Building and Sustaining New Jersey s Program to Prevent Healthcare-Associated Infections

Transcription

1 Building and Sustaining New Jersey s Program to Prevent Healthcare-Associated Infections I. Background and Need Healthcare-associated infections (HAI) are a significant public health problem in the United States, contributing to substantial morbidity, mortality, and cost. Based on estimates from the Centers for Disease Control and Prevention (CDC), between five to 10 percent of hospitalized patients experience at least one HAI each year, resulting in an estimated 1.7 million infections and 99,000 deaths in In addition, it is estimated that HAIs are associated with nearly $33 billion in additional healthcare costs each year. Focused interventions such as the Johns Hopkins University-led effort targeting catheter-related bloodstream infections among patients in intensive care units in Michigan demonstrate that substantial reductions in infection rates are possible. Yet, while there are many simple and effective practices in hospitals that can dramatically reduce the incidence of HAI, the application of these best practices is inconsistent across facilities. On the national front the American Hospital Association (AHA) and other national healthcare stakeholders have been meeting with President Obama over the past month to discuss ways the industry could collaborate in restructuring the nation s healthcare system. Recently the AHA offered immediate cost-saving initiatives under a new campaign entitled Hospitals in Pursuit of Excellence, where the plan s specific objectives call for reducing the incidence of HAIs including: surgical site infections (SSI), central line-associated bloodstream infections (CLABSI), ventilator associated pneumonia (VAP), catheter-associated urinary tract infections (CAUTI), methicillin-resistant Staphylococcus aureus (MRSA) infections, and Clostridium difficile infections. A. Current HAI Activities in New Jersey In New Jersey, various groups have taken on the charge of preventing HAIs. First, New Jersey s government has identified the CDC National Healthcare Safety Network (NHSN) as the reporting framework for the State s HAI and MRSA surveillance and reporting programs. Multidrug-Resistant Organisms and Methicillin-Resistant Staphylococcus Aureus Within the New Jersey Department of Health and Senior Services (NJDHSS), surveillance for antimicrobial-resistant organisms has long been the charge of staff in the Infectious and Zoonotic Disease Program of the NJDHSS Communicable Disease Service (CDS). The New Jersey Administrative Code, which addresses communicable diseases, and state hospital licensure standards were modified in 1990 to require hospitals to submit antibiotic-resistant bacteria (including MRSA) data, and in 1991, a statewide hospital laboratory-based Epidemiology Surveillance System was established. In this early effort, reports were submitted monthly by each acute care hospital in New Jersey. These forms were checked for completeness upon receipt by staff in the NJDHSS Infectious and Zoonotic Diseases Program. Follow-up telephone calls were made as needed to ensure that all forms were submitted each month and that all isolates Page 1 of 20

2 were sent to the NJDHSS Public Health and Environmental Laboratories. In light of resource limitations, an effort to monitor antimicrobial resistance in a less labor intensive way was pursued. As a result, a module has been created in the Communicable Disease Reporting and Surveillance System (CDRSS) which would allow the collection and compilation of hospital antibiogram data for the purpose of developing a statewide antibiogram. This module will allow NJDHSS CDS to track antimicrobial resistance among clinically important bacteria, including MRSA, over time. Per legislation that was signed into law in August 2007, general hospitals in New Jersey are required to screen patients for MRSA and report the number of "hospital-acquired" cases of MRSA to the NJDHSS. The impetus behind this legislation was the experience of the Department of Veterans Affairs Pittsburgh Healthcare System and hospitals in Denmark and Holland which demonstrated substantial declines in HAIs caused by MRSA after they initiated an aggressive MRSA screening program. As the bill was making its way through the New Jersey Legislature, NJDHSS convened MRSA advisory and working groups and ultimately drafted guidelines for preventing and controlling MRSA transmission in the State s general hospitals. These guidelines were released in February Effective January 1, 2009, hospitals were to begin collecting: 1) the number of hospital-onset MRSA bloodstream infections per 1,000 patient days, monitored within a hospital unit where active surveillance testing (AST) for MRSA is being performed and 2) the percentage of eligible patients who are screened for MRSA upon admission to a hospital unit where AST for MRSA is being done. The NHSN Multidrug-Resistant Organism and Clostridium difficile-associated Disease (MDRO/CDAD) Module has been identified as the mechanism by which the above measures should be reported to NJDHSS. Hospitals began reporting the requisite MRSA data to the NJDHSS CDS via the MDRO/CDAD module when it became available in March To the extent that resources permit, the impact of AST for MRSA on hospital-onset MRSA infections will be assessed. Healthcare-Associated Infections An informal survey of New Jersey general acute hospitals indicates that individual hospitals have participated or are currently participating in a variety of collaboratives. Of note, prevention collaboratives organized by the New Jersey Hospital Association (NJHA) have targeted VAP, CLABSIs, and antimicrobial resistance focused on CAUTI. Currently, NJHA is one of twenty hospital associations working with Johns Hopkins University on their STOP BSI Campaign. In addition, Healthcare Quality Strategies, Inc., the Medicare-designated Quality Improvement Organization (QIO) for New Jersey, is implementing the MRSA Reduction Project as part of their Ninth Scope of Work contract with the Centers for Medicare and Medicaid Services (CMS). Recognizing the economic burden of HAIs, payors have also begun to implement and evaluate the use of financial levers to reduce HAI. Mirroring national trends, New Jersey Medicaid will no longer pay for preventable medical errors, including several HAI. NJHA has also been selected to participate in the CMS Gainsharing Demonstration and plans to track the impact of gainsharing on the incidence of selected types of HAI. Page 2 of 20

