Kahn, Katherine L. MD*,†; Mendel, Peter PhD*; Leuschner, Kristin J. PhD*; Hiatt, Liisa MS*; Gall, Elizabeth M. MHS‡; Siegel, Sari PhD‡; Weinberg, Daniel A. PhD‡
Health care–associated infections (HAIs) have long been the subject of research and prevention practice. When research provides evidence that a particular intervention or practice has the potential to improve HAI outcomes, clinicians, policymakers, safety experts, and stakeholders seek to identify mechanisms and assign responsibility for translating research to practice. However, the science of translating research to practice is still evolving.1–4 Translation and implementation sciences have been the subject of much discussion in recent years, and have been the driving force behind a major reorganization of funding for American’s academic medical centers,5–7 and for multiple governmental agencies and nongovernmental organizations.8,9
To develop a coordinated approach, the US Health and Human Services (HHS) introduced its National Action Plan to Eliminate HAIs in 2009.10,11 The Action Plan identified the challenge of aligning research priorities with the adoption of prevention practices across federal and state agencies and down to the point of care. In this paper, we assess efforts put forth by HHS’s Action Plan to address 2 key functions of the HAI prevention system framework: Knowledge Development and HAI Prevention Practice Adoption.12 Knowledge development pertains to the full range of HAI-related research, from basic science and epidemiology, to development of prevention practice interventions and implementation science.13 HAI prevention practice adoption refers to the implementation, use, and sustainability of HAI prevention practices in healthcare and community settings. The 2 functions are closely related as a critical predictor of successful adoption of HAI prevention practices is a well-defined evidence base. This paper describes progress and challenges in both of these functions, as explained through an examination of goals, inputs, and implementation in each area.12 In addition, this paper examines links between knowledge development and adoption of prevention practices, and the relationship between the 2 in the context of HAI prevention. We also examine the role of other system functions (infrastructure development14 and data and monitoring15) in supporting the link between research and adoption of prevention practices, and the role of system properties (eg, coordination and alignment, accountability and incentives, stakeholder engagement, resources) in enabling and linking functions to improve system performance and outcomes.
This evaluation used the Context-Input-Process-Product (CIPP) model,16 together with the HAI prevention system framework described by Kahn and colleagues12,13 in this issue. There are 4 core components of CIPP as used in our research: (1) the Context in which HAIs and efforts to mitigate them developed; (2) the Inputs and decisions made about how to leverage resources, infrastructures, and relationships to select the set of activities for implementation; (3) Processes of implementation for selected activities; and (4) Products and outcomes. In this article, we focus in particular on the first 3 components of the model: context, inputs, and process. Outcomes defined as trends in HAI rates and capacity for HAI interventions are discussed later in this issue. To provide a more-focused categorization with the components of the CIPP model and to facilitate understanding of the data collected for the evaluation, we also developed a system framework specific to HAI prevention. This framework includes 4 system functions, which enable the healthcare system to prevent and mitigate HAIs (Infrastructure Development, HAI Data and Monitoring, Knowledge Development, and Adoption of HAI Prevention Practices), and 5 system properties, which affect the Action Plan’s ability to foster change and improvement in the system functions (Prioritization, Coordination and Alignment, Accountability and Incentives, Stakeholder Engagement, Resources). To inform the CIPP evaluation, we implemented multiple methodologies, including ongoing review and assessment of articles and other documents, observations of interagency meetings and national stakeholder conferences, semistructured interviews with federal and other governmental and nongovernmental stakeholders.
A supplemental Online Methods Appendix (Supplemental Digital Content 1, http://links.lww.com/MLR/A669) provides further information on the methods used.
Context for HHS’s Action Plan Addressing Research and Prevention Practice Adoption
There was a long history—and rich context—of research and prevention practices related to HAIs from which Action Plan leaders could draw. Over the several decades before the Action Plan, multiple agencies and organizations leveraged their resources in efforts to stem the tide of the HAI epidemic. In 1976, to support adoption of evidence-based practices, the Joint Commission on Accreditation of Healthcare Organizations added the requirement for infection surveillance and control programs as a hospital accreditation standard.17 In 1978, the Healthcare Infection Control Practices Advisory Committee was endorsed as “an advisory committee on nosocomial infection control practice” to ensure that “all nosocomial infection control practices and policies should be based on good scientific data adapted to the unique needs of each hospital.”18 Center for Disease Control (CDC) revised its methodology for targeted surveillance with the National Nosocomial Infections Surveillance System, refined definitions for infections,19,20 introduced advanced methods for risk adjusting infection rates, and systematically fed infection rