1. HB 197 Barbara W. Bradley, MS, RN, CIC Chief, Bureau of Infectious Disease Control Ohio Department of Health

2. Enactment of House Bill 197 HB 197 became law in November 2006 Requires Ohio hospitals to report performance measure data to the Ohio Department of Health for the purpose of public reporting Some measures are required to be selected from several national organizations: Centers for Medicare and Medicaid Services (CMS) The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) National Quality Forum (NQF) Agency for Healthcare Research and Quality (AHRQ)

3. Creation of Advisory Council By statute, a Hospital Measures Advisory Council was created and consists of: Director of Health, Council Chair Two members of the Ohio House of Representatives Two members of the Ohio Senate Superintendent of Insurance Executive Director of the Commission on Minority Health Representative from each of the following: Health Insurers, Small and Large Employers, Organized Labor, Physicians in General Practice, Physicians Specializing in Public Health, Children’s Hospitals, Hospitals, Health Care Consumers and Health Services Researchers

4. Creation of other Groups Each member of the Hospital Measures Advisory Council was required to appoint a data expert (Data Expert Group) An Infection Control Group was also required to provide information about infection measures The Advisory Council created Pediatric and Perinatal workgroups These group looked at measures specific to these populations

5. Process for Measure Selection The Data Expert Group met monthly to review each measure created by the organizations mentioned in the law The Data Expert Group created a set of criteria that would serve as guidelines for selection The specifications for each measure were examined and it was determined whether or not it met the majority of the criteria

6. Measure Selection Criteria Importance Do the measures reflect unequivocally important aspects of patient care? Preventability Can a poor score be prevented through proper care? Is excess variation in the data accounted for by factors unrelated to hospital quality? Genuine quality improvement Can a hospital’s rate be improved without improving quality? Data integrity Can a hospital accurately collect the data from its records? Does the measure adequately measure the construct it attempts to measure?

7. Measure Selection Criteria (cont.) Usefulness of data to the public Is the measure of use to consumers? Is the measure comprehensible to consumers? Do hospitals have a sufficient case load to accurately report quality? Burden Does calculating the measure place undue burden on hospitals? Evidence-based Is there scientific research demonstrating the accuracy and importance of the measure? Variance Is there sufficient variability in performance among hospitals to allow for comparison? National Quality Forum endorsement Is the measure endorsed by the National Quality Forum?

8. Next Steps Adopt rules reflecting recommended measures Six to nine month process Public comment period Public hearing Reporting of new measures to begin no earlier than October 2009 Development of the consumer website To be operational by January 2010

9. Hospital Infection Reporting Infection Control Group Many members from Director’s Advisory Committee for Emerging Pathogens Hospital Infection Control Professionals/Infection Preventionists included Infectious Disease Physicians included

10. Background of Hospital Infection Reporting APIC was conceived in 1972 in recognition of the need for an organized, systematic approach to the "control" of infections acquired as a result of hospitalization. (apic.org) Hospital reporting of infections into the CDC National Nosocomial Infection Surveillance System (NNIS) has been going on since the early 1970s.

11. Background (continued) The NNIS database was used to: Describe the epidemiology of Healthcare Associated Infections (HAI) Describe antimicrobial resistance associated with HAIs Produce aggregated HAI rates suitable for interhospital comparison.

12. Background (continued) The National Healthcare Safety Network (NHSN) was launched in 2005 as a new electronic surveillance system One of the enhanced features of this surveillance system is that while maintaining data security, integrity, and confidentiality, NHSN has the capacity for healthcare facilities to share data in a timely manner: Between a facility and public health agencies Between facilities (e.g., multihospital system)

13. NHSN - Purpose Collect data from a sample of healthcare facilities in the United States to permit valid estimation of the magnitude of adverse events among patients and healthcare personnel. Collect data from a sample of healthcare facilities in the United States to permit valid estimation of the adherence to practices known to be associated with prevention of HAIs. Analyze and report collected data to permit recognition of trends.

14. NHSN – Purpose (continued) Provide facilities with risk-adjusted data that can be used for interfacility comparisons and local quality improvement activities. Assist facilities in developing surveillance and analysis methods that permit timely recognition of patient and healthcare personnel safety problems and prompt intervention with appropriate measures. Conduct collaborative research studies with NHSN member facilities (e.g., describe the epidemiology of emerging HAI and pathogens, assess the importance of potential risk factors, further characterize HAI pathogens and their mechanisms of resistance, and evaluate alternative surveillance and prevention strategies).