3 On October 31, 2007, Governor Corzine signed into law the Healthcare Facility Associated Infection Reporting and Prevention Act, N.J.S.A. 26: 2H-12:39 through The law requires New Jersey hospitals to collect and report information on HAI and related recommended processes of care to the NJDHSS Office of Health Care Quality Assessment (HCQA). In addition to establishing a coordinated statewide HAI surveillance effort, the law also calls for NJDHSS to publicly report facility-level rates of HAI in the annual New Jersey Hospital Performance Report. Starting January 1, 2009, all licensed general acute care hospitals were required to begin reporting on three healthcare-associated infections to NJDHSS HCQA: CLABSIs in all intensive care units (ICUs), SSIs following coronary artery bypass graft surgery (CABG), and SSIs following abdominal hysterectomy. B. Need and Proposed Activities Given the recently enacted HAI reporting legislation, which did not include state appropriations, it is necessary for NJDHSS HCQA to collect and analyze accurate and reliable HAI surveillance data both to inform HAI prevention and control measures and to publicly report this information in a meaningful way to consumers. Selection of the NHSN as New Jersey s HAI reporting framework allows NJDHSS to more effectively partner with groups focused on HAI prevention and maximize the utility of the collected HAI data in several ways. First, using the NHSN provides NJDHSS with a nationally accepted surveillance methodology and data warehousing capability with which to collect statewide HAI surveillance data, compare New Jersey performance against national trends, and assist policymakers in identifying State priorities. NJDHSS will also increase awareness and promote data-driven quality improvement through the analysis and sharing of information on facility-level rates of HAI with hospitals and the public. Finally, use of the NHSN provides NJDHSS and partners focused on HAI prevention with a shared data infrastructure that NJDHSS can leverage to track and evaluate the impact of HAI prevention efforts. Expansion of the NJDHSS HAI reporting program to include additional HHS Prevention Targets and the performance of assessments of the quality of data reported to the NHSN by New Jersey hospitals will strengthen these efforts. Activity B: HAI Detection and Reporting Public reporting of HAI relies on consistent, accurate data collection and reporting across hospitals. Leveraging the NHSN to support New Jersey s HAI reporting initiative provides an opportunity for all licensed general acute care hospitals in the State to report HAI-related information in a standardized way. However, the NHSN was developed as a voluntary and confidential system for HAI surveillance and reporting, and the CDC does not validate of the data currently being submitted to the NHSN. To ensure that the HAI data NJDHSS collects through the NHSN are reported and interpreted accurately and appropriately, funds will be needed to: Page 3 of 20

4 Develop a data validation methodology for the assessment of device-associated infection and surgical site infection data submitted to the NHSN; Audit the HAI data submitted by New Jersey general acute care hospitals to the NHSN; Strengthen capacity within hospitals to consistently and reliably report on an expanded set of HHS National Prevention Targets through the training of infection preventionists; and Strengthen state health department capacity in HAI surveillance and use of the NHSN through education of NJDHSS HCQA staff. As noted above, the recently enacted HAI reporting legislation did not include state appropriations. Funds are also requested to hire an analyst to provide additional technical support to hospitals as they expand their reporting to include additional HHS National Prevention Targets and to conduct analyses of the HAI data. Activity C: Establishing Prevention Collaboratives NJDHSS plans to collaborate with the NJHA Institute for Quality and Patient Safety through a Confirming Authorized Waiver. This would involve a two-year statewide collaborative to reduce the incidence of HAI, using a methodology model originally developed by the Cambridge, MA-based Institute for Healthcare Improvement. An Advisory Council would be convened to review healthcare infection prevention activities in the state and to identify areas of focus for the collaborative. Data will be gathered in order to develop specific targeted goals for the statewide initiative. Participating hospitals would attend learning sessions focusing of HAI prevention, as well as incorporating culture of safety in the organizations and the importance of involving senior leadership in improving quality. II. Accomplishments and Proven Capacity A. NJDHSS Office of Health Care Quality Assessment The NJDHSS HCQA is responsible for conducting evaluations of hospital quality in New Jersey and produces public reports that can be used by consumers, health care providers, policy makers, and regulators. NJDHSS HCQA collects and analyzes data using a broad set of metrics to evaluate hospital quality, including the CMS hospital quality process measures, the Agency for Healthcare Research and Quality (AHRQ) Quality Indicators, and outcomes following cardiac surgery. In addition, NJDHSS HCQA houses the Patient Safety Reporting Initiative, a confidential medical error reporting system designed to improve quality and patient safety through the promotion of more comprehensive reporting of adverse patient events, systematic analysis of their causes, and creation of action plans for improvement. NJDHSS HCQA staff include: six PhD-level professionals with backgrounds in public health, demography, epidemiology, community health, and economics; three professionals with graduate level training in public health and economics; one physician; and two registered nurses. In addition, NJDHSS HCQA retains the services of a dedicated programmer, and has well-rounded Page 4 of 20

5 additional staff ranging from a CPA to a computer programmer/mba who runs New Jersey s hospital discharge Uniform Billing system. Eight of our staff are well versed in the use of SAS to analyze large scale databases for public reporting as well as for more complex evaluations, and have research and data analysis experience ranging from five to twenty-five years. To guide our programs on hospital quality, including the program on HAI reporting, NJDHSS HCQA consults on a quarterly basis with the Quality Improvement Advisory Committee (QIAC), a Commissioner-appointed committee composed of health care quality experts, the state hospital associations, the Medicare QIO, academia, representatives from hospital administration, and consumer advocacy groups. Since the passage of the Healthcare Facility Associated Infection Reporting and Prevention Act, N.J.S.A. 26: 2H-12:39 through 12.45, in October 2007, NJDHSS has made significant and rapid progress in establishing a statewide HAI surveillance and reporting program in New Jersey. New rules were developed and adopted in November 2008 at N.J.A.C. 8:56. These regulations require general acute care hospitals to report HAI data using the NHSN. HAI reporting metrics are to be selected by the Commissioner in consultation with the QIAC. Hospitals will be notified by August 1 each year of required reporting metrics for the following calendar year. An HAI Technical Work Group was established to provide recommendations to the QIAC on various aspects of the HAI public reporting program. This Work Group is composed of representatives from the northern and southern New Jersey chapters of the Association of Professionals in Infection Control (APIC), infectious disease physicians, the state hospital associations, and health care quality experts. In September 2008, general acute care hospitals attended a one-day training conference led by CDC on the NHSN and HAI surveillance. In October 2008, hospitals attended a second one-day training conference led by CDC to review the MDRO/CDAD module. Two NJDHSS HCQA staff (Nancy Lin, ScD and Debra Virgilio, RN, MPH) have completed NHSN training and are actively providing technical support to hospitals. Starting January 1, 2009, hospitals began using the NHSN to report: CLABSI in all ICUs; SSI following CABG; and SSI following abdominal hysterectomy. NJDHSS HCQA is currently developing automated quality assurance protocols to monitor and provide feedback via to hospitals on data reported to the NHSN. NJDHSS staff provides additional support by telephone on a case-by-case basis. As of April 26, 2009, 100% of hospitals are enrolled in the NHSN, have Joined the New Jersey State HAI Group, and have Conferred Rights to NJDHSS to view their data. Sixty-six of the 72 hospitals have reported at least one month of data using the NHSN. NJDHSS plans to continue the aforementioned HAI surveillance and public reporting activities. As described in the Table below, many of the Objectives under Activity B will be achieved through the performance of legislatively mandated activities. Page 5 of 20

