. "You may know or you will soon know that in the initial startup there is a huge amount of variability. It takes a lot of training — there is a constant amount of overhead involved in training. We can stay in close contact with you about that — seven years [reflects] a lot of good and bad experiences — but we certainly applaud you going in this direction, even though it is fraught with a number of methodological issues."

Noting that the CMS was "open to suggestions," Schwartz characterized the training issue as a legitimate challenge that could nevertheless be met.

The bottom-line is that "there isn't a hospital in the country that doesn't want to provide a safe environment for their patients and make sure they do everything possible to prevent transmission of infectious diseases," he said.

A gap analysis tool

In that regard, the CMS survey and inspection process could ultimately serve as a "gap analysis" tool for hospitals to ensure infection control is a facility priority. "This would be available to hospitals as a self assessment," Gould said. "It would be a way for hospitals to survey themselves prior to [CMS] surveys so they can be better prepared."

Veteran infection preventionist and HICPAC consultant Judene Bartley, MS, MPH, CIC, underscored the importance of ensuring the CMS survey is based on scientific evidence as CDC interpretive guidelines are reduced and condensed. "[I like] the whole idea of using this as a self-assessment tool that could help train the newbies that haven't done this before," she added.

The considerable tasks ahead include honing down the infection control areas or "modules" to be assessed, as a basic checklist of CDC recommendations came to 22 pages, Schwartz told the panel. Various suggestions for inclusion by HICPAC members included infection control during care transitions and hospital employee health.

"There will be some questions on occupational health, when you get a chance to look at the tool — in whatever form it comes out in the next couple of months — take a look at those sections and tell us what we can do to make it better," Schwartz said. "We can't always use everything [HICPAC] puts out, and to a certain degree that is unfortunate, but we have to work with the regs as they are written. We will try to use as much as we can."