Audacity of hope? Infection preventionists know federal HAI legislation likely under Obama
Audacity of hope? Infection preventionists know federal HAI legislation likely under Obama
Will IPs be empowered or face unfunded mandate?
Having proposed federal "hospital report card" legislation while in the U.S. Senate that specifically cites heath care-associated infections (HAIs), President-elect Barack Obama comes into power this month with an unprecedented history of interest and advocacy about infection prevention. The ascendancy of such a president — backed by a friendly majority in Congress — appears to set the stage for federal HAI legislation if there is ever going to be any.
There are, we should add, a few competing priorities. Yet amid economic crisis and international wars, it bears noting in the infection prevention community that we now have a president who as recently as July 7, 2007, stated the following on the Senate floor:
"I rise today to reintroduce the Hospital Quality Report Card Act, a quality-focused initiative that will actively engage all relevant stakeholder groups — patients, providers, administrators, and payers — and increase availability of information about the quality of health care services in local hospitals and health systems," Obama said. ". . . The [act] grants the Secretary of Health and Human Services (HHS) the power to collect hospital information related to the staffing levels of nurses and health professionals, the accreditation of hospitals, the quality of care for vulnerable populations, the availability of specialty services and intensive care units, hospital-acquired infections, measures of crowding in emergency rooms, and other indicators of quality care."
Obama introduced a similar measure for hospitals in the Veterans Affairs Health System. The information would be electronically accessible to the public, meeting the demand for HAI transparency by patient advocates. "The report card initiative builds upon current work at the Centers for Medicare & Medicaid Services (CMS), as well as initiatives in a number of states including my own home state of Illinois," Obama said in reintroducing a bill he originally proposed in 2006. Indeed, Obama steered through similar state legislation as a senator in Illinois, where his wife Michelle was vice president of community affairs at the University of Chicago Medical Center (UCMC).
"We have long known here in Illinois of state Sen. Obama's interest in infections," says Stephen Weber, MD, hospital epidemiologist at UCMC. "All the other societal woes not withstanding, this would seem to be an administration that would be primed to give this issue some much needed attention in terms of trying to encourage even greater strides in reducing infections."
As a member of the Society for Healthcare Epidemiology of America, Weber has written and spoken in opposition to legislation that mandates specific clinical practice (i.e., active surveillance cultures for MRSA). However, he argues that it is in the best interest of the infection control community not to oppose increasing patient demands and legislative momentum toward the transparency mandated in bills such as Obama's report card initiatives.
"I see nothing wrong personally with a thoughtful approach to transparency that is respectful of risk stratification and the best scientific evidence," he says.
Obama's state bill for hospital report cards still is being phased in Illinois, in part because there has been a lot of work and discussion on the metrics and logistics to ensure fair reporting, he adds. "Within institutions, it has compelled administrators and stakeholders in hospitals to give greater attention to these issues," Weber says. "In some cases, people working in infection prevention have been able to leverage these mandates into greater attention to the things we really care about — which is preventing infections in our patients."
No shortage of bills, momentum
In addition to proposing the Report Card Act, Obama is a co-sponsor of the Community and Healthcare-Associated Infections Reduction Act of 2007 (CHAIR Act), which would require in part that hospitals report information about community infections and HAIs to the Centers for Disease Control and Prevention in order to develop a national database of infection rates in hospitals. In addition to Obama's proposals, several other federal bills in various stages of discussion address some aspect of HAIs.
With many states already passing laws requiring infection rate disclosure and HAI pay-for-performance initiatives under way, the issue already had considerable momentum before the election. "Given that you have two or three legislative measures that have already been fairly well vetted, I think it is reasonable to think that one law will emerge from this — whether it will be in this legislative session, I don't know," Weber says. "Ultimately, it may be the bill that moves forward will be determined less by us on the front line of infection prevention than the politicking that goes on for all legislation at the federal level."
Regardless, we know where Obama stands on the issue — and it's not in the way.
"One would have to conclude that Barack Obama's election would only make it more likely," Weber says. "He is not going to be an obstructionist to any of this. The ultimate question is just how high on the radar is this theme and whether they will see this as a distraction from the primary issues around the economy. It could be seen as a potential means to get at some of the [cost] issues in our economy."
Indeed, the Department of Health and Human Services (HHS) recently estimated that HAIs cost as much as $20 billion annually. In a nation already bleeding red ink, the argument could be made that investment in infection prevention addresses both health care quality and costs. One is tempted to follow this scenario to the rosy conclusion that Obama could emerge as the most powerful of allies to infection prevention programs, but throwing a cold bucket of water on all this is Larry Van Horn, PhD, a leading expert and researcher on health care and director of the Health Care MBA Program at Vanderbilt University in Nashville. Obama has a bigger purchase in mind when it comes to spending his political capital in health care, he reminds. The quest for some semblance of universal health care insurance will likely dominate the immediate agenda.
"With respect to the nuanced area of infection control, reporting of adverse events and things like that, it is not a 'first-order' push," Van Horn says. "[Health care initiatives] typically focus on cost, quality, and access. Obama's primary push is around access. The ability to do that in a financially responsible way is going to be a real challenge."
The high-profile pick of former U.S. Sen. Tom Daschle to take the helm at the HHS underscores that Obama views health care as a high priority, he adds.