6 ACTIVITY B OBJECTIVES Year 1 Define which facilities will report HAI data to NJDHSS and type of HAI data to be reported and shared with NJDHSS Demonstrate that >80% of facilities in HAI surveillance plan have successfully enrolled, trained, and reported at least one month of data to NHSN Participation in monthly NHSN state users teleconferences Develop, in collaboration with CDC staff, and report state baseline data for two or more HHS Prevention Targets Year 2 All designated facilities have reported data Successfully produce and disseminate at least one report of aggregate HAI data relevant to the surveillance plan Develop, planned and implemented some validation of reported data Enabled electronic reporting of laboratory data to NHSN from at least 10% of participating facilities State report on quarterly basis on two or more HHS HAI Prevention Targets NJDHSS HCQA CURRENT/PLANNED ACTIVITIES Regulations adopted at N.J.A.C. 8:56 require all licensed general acute care hospitals to report HAI data to NJDHSS using the NHSN. HAI metrics to be reported are selected on an annual basis by the Commissioner in consultation with the QIAC. In 2009, hospitals began reporting on three HAI metrics. As additional HHS Prevention Targets are added, hospitals will be required to report these data to NJDHSS using the NHSN. As of April 26, 2009, over >80% of the 72 licensed general acute care hospitals in New Jersey have successfully enrolled in, trained on, and reported at least one month of data to NHSN. NJDHSS is currently participating in the monthly NHSN state users teleconferences. The legislation requires that NJDHSS report facility-level rates of HAI in the annual New Jersey Hospital Performance Report. NJDHSS anticipates that baseline data (2009 data) on CLABSI and two SSI metrics will be reported in the 2010 report. NJDHSS will work in collaboration with CDC to develop and report state baseline data on HHS Prevention Targets. NJDHSS staff is actively working to improve facility reporting to the NHSN. NJDHSS will work in collaboration with CDC and the New Jersey HAI Steering Committee (to be established) to develop and report aggregated state baseline data on HHS Prevention Targets in a manner that is aligned with the State HAI Plan. See Section III - Project Work Plan. NJDHSS anticipates that the increased attention on HAI arising from public reporting of facility-level HAI rates will promote interest in and use of automated laboratory surveillance systems by hospitals. These vendors are already actively working with the CDC to enable electronic reporting of these data to the NHSN. See Section IV - Performance Measures and Evaluation. Page 6 of 20

7 B. Formal Working Agreements with Firms with HAI Prevention Expertise NJDHSS has a successful history of partnering with NJHA on quality improvement initiatives, including a collaborative to prevent HAI. In 2006, with funding from the Healthcare Foundation of New Jersey, NJDHSS partnered with the NJHA Institute for Quality and Patient Safety to establish a statewide collaborative to reduce the incidence of CAUTI across hospitals, long term care facilities, home health agencies and rehabilitation hospitals. At the end of two years, this work resulted in a 20% reduction in CAUTI. As described below, NJDHSS is proceeding with an accelerated purchase through Confirming Authorized Waiver with NJHA to establish a statewide HAI Prevention Collaborative that will be aligned with the State HAI Plan. C. Timely Completion of Activity A, Alignment Across Activities, and Sustainability 1. Timely Completion of Activity A Funds are not requested for Activity A. Timely completion of Activity A will be achieved as follows: State HAI Plan coordinator identified. We anticipate that this individual will be identified from existing staff in either the NJDHSS HCQA or NJDHSS CDS. Multidisciplinary group (HAI Steering Committee) convened. As described above, NJDHSS HCQA currently consults with a HAI Technical Work Group and QIAC to guide development of the New Jersey HAI Public Reporting program. NJDHSS anticipates that the multidisciplinary HAI Steering Committee will be composed of the members from these existing advisory groups. State HAI Plan drafted and submitted to HHS no later than January 1, New Jersey has certified that a state HAI plan will be submitted to HHS no later than January 1, NJDHSS is proceeding with an accelerated purchase through Confirming Authorized Waiver with the national APIC to develop New Jersey s State HAI Plan; this will be supported with funds from the Preventive Health Block Grant. State baseline for HHS prevention targets. Starting January 1, 2009, general acute care hospitals began using the NHSN to report on CLABSI in all ICUs and two SSI metrics. State HAI Plan approved by HHS. NJDHSS is proceeding with an accelerated purchase through Confirming Authorized Waiver with the national APIC to develop the State HAI Plan. Should revisions be required by HHS, NJDHSS will work with the contractor to ensure that these revisions are completed according to HHS requirements in a timely manner. Quarterly reporting on HHS Prevention Targets. As described above, all general acute care hospitals in New Jersey are required to use the NHSN to report HAI data to the Department. As the New Jersey HAI public reporting program continues to expand to include additional HHS Prevention Targets, hospitals will be required to use the NHSN to collect and report these data. Page 7 of 20

