The widespread prevalence and enormous cost of healthcare–associated infections (HAIs) constitute a major public health problem and patient safety concern.1 HAIs are one of the most preventable leading causes of mortality in the United States. Patients acquire HAIs—such as central line–associated blood stream infections, catheter-associated urinary tract infections, and surgical site infections (SSIs)—while receiving treatment for medical or surgical conditions. HAIs occur in all care settings, including acute-care hospitals, same-day surgical centers, dialysis centers, healthcare clinics, and in long-term care facilities, such as nursing homes and rehabilitation facilities.
In today’s healthcare system, HAIs are targeted for prevention and elimination; however, there are many challenges involved in addressing, and especially in eliminating, HAIs. The many different types of HAIs, the range of locations in which an HAI can occur, and the many ways in which an infection can spread mean that a wide spectrum of approaches are needed to address HAIs in the varied circumstances in which they can occur. Prioritization of efforts and the ongoing involvement of stakeholders from all parts of the healthcare system are key. In addition, reliable data are needed to understand the progress made in the battle against HAIs.
To address the national epidemic of HAIs, in 2009 the US Department of Health and Human Services (HHS) released the HHS National Action Plan to Prevent Healthcare-associated Infections, which was updated and expanded in 2012. The Action Plan established national goals for HAI prevention and identified the key actions needed to reduce, prevent, and eventually eliminate the burden posed by HAIs. In 2009, IMPAQ International and the RAND Corporation received a contract to conduct an independent, outside evaluation of HHS’s HAI prevention efforts, as guided and driven by the Action Plan. The 3-year evaluation was intended to assess the outcomes of HHS’s past efforts, and also to provide ongoing, formative feedback to Action Plan leadership to guide their efforts. This special issue of Medical Care presents results from the IMPAQ-RAND evaluation, along with related articles intended to examine the issue of HAIs from many angles.
MOTIVATION FOR THE NATIONAL HAI ACTION PLAN
Jeeva and Wright2 set the stage by describing the key components of HHS’s Action Plan and many of the activities that have been implemented as a result. They paint a picture of the multipronged public health approach taken by the Action Plan, describing key initiatives at the national, state, and regional levels, as well as some of the general approaches used to support the Action Plan and some of the challenges leading to the need for a formal evaluation.
EVALUATING THE ACTION PLAN
The next 4 articles discuss the results from the IMPAQ-RAND evaluation of HHS’s National HAI Action Plan.
Kahn et al3 begins this sequence by explaining the evaluation approach used to assess the Action Plan’s progress. As the authors explain, developing an adequate approach for evaluating the Action Plan was itself a challenge, as the model needed to be capable of tracking the many “moving parts” of the Action Plan as well as the relationship between components and how they change over time. The evaluation team used a “Context-Input-Process-Product” (CIPP) model for the evaluation. This model provides a structured, yet flexible tool that examines the Action Plan progress from 4 broad perspectives: the context in which the Action Plan began and developed; the inputs (programs and activities) selected by the Action Plan leaders; the processes associated with implementing the Action Plan–related efforts; and the products and outcomes of these efforts, both in terms of HAI rates and overall system capacity. To support the CIPP model, the evaluation team developed and applied a system framework, which allowed the team to understand what the Action Plan is doing and how it aims to facilitate change in the healthcare system to address the problem of HAIs; the system framework focuses on both the functions of the Action Plan (eg, infrastructure development, prevention practice adoption), and the properties with which those functions are carried out (eg, coordination and alignment, prioritization).
The next 3 articles describe applications of the CIPP evaluation framework as applied, respectively, to infrastructure development, HAI data and monitoring, and HAI research and adoption of HAI prevention practices. Mendel et al4 describe how the Action Plan developed a model of interagency coordination—including a dedicated “home” and culture of cooperation—at the federal level along with infrastructure for stimulating change through the wider healthcare system, such as incentives, changes in safety culture, and mechanisms for stakeholder engagement. In the next article, Kahn et al5 describe the infrastructure developed specifically to support the Action Plan’s data and monitoring program. This infrastructure builds upon technological advances and embodies a commitment to prioritization, coordination and alignment, accountability, stakeholder engagement, and the need for predictable resources. The next article in this group, Kahn et al,6 focuses on progress made in HAI research and in the adoption of HAI prevention practices. In particular, the article considers the Action Plan’s success in prioritizing research projects, translating findings from these projects into practice, and designing and implementing research projects in multisite practice settings.