15. Process Within Hospitals for Reporting Outbreaks in hospitals in Ohio are reportable to LHD/ODH based on Class C Reportable Infectious Diseases 24 outbreaks in hospitals have been reported since between 2002 and 2007 Infection Preventionist (IP) identifies infection based on reports from hospital staff, microbiology reports, personal observations IP conducts investigation with standard case definitions provided by infectious disease control manual/ NNIS/NHSN

16. Process Within Hospitals for Reporting (cont’d) Identified infections are addressed with the hospital staff and attending physician A line listing is prepared and the data is characterized by person, place and time Outbreaks and infection rates are shared with the Infection Control Committee JCAHO reviews infection control data when hospitals are accredited

17. Professional Organizations Multiple professional organizations are involved in mandatory reporting of HAIs across the U.S. Association for Professionals in Infection Control and Epidemiology (APIC) Society for Healthcare Epidemiology of America (SHEA) Infectious Disease Society of America/Ohio (IDSA/IDSO) Veterans Administration (VA) Center for Medicare and Medicaid Services (CMS) National Quality Forum (NQF) Joint Commission on Accreditation of Healthcare Organizations (JCAHO) AHRQ

18. What has ODH been doing? Bureau of Infectious Disease Control, Bureau of Health Surveillance Information and the State Epidemiologist have been collaborating on this issue for about 3 years Director’s Advisory Committee on Emerging Pathogens convened on this issue National APIC conferences bringing together IPs from across U.S. ODH staff traveled to Pennsylvania to visit and learn about Pennsylvania system

19. More of what ODH has been doing Monitoring legislation in Ohio and across the U.S. Hearing from and monitoring actions of consumer groups Made C. difficile reportable in 2006: mandatory reporting; case definitions; data analysis; education Participating with LHDs in investigations of HAIs Training staff across the state in infection control and epidemiology

20. Available Measures What do hospital IPs collect now? Catheter-Associated Bloodstream Infections (CA-BSI) Surgical Site Infections (SSI) Ventilator-Associated Pneumonia (VAP) Catheter-Associated Urinary Tract Infections (CA-UTI) Multiple other infections available for monitoring from NNIS/NHSN system

21. What offers the best transition to mandatory reporting for hospitals? Use data that is already being collected Use a standardized data collection system Provide reporting to meet the statute’s requirement Provide reports that are easily understood by healthcare professionals Provide reports that are easily understood by the general public

22. What are the anticipated needs? Public education Provider education Electronic system with easy access Staff to provide education and technical assistance

23. Statutory Reporting Guidelines April 1 st and October 1 st of each year Data that reflects performance over a twelve-month period Use the specifications and risk adjustment methodology recommended by the entity that developed or endorsed the measure

24. Statutory Reporting Guidelines The data collected must include measures from The Centers for Medicare and Medicaid Services The Joint Commission on the Accreditation of Healthcare Organizations The National Quality Forum The Agency for Healthcare Research and Quality The data collected may include other measures that the Hospital Measures Advisory Council recommends to the Director

25. CMS Infection Measures Surgical Care Improvement Project (SCIP) is a national quality partnership of organizations (CMS, JCAHO, NQF) There are 9 SCIP procedural measures intended to improve the safety of surgical care through the reduction of postoperative complications Five measures are currently required for CMS reimbursement and by the end of 2008 others will be required pending NQF endorsement.

26. AHRQ Infection Measures Agency for Healthcare Research and Quality (AHRQ) currently has two infection control measures Selected infections due to medical care This measure is intended to flag cases of infection due to medical care, primarily those related to intravenous (IV) lines and catheters. Post-operative sepsis This measure is intended to flag cases of nosocomial postoperative sepsis. These measures are not currently nationally collected

27. NQF Infection Measures NQF endorses a variety of measures from multiple National organizations including: CMS and JCAHO CDC IHI (Institute for Healthcare Improvement) Vermont Oxford Network NQF’s healthcare-associated infections consider infections in 4 clinical areas and 2 specialty areas

28. Statutory Guidelines Data reported must be made available to the public The public must be able to compare hospital’s performance in meeting the measures

29. Infection Control Group A group of Health care consumers Nurses Experts in infection prevention and control Provide information about infection control issues to the council as needed for the council to perform its duties

30. Proposed Charge To assess and recommend existing hospital associated infection measures that could be used to provide meaningful information to consumers.

31. What is happening nationally?

32. Questions?