8 2. Alignment of Activities B and C with the State HAI Prevention Plan As noted above, New Jersey's State HAI Plan is still in development in collaboration with the CDC. However, the following decisions have been made regarding our plan and are reflected in this proposal. 1. Phase-in of infection types. CDC has 13 guidelines for hospitals on infection control and prevention, which contain almost 1,200 recommended practices. We have considered prioritization and phase-in critical to the development of a state plan. New Jersey's QIAC has decided to focus first on three types of infections: CLABSI in all ICUs; SSIs following CABG; and SSIs following abdominal hysterectomy. Our proposal regarding public reporting and training reflects that prioritization. NJDHSS anticipates that New Jersey s State HAI Plan will specify a schedule for phasing in other infection types and that the ARRA-funded work will continue to track this prioritization. 2. Emphasis on public reporting mutually reinforcing training and consultation. New Jersey's work on quality improvement in healthcare has consistently combined public reporting by facility with consultation and training. Training must include both intensive work on accurate public reporting itself and consultation regarding quality improvement infrastructure and best practices. These core principles are the bedrock of our developing State HAI Plan and are clearly reflected in our proposal. 3. Sustainability As described in the Accomplishments and Proven Capacity section, much of the program capacity and infrastructure for supporting HAI surveillance and reporting in New Jersey is already being built to meet legislative requirements. As such, these activities would continue after the funding period expires. The proposed education activities for hospital personnel represent critical short-term investments that are intended to build skills sets, knowledge, and working relationships sustainable beyond the project period. The general one-day training conference on the NHSN would provide infection preventionists with the basic tools needed to accurately and consistently collect and report data. The on-site audits will be designed to provide hospitals with specific actionable information on the areas in which improvement in HAI surveillance or reporting is needed (e.g., through review of discrepancies in the identification of cases of infection). Participation in Preventive Collaboratives is intended to bring together and strengthen constructive interactions among key personnel within the hospital as well as to establish learning networks among hospitals to share information on effective implementation strategies and/or tools. Funded education of NJDHSS HCQA staff will allow them to develop substantive area knowledge in HAI surveillance and the NHSN. This acquired expertise will better equip NJDHSS staff to provide technical support to hospitals and to partner with other groups in the State working on HAI prevention. Page 8 of 20

9 Development of a data validation program would provide NJDHSS with a methodology and data collection tools, developed by national experts in infection prevention, that can be used in future audits. Performance of the initial audit at this, the start of New Jersey s HAI reporting program, would identify deficiencies in data quality NJDHSS can work to address (e.g., through targeted guidance, Webinars on specialized topics, refinement of data monitoring protocols, etc.); we expect that such actions would have a lasting impact on the quality of data reporting. In addition, the lessons learned from the audit would inform our analysis and interpretation of the HAI data. D. Ability to Quickly Initiate Proposed Activities To ensure a quick start on proposed Activity B activities, we are proceeding with an accelerated purchase through Confirming Authorized Waiver with national APIC to: (1) develop a data validation program and (2) conduct an audit of the HAI data submitted by New Jersey general acute care hospitals to the CDC NHSN. Under Activity C, we are proceeding with an accelerated purchase through Confirming Authorized Waiver with the New Jersey Hospital Association to establish a statewide Prevention Collaborative. These activities comprise over 75% of the budget for our proposed activities. III. Project Work Plan A. Project Objectives and Activities 1. Work Plan for Activity B - HAI Detection and Reporting The NJDHSS HCQA plans to continue all of the aforementioned HAI surveillance and public reporting activities during the project period. The New Jersey HAI reporting program described above will be enhanced in the following ways during the project period. Objectives Develop a data validation methodology for the assessment of device-associated infection and surgical site infection data submitted to the NHSN; Audit the HAI data submitted by New Jersey general acute care hospitals to the NHSN; Strengthen capacity within hospitals to consistently and reliably report on an expanded set of HHS National Prevention Targets through the training of infection preventionists; and Strengthen state health department capacity in HAI surveillance and use of the NHSN through education of NJDHSS HCQA staff. Project Activities Contract: Development of Data Validation Program and Performance of Data Audit We are proceeding with an accelerated purchase through Confirming Authorized Waiver with the national APIC to: (1) develop a data validation program sustainable in New Jersey for the evaluation of device-associated infection and surgical site infection information reported to the Page 9 of 20

10 CDC NHSN; and (2) perform a data audit in a sample of New Jersey general acute care hospitals. The data validation program developed by national APIC would include: (1) a methodology for selection of medical charts for review; (2) data collection forms, databases, and protocols to be used by surveyors; (3) data analysis plan; and (4) recommendations on the frequency of auditing and method for selection of hospitals to be audited. We anticipate that development of the data validation program would be achieved via: (1) weekly teleconferences between national APIC, or its affiliates, and NJDHSS HCQA staff, with participation of HAI Steering Committee members as appropriate; (2) provision of the draft program methodology and materials for review by NJDHSS HCQA staff and HAI Steering Committee members; and (3) revisions and finalization of the data validation program. Communication between meetings will be via . To perform an audit of the HAI data submitted to the NHSN by New Jersey hospitals, national APIC would be responsible for: (1) recruitment of New Jersey-based or regional surveyors; (2) organization and provision of at least one train-the-trainer session to train surveyors on NHSN definitions and New Jersey audit data collection forms and protocols; (3) scheduling, coordination and other preparatory activities; (4) performance of on-site audits; (5) data analysis; and (6) presentation and preparation of a report describing audit findings. Increasing NJDHSS HCQA Staff Capacity in HAI Surveillance and/or NHSN As noted above, the HAI reporting legislation was passed without state appropriations. Existing staff assumed additional responsibilities to implement this new program. Funds are requested to hire a data analyst to provide additional technical support to hospitals as they expand their reporting to include additional HHS National Prevention Targets, conduct analyses of the HAI data, and prepare summary reports. Funds are requested to support out-of-state travel by a NJDHSS HCQA staff member to attend two national meetings (e.g., CSTE, APIC), or workshop(s) developed by CDC, on HAI surveillance or the NHSN, over the course of the project period. Attendance at the two national meetings will provide an opportunity for on-going educational awareness/training to NJDHSS HCQA staff by participating and networking with national and other state experts on HAI surveillance and NHSN activities. Funds are also requested to support intra-state travel by NJDHSS HCQA staff to attend 10 oneday on-site audit visits. This will provide an opportunity for NJDHSS to evaluate the implementation of surveyor audits. In addition, NJDHSS staff will have the opportunity to gain insight into how HAI prevention, surveillance, and reporting activities are integrated into the workflow at individual facilities and potential impacts on the data reported to the NHSN. Training/Education For New Jersey Acute Care Hospitals To support expansion of the HAI Reporting Program to include additional HHS National Prevention Targets, funds are requested to hold a one-day training workshop for hospital infection preventionists. Content may include: NHSN definitions and protocols on new reporting Page 10 of 20