ADDRESSING HAIs ACROSS MULTIPLE LOCATIONS AND LEVELS
HHS’s Action Plan was designed as a national plan with a broad scope. However, the success of the national plan depends on the corresponding success of efforts to address HAIs at multiple levels of the health system—ranging from the regions, states, and local levels, to the level of the individual hospital or healthcare clinic. Three articles provide a range of perspectives on addressing HAIs.
Siegel and Kahn7 examine the impact of HHS’s Regional Office projects in supporting the National Action Plan and in contributing to the federal effort to combat HAIs. As Siegel and colleagues explain, regional activities have the potential to play an important role in curbing HAIs across multiple states while also addressing local problems that extend across state borders.
Fischer et al8 take a focused look at the state and territorial efforts to address HAIs. In 2009, the Centers for Disease Prevention and Control awarded cooperative agreements to 51 state and territorial health departments to develop and implement strategies to reduce HAIs. This article describes different types of technical assistance delivered by Centers for Disease Prevention and Control public health analysts to state health departments, assistance that in many cases was key to the sustainability of such efforts.
Pegues,9 provides a hospital epidemiologist’s perspective on how the Action Plan affected a large hospital. The Action Plan set 5-year national-level goals for reducing the most common and serious HAIs. As Pegues explains, progress toward reducing targeted HAI rates at the University of California, Los Angeles has paralleled results observed on the state and national level, including declining infections associated with medical devices, surgical procedures, and some multidrug-resistant organisms. Challenges to implementing and sustaining HAI prevention practices at the hospital level include resource constraints and the expanding administrative burden of public reporting, among others.
ASSESSING THE IMPACT OF THE ACTION PLAN ON HAI RATES AND HAI PREVENTION SYSTEM CAPACITY
The ultimate goal of the Action Plan is to prevent and eliminate HAIs, and a key focus of the Action Plan is to identify HAI metrics, set targets, and develop data systems to support HAI surveillance. At the same time, strengthening capacity across the healthcare system is critical to ensuring that Action Plan efforts and investments establish a foundation for sustaining progress. Three articles address these issues.
The Surgical Care Improvement Project (SCIP) requires hospitals to comply with preventive measures to reduce the incidence of SSIs, a leading cause of HAIs and an area targeted by the Action Plan. Cataife et al10 consider whether hospitals with higher levels of compliance with SCIP measures have lower incidence of SSIs, finding that there is a clinically and statistically meaningful relationship between adherence to 2 SCIP measures and SSI rates.
Weinberg and Kahn11 identify and assess the strengths and weaknesses of the existing HHS data systems available for surveillance of major HAIs (ie, Medicare claims data, Healthcare Cost and Utilization Project, the Medicare Patient Safety Monitoring System, and the National Health Safety Network) and use the systems to examine trends in HAI rates. Although the data systems used in the analysis vary along desirable data system dimensions (eg, clinical validity, large sample size, representativeness), researchers found trends in HAI rates, which were generally concordant across the systems, increasing confidence in observed trends.
Although HAI prevention is the ultimate goal of the Action Plan, other important outcomes include the capacity of the healthcare system to achieve what Mendel et al12 refer to as “second order” learning, that is, “absorbing and acting upon new or accumulated knowledge—to drive and sustain such improvements.” Mendel and colleagues demonstrate the value of a systems approach to understanding capacity and sustainability of healthcare change. They report that key systems capacity and sustainability issues for the Action Plan center on coordination and alignment among stakeholders, infrastructure for data and accountability, cultural embedding of prevention practices, and uncertainty and variability in resources.
The final 2 articles in the collection assess what has been learned overall from the Action Plan and its evaluation.
Battles et al13 discuss HAI prevention research within the context of the overall Patient Safety Portfolio at the Agency for Healthcare Research and Quality (AHRQ). Their article describes the history of HAI prevention research at AHRQ, focusing on decisions to fund HAI projects and describing research results and contributions that have emerged from AHRQ-funded HAI projects.
In the final article in this volume, Kahn et al14 describes broad lessons learned from the evaluation of the Action Plan. Kahn focuses on the overall impact of the Action Plan on the campaign to eradicate HAIs and identifies lessons that are applicable to other large federal implementation efforts.
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