"With Daschle's background, I think there is little question that in the first 100 days, health care is going to be one of the points in the common discussion of legislative initiatives," he says. "The question is whether what Obama has put forward in his campaign platform is going to morph into something that is fiscally responsible and passable, particularly given the [economic] pressures we currently have."
The proposed Healthy Americans Act — which is similar to Obama's plan — could emerge as the health care reform bill with the most widespread support on both sides of the aisle, he adds. In its current form, it would require adults to have the opportunity to purchase a Healthy Americans Private Insurance Plan (HAPI). It makes individuals who are not enrolled in another specified health plan — and who are not opposed to coverage for religious reasons — responsible for enrolling themselves and their dependent children in a HAPI plan offered through their state of residence. There are penalties for failure to enroll.
How would a move to universal health care coverage affect infection prevention programs? It's hard to forecast, but the Veterans Affairs hospital system is the most obvious analogy. "It's interesting, because theoretically it could create more opportunity for more standardization of practice," Weber says. "When you look at the measures that have been able to be undertaken across the whole VA system, it makes you wonder whether a similar overarching approach could be taken if a larger proportion of the payments are coming from the federal government."
Under this scenario, one can imagine outcomes that bode good or ill, anything from a "Big Mother" system achieving extraordinary hand washing compliance to mandates for specific clinical practices at hospitals with different problems and priorities. "I am not against all legislation but I really want it to be on things that are going to focus on transparency, openness, communication of best practices and setting standards for best practices, rather than defining, establishing, or mandating particular practices," Weber reiterates. "I think that is a strategy that a lot of people could get on board with."
Daschle, HHS may be the key
Even if the various federal bills dealing with HAIs get lost in the shuffle in the debate over national health care reform, Daschle will take leadership of an HHS that was recently slammed by the U.S. Government Accountability Office (GAO) for the "needless suffering and death" caused by health care infections.1 The GAO report specifically cited a failure of leadership at the HHS on the issue of HAIs, so Daschle enters office with a blinking message on his desk phone. Specifically the GAO report, 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.
Some work already is in progress toward this effort, with The Joint Commission and all the major infection prevention associations creating a compendium that is essentially a synthesis of established prevention guidelines to prevent the major HAIs. Meanwhile, one of Daschle's direct reports — Don Wright, MD, MPH, principal deputy assistant secretary for health at the HHS — has formed the HHS Steering Commission for Prevention of Healthcare-Associated Infections. The group will work with the CDC's Healthcare Practices Advisory Committee (HICPAC) to address the concerns raised in the GAO report. In a memo recently distributed by the Association for Professionals in Infection Control (APIC), he stresses that HAIs have become "a top priority" at the HHS. Wright has also addressed the issue at recent infection control meetings.
"My opinion — after listening to him talk — is that we are not far away from a federal report card and a mandate," says Janet Frain, RN, CIC, CPHQ, CPHRM, APIC president and director of Integrated Quality Services at Sutter Medical Center in Sacramento. "The good news is he has put all the key players at the same table. Everybody will at least be talking from the same page and agreeing on definitions and what data they are going to use. If you look at the way Congress has been voting and the GAO report, I think it would be safe to say that transparency of data is really going to be the focus."
Frain is withholding judgment on whether federal action will be "good or bad" for IPs and their programs. The primary concern is that the requirements will divert scarce resources, particularly at smaller facilities, away from more pressing prevention efforts.
"That's the risk," she says. "But I think consumers have a right to know rates of preventable infections, especially with all the work that has been done and the unbelievable zero [rates] that hospitals have been able to sustain over time. That is just tremendous. But when you squeeze that balloon, there's always unintended consequences."
For example, California recently passed a law that requires hospitals to report all catheter-related bloodstream infections, which will require housewide surveillance for many IPs.
"Most of our focus has been in the ICUs because that is where most of the lines are, now we have to divert resources from that surveillance downstream to medical/surgical floors and so forth," Frain says. "That is the impact when legislation like this happens. How are we going to get that additional work done if we are already doing the targeted surveillance that most hospitals have already adopted?"
The challenge of leveraging mandates into program resources arises again, a recurrent theme whether the initiative is at the state or federal level. But there are some intangibles in Obama's message that, dare we say, give IPs the audacity of hope that federal HAI initiatives will acknowledge that preventing 100,000 infection deaths a year cannot be the onus of one profession.
"It seems — just from my thinking — that there may be a stronger sense of accountability both personal and corporate," says Ruth Carrico, PhD, RN, CIC, assistant professor of Health Promotion and Behavioral Sciences at the University of Louisville. "That may translate to, "If I'm involved in the problem, I better be accountable, and that means I'm going to be working to keep the problem from recurring.' Infection is a shared-responsibility outcome. Until you get everybody being responsible — including patients and families— it's going to be really hard."
Reference
Government Accountability Office. "Health-Care-Associated Infections in Hospitals: Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on these Infections." GAO-08-673T; April 16, 2008. Available at http://www.gao.gov/products/GAO-08-673T.
Having proposed federal "hospital report card" legislation while in the U.S. Senate that specifically cites heath care-associated infections (HAIs), President-elect Barack Obama comes into power this month with an unprecedented history of interest and advocacy about infection prevention.Subscribe Now for Access
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