11 metrics; case examples; and review of NHSN or introduction to more advanced NHSN capabilities as requested by hospital infection preventionists. Timeline and Outputs The Table below describes the proposed tasks, timeline, and outputs for Activity B. TASK TIMELINE OUTPUT I. Development of Data Validation Program and Audit Selection of vendor Month 1-2 Contract awarded Development of Months 3-7 Draft methodology and materials methodology and materials Revisions and finalized Months 8-10 Finalized data validation program validation program Recruitment and training of surveyors Months % of surveyors recruited by Month % of surveyors successfully trained (e.g., passed training evaluation module) by Month 13 On-site audit Months >75% of visits scheduled by Month 15 >50% of on-site audits completed by Month 16 Analysis and interpretation of results Revisions and finalized report of audit findings Months Months Draft report of audit findings Final report from contractor describing audit results II. Training/Education of NJDHSS Staff Train/Hire new staff Existing staff enrolled in NHSN by Month 4 (Dr. Holloway-Owens) New staff enrolled in NHSN by Month 18 Attendance at annual national conference(s) or CDC-led workshop for state health department staff III. Outreach/Training of Facilities In person training workshop Attendance at one conference/ workshop in each year during the project period Participation in CDC NHSN state users teleconferences Aggregated data report of state baseline data, developed in collaboration with CDC staff, by Month 12 Workshop evaluation forms completed by participants Page 11 of 20

12 2. Work Plan for Activity C Establishing a Prevention Collaborative NJDHSS plans to collaborate with the New Jersey Hospital Association (NJHA) Institute for Quality and Patient Safety (Institute) through a Confirming Authorized Waiver. This would involve a two-year statewide collaborative to reduce the incidence of HAI, using a methodology model originally developed by the Cambridge, MA-based Institute for Healthcare Improvement and used by the Institute in several prior statewide collaboratives in New Jersey. The Institute s purpose is to assist hospitals in best practices, patient safety, improved quality and efficiency. The Institute has extensive experience in working with hospitals and clinical staff to implement evidence-based best practices to achieve success in reducing HAI. In 2004, the Institute initiated a statewide collaborative designed to reduce the incidence of CLABSI and VAP working with 33 New Jersey acute care hospital ICUs. Over the course of two years, these hospitals were able to reduce the incidence of CLABSI by 73% and the incidence of VAP by 55%. In 2006, with funding from the Healthcare Foundation of New Jersey and in partnership with NJDHSS, the Institute began a statewide collaborative to reduce the incidence of CAUTI across hospitals, long term care facilities, home health agencies and rehabilitation hospitals. Working with 150 organizations, the Institute developed a CAUTI Prevention Bundle and implemented consistent interventions and developed standardized outcome measures. After two years, there was a 20% reduction in CAUTI. Finally, NJHA was one of twenty hospital associations selected to work with Johns Hopkins University on their STOP BSI Campaign. The proposed NJDHSS/Institute collaborative would utilize a similar methodology as has been used for prior collaboratives. An Advisory Council would be convened, including regional chapters of the APIC, the state chapter of SHEA, Healthcare Quality Strategies, Inc., the New Jersey Council of Teaching Hospitals, representation from various physician organizations (e.g., Medical Society of NJ), NJDHSS staff, academia, and Institute staff to review the State HAI Plan to identify areas of focus for this new collaborative. Consideration will be given to current infection data reported and any new indicators to be added over the course of this two year project. The Council will review and develop an implementation plan. The Council will meet at least quarterly or as needed. Over the course of the two year project, participating hospitals would attend two one-day learning sessions with content focusing on HAI prevention as well as culture of safety in their organization, key strategies of highly reliable organizations and the importance of involving senior leadership in all patient safety improvement work. At the first learning session hospitals would be expected to develop an AIM statement and to plan for their first few PDSA cycle (Plan-Do-Study-Act). Nationally known faculty members and state experts will assure that participating facilities have evidence based best practices in the prevention of many HAI, including ongoing work with CLABSI, VAP and CAUTI. Additional content areas will include any new foci as identified by the Council, such as SSI prevention. Participants will maintain continual contact with each other, faculty members and NJDHSS program directors via conference calls, , a dedicated listserv, a password-protected dedicated website where resources and data can be shared, and site visits. A final one day educational session will focus on outcomes and the opportunity to share best practices and implementation strategies. Data and outcomes will be evaluated and assessed, and a final report developed. Page 12 of 20

13 A project manager will be hired by the Institute to oversee this initiative and to provide technical assistance to participants in the areas of performance improvement, data collection and using data to implement evidence-based best practices. This individual will be the key contact person for all of the participating hospitals and be a resource for them in data collection through NHSN. The project manager will ensure that a senior leader is part of all hospital teams and will provide them with resources to help their teams in their work. Senior leadership of these organizations will: incorporate this project into the strategic initiatives of their organizations; make sure that the project team includes appropriate representation from the organization to actively support the team s plans; champion the implementation of improvement interventions and the spread of a culture of safety and quality; provide resources to support the teams, including materials and time necessary for learning sessions, conference calls and webinars. Monthly conference calls and webinars will focus on new content in performance improvement, highly reliable organizations, safety culture and infection prevention. Other calls will provide opportunities for organizations to report out on what they have been working on and what successes/barriers they have identified so that everyone can share in their learning. At the end of this project, the Institute and NJDHSS will collaborate on the final educational session and reports, the website will be reworked and organized, and then opened up for all hospitals to learn from the resources and tools gathered. Hospitals will also have developed strategies to spread their work throughout their organizations. Mentor hospitals will be identified to share in the key best practices. The Table below provides the tasks and timeline for Activity C. ACTIVITY I. Set up project administration. 1. Convene Advisory Council to review plans. 2. Conduct routine communication with council members for ongoing feedback and needed adjustments in plans, resources, training curriculum, etc. 3. Hire Project Manager , 5, II. Identify and engage N.J. hospitals in planning and implementing HAI Collaborative. 4. Identify project leader at each hospital. 5. Develop project communication plans, list servs, newsletters, Web site, contact info of project leader & TA staff. III. Determine measures to be collected throughout the project 6. Identify measures, method of data collection and distribute to all participating hospitals. Ensure all hospitals are entering data into NHSN. Identify hospitals which have participated in prior collaborative, including VHA and IHI. 8 9 Page 13 of 20

14 ACTIVITY 7. Hospitals to provide baseline data for all measure sets , 5, IV. Develop training and educational tools and resources in HAI Prevention 8. Develop training curriculum. Gather training materials from prior NJHA collaborative related to infection prevention. Ensure all participating hospitals also in JHU Stop BSI 9. Design a training resource manual for hospital participants 10. Review by Advisory Council and obtain several rounds of edits and revisions. 11. Work with NJHA Design & Print department and coordinate design of tools/resources, including reference manual cover design, and order printed binders and tabs. 12. Order/print copies of tools/resources. 13. Identify topics for possible face to face meetings, Webinars, conference calls V. Provide education and training for hospital staffs. 14. Plan the statewide kick-off learning session. 15. Hospitals develop individualized AIM statements, goals and implementation strategy for their organization. Ongoing revision and redesign. 16. Provide regular consultation and TA to hospitals. 17. Develop schedule of monthly conference calls and/or Webinars 18. Plan for and implement second one day learning sessions. VI. Measure effectiveness of Collaborative. 19. Develop reporting tools and forms. 20. Provide TA for data collection reporting. 21. Collect hospital monthly data. 22. Collect participating hospitals outcomes data. 23. Prepare hospital-specific data reports and aggregate data reports. 24. Evaluate and assess outcomes. 25. Prepare project reports Page 14 of 20

15 ACTIVITY , 5, VII. Promote HAI Collaborative with NJ hospitals through a statewide communication campaign on effectiveness. 27. Initiate a campaign to announce the project and availability of all resources. 28. Educate all hospital CEOs/CNEs through varied communication channels, physician & nursing constituency groups, QI Education & Performance Improvement Committee, etc.) 29. Hold a statewide conference to highlight the initiative s results/outcomes. B. Staffing Nancy Lin, ScD (Co-Principal Investigator / Program Lead): Dr. Lin is a Research Scientist in NJDHSS HCQA. An epidemiologist and health services researcher with 10 years of data analysis experience, Dr. Lin manages the development and day-to-day operations of the New Jersey HAI public reporting program. Dr. Lin is the primary NJDHSS liaison to the CDC, other states, and the New Jersey QIAC and HAI Technical Work Group on issues relevant to HAI public reporting. She is responsible for: program and policy development; development of approaches to assess the quality of HAI data reported by hospitals; technical support to hospitals; and state reporting requirements to hospitals; and design and performance of analyses of HAI data. She will be responsible for overseeing implementation of the grant activities, including evaluation of project progress and measurement of its anticipated outcomes. (100% in-kind) Christina Tan, MD (Co-Principal Investigator): Dr. Tan is the State Epidemiologist and Medical Director of NJDHSS CDS. Dr. Tan will serve on the HAI Steering Committee and will assist in review and interpretation of aggregated data reports describing New Jersey progress on HHS National Prevention Targets. (4% in-kind) Corey Robertson, MD, MPH: Dr. Robertson is currently the Medical Director of Emerging Infectious Diseases at NJDHSS. In this position, Dr. Robertson s responsibilities include the development of epidemiology and surveillance capacity building activities, especially those related to emerging infectious diseases. He also serves as co-chair of NJ CAUSE (a statewide task force against antimicrobial resistance), the current chair of the Antimicrobial Resistance Collaborative (a partnership of NJHA and the Healthcare Foundation of New Jersey), and the Get Smart project coordinator for New Jersey. Dr. Robertson will act as a clinical consultant and is the primary CDS contact regarding NJDHSS MRSA reporting efforts. (4% in-kind) Cynthia Kirchner, MPH: Ms. Kirchner is Senior Policy Advisor in the Office of the Commissioner, and Office of Policy. Ms. Kirchner oversees the NJDHSS HCQA and is a member of the Senior Staff at the Department of Health and Senior Services. She will work on the policy aspects, implementation of the grant activities from a Department-wide perspective, and assist in the outcomes related to all activities of the HAI reporting program. (4% in-kind) Page 15 of 20

16 Emmanuel Noggoh, MS: Mr. Noggoh is the Director of NJDHSS HCQA. Mr. Noggoh oversees HCQA programs which include cardiac services data collection and reporting, hospital quality reporting programs, and patient safety initiatives. Mr. Noggoh will oversee program and grant activities to ensure adequate staffing and resources, manage consultant/contractual issues, and will provide analytical expertise on data validation methodology and interpretation of the HAI data. (20% in-kind) Debra Virgilio, RN, BSN, MPH: Ms. Virgilio is a Research Scientist in NJDHSS HCQA. Ms. Virgilio has over 25 years of nursing experience in positions within hospitalsand public health environments. Her expertise encompasses clinical, quality review and research, and maintenance of institutional/organizational standards. She will act as a clinical consultant. (10% in-kind) Paul SanFilippo: Mr. SanFilippo is the lead programmer and database administrator supporting the Office of the Commissioner. In this capacity, he developed the Integrated Cardiac Services Processing System, which includes the New Jersey Cardiac Catheterization Data Registry, New Jersey Open Heart Surgery Registry, and New Jersey Acute Stroke Registry. Mr. SanFilippo is responsible for automating data quality monitoring processes and production of analytic reports of HAI data (e.g., hospital-specific feedback reports on HAI rates). (10% in-kind) Sharon Sedlak, MBA: Ms. Sedlak is a Research Scientist in NJDHSS HCQA and is an accountant with 25 years of experience in NJ state government. Ms. Sedlak will be responsible for budget tracking related to this grant. (10% in-kind) Letitia M. Holloway-Owens, PhD, MPH, MS, BSMT: Dr. Holloway-Owens is a certified Medical Technologist with over 15 years experience. She has extensive leadership experience promoting various public health initiatives and alliance-building through strategic marketing, planning, development, implementation, evaluation, training and education. Dr. Holloway- Owens currently supports the cardiac services data collection and reporting program in NJDHSS HCQA. For the HAI reporting program, she will be assuming new responsibilities in assisting the Program Lead on all of the aforementioned tasks, as needed, and in particular, in providing technical assistance to hospitals and analytic support for tracking process and outcome measures related to the Prevention Collaborative. To meet these new responsibilities, Dr. Holloway-Owens will complete the web-based NHSN training modules developed by CDC and enroll in the NHSN; participate in the monthly NHSN state users teleconferences; and to the extent that resources allow, participate in training workshops in HAI surveillance or the NHSN as they are developed by CDC (30% in-kind) Research Scientist 2 (new position): The Research Scientist will hold a graduate level degree in public health, epidemiology, or a related field; experience in quality improvement or infection prevention is preferred. Required computer skills include experience using database and statistical programming software (e.g., SAS). Under the supervision of the Program Lead, this individual would be responsible for: coordination of day-to-day activities; monitoring of the monthly submission of data; analyses of the HAI data; and would become the key technical support contact for participating hospitals. To meet these responsibilities, this individual is expected to complete the web-based NHSN training modules and enroll in the NHSN; participate Page 16 of 20

17 in the monthly NHSN state users teleconferences; and participate in other training workshops in HAI surveillance or the NHSN as they are developed by CDC. (100%) C. Limitations of the Implementation of the HAI Surveillance and Prevention Program As described above, neither the HAI public reporting legislation nor the MRSA reporting legislation received state appropriations. Existing staff within NJDHSS have assumed additional responsibilities to implement these new reporting initiatives. While expansion of HAI surveillance to other health care settings is desirable, there is currently no NJDHSS capacity to expand surveillance beyond the acute care setting. Without additional staff, there is also limited capacity to analyze the data reported by hospitals to the NHSN in epidemiologic investigations. In addition, a 2009 national survey conducted by APIC found that hospital infection prevention departments are experiencing severe staffing and resource constraints. The New Jersey HAI Technical Work Group identified similar challenges, with infection preventionists expressing strong concerns that competing demands have led to a substantial reduction in the time and effort they can focus on surveillance and infection prevention. Currently, New Jersey's infections public reporting statute does not allow hospitals to transmit identified patient data for the CDC measures to the Department. This limits our ability to comprehensively assess the burden associated with HAIs (e.g., estimate costs via linkage to billing data). However, we have discussed with the legislature the need to amend the statute and the rules to allow the collection of NHSN data with patient identifiers, and we anticipate this legislative change during calendar year D. Summary HAI Reports, Dissemination Strategy, and Targeted Audiences The HAI public reporting legislation calls for NJDHSS to publish information on facility-level performance on HAIs in the annual New Jersey Hospital Performance Report, a publication intended to reach several audiences including consumers, health care providers, and policymakers. These data will be made available on the New Jersey Hospital Performance Report website, an interactive website designed to present information on facility-level performance and allow individuals to conduct targeted queries on a range on hospital quality metrics. Provision of report cards to health care providers has been shown to track with improved performance. Data on CMS surgical infection prevention measures were first reported in the Hospital Performance Report in 2007 (using 2006 data). Comparing two years of publicly reported data, from 2006 to 2007, the overall percentage of New Jersey surgery patients (among selected surgeries) who received timely discontinuation of antibiotic prophylaxis increased from 86% to 90%; during that time, the gap in quality between high performing and low performing hospitals narrowed from 29% to 19%. NJDHSS will also produce a report describing aggregated state baseline data on HHS Prevention Targets, in collaboration with CDC staff, to meet the Objectives of Activity B. As reporting continues and to the extent that resources allow, NJDHSS may produce updated reports to describe trends in HAI over time in order to evaluate the impact of HAI prevention activities. We anticipate that the aggregated data report will be provided to the HAI Steering Committee and Page 17 of 20

18 QIAC to aid them in monitoring progress on reducing HAI and evaluating HAI prevention priorities for the State. Other target audiences include groups engaged in HAI prevention activities (e.g., Medicare QIO, state hospital associations, local APIC chapters); sharing this information would provide these groups and NJDHSS with the opportunity to plan and partner on HAI prevention activities. Finally, electronic copies will be made available to health care providers and the public via the NJDHSS HCQA website. E. Web-Based Communication Tools As described above, information on facility-level performance on HAI will be posted as part of the interactive New Jersey Hospital Performance Report website. As the HAI public reporting program expands to include reporting on additional HHS Prevention Targets, these data will be added to the website. Web-based communication tools developed as part of Activity C are described in the Project Work Plan. F. Surveillance System and Compatibility with NHSN Definitions NJDHSS requires that hospitals report HAI data using the NHSN. G. Plan to develop a sustainable infrastructure Despite economic challenges, New Jersey s hospitals offer excellent quality of care. This is demonstrated by the annual New Jersey Hospital Performance Report. New Jersey hospital performance has improved significantly since the initial Jencks report in 2000, in which the federal Medicare program ranked New Jersey 41 st among states in terms of how well hospitals/physicians adhered to well established standards for heart attack, pneumonia, and congestive heart failure. New Jersey is now above national norms on most quality measures. In the latest version of the report using 2007 data, released in September 2008, New Jersey s hospitals exceeded national measures in 20 of 23 national best practice measures evaluating care for heart attack, pneumonia, heart failure and surgical care. The federal Agency for Healthcare Research and Quality ranked New Jersey second in their state snapshots when considering best performing states across all measures in hospital care. The continued sustainability of the quality measures has been proven for New Jersey hospitals over the past several years. This is also true for the cardiac surgery in New Jersey s Cardiac Surgery Hospital Report. Overall, the State s heart centers have achieved a 53.7 percent reduction in operative mortality between 1994 and 2006 (latest data released in April 2009). Public reporting of facility-level infection rates - with appropriate assessments of the quality of reported data and evaluation of unintended consequences that may arise - will provide an opportunity to make similar gains in preventing HAI. NJDHSS plans to explore sustaining these efforts in the following ways: Page 18 of 20

19 NJDHSS staff will consult with CDC on the development of lower-cost or free refresher courses (e.g., live Webinars) to support continuing education of infection preventionists; we envision that these will be led by NJDHSS staff, solely or in conjunction with CDC. As noted above, we have discussed with the legislature the need to amend the statute and the rules to allow the collection of NHSN data with patient identifiers. Contingent on gaining access to patient identifiers, NJDHSS will evaluate alternate or supplementary approaches to assessing data quality. Potential strategies include linkage of the NHSN data with hospital billing data and/or comparison to internal data sources (e.g., NJDHSS CABG registry used to track cardiac outcomes also collects selected information on infections). The validation program proposed under Activity B is designed to be sustainable for New Jersey in several aspects: (1) NJDHSS will be able to apply the validation methodology and data collection tools developed by APIC in future audits; and (2) APIC will train New Jersey-based or regional surveyors for the initial audit, thereby building local capacity to perform audits in the future. With an established data validation methodology in place, NJDHSS will explore contracting for future audits via the RFP process. NJDHSS will actively work with NJHA and other quality improvement organizations to identify potential sources of funding (e.g., foundations) to support future prevention collaboratives. H. How Proposed Work Complements Other HHS-Funded Activities in New Jersey The NJDHSS CDS uses the CDRSS, a NEDSS-based patient-centric application for managing notifiable communicable disease reports from local public health and healthcare partners statewide. During 2002 to 2004, report volume doubled with the introduction of electronic laboratory reporting (ELR) from one commercial laboratory. To continue improvements in reporting, during June 2008 to the present, CDS obtained federal funding from ASPR to launch and implement ELR pilot projects with six selected hospital laboratories. Hospital laboratories followed an NJDHSS-developed ELR technical manual that specifies acceptable file formats (e.g., HL7 standards per PHIN specifications, custom XML schema, LOINC/SNOMED mapping with hospital local codes), mode of electronic transmission, and test plans for ELR interfaces. NJDHSS's proposed HAI project and the existing CDS ELR initiatives will complement each other, through the potential for enhancing data collection and analysis purposes. IV. Performance Measures and Evaluation Plan The New Jersey HAI Steering Committee established under Activity A will be responsible for performance measurement. The Steering Committee will make formal HAI performance reports to the Quality Improvement Advisory Committee on a quarterly basis for the duration of the grant period. These reports will be reviewed by the QIAC and revised per QIAC review. At each meeting of the Steering Committee, the following three questions will be on the agenda: 1. How is the project proceeding in meeting its workplan, and in meeting ELC-defined Activity Objectives and Outputs? 2. Are we spending project funds appropriately? 3. How are we succeeding in reducing healthcare-associated infections? Page 19 of 20

20 These three questions will drive our performance measurement. We will measure and evaluate performance on the following parameters, corresponding to the three questions listed above: 1. Project Measures: Meeting Project Objectives and Milestones. 2. Financial Integrity Measures: Financial Tracking and Reporting. 3. Outcomes Measures: Reduced Rates of Selected Healthcare Associated Infections. These three parameters will be captured using the following specific measures and data sources. PARAMETER 1. Project Measures 2. Financial Integrity Measures 3. Outcomes Measures MEASURES TO BE PRESENTED BY STEERING COMMITTEE AND REVIEWED BY QIAC A. Overall Milestones: Tasks under Timeline and Output Tables above completed on schedule. B. Staffing: Program staff hired and trained relative to staffing plan, retained or backfilled as vacancies arise. C. ELC Outputs: Activity-specific Objectives and Outputs met A. Contractors Spending Project Funds Appropriately B. Quarterly Reporting of Use of Funds per Section 1512(c) of Division A of the ARRA: All ARRA funds are accounted for in separate and distinct accounts in the State s central financial system NJ Comprehensive Financial System. A. Rate of selected HAIs in New Jersey Hospitals of Specific Types B. Overall rate of selected HAIs in New Jersey hospitals DATA SOURCE Steering Committee Reporting NJDHSS and Contractor Staffing Reports NJDHSS and Facility Level Reporting A.1 Monthly Reporting on Expenditure of Project Funds Contractor will submit invoice to NJDHSS monthly. A.2 Program Staff review invoices against Timeline and Output Tables. A.3 Financial Services review and process payments in accordance with NJCFS payment guidelines. Certification of financial reporting by NJDHSS Division of Management and Administration, Financial Services Office. NJDHSS and Facility Level Reporting Aggregated state baseline NHSN data compared to ongoing trended statewide rates of selected HAIs Page 20 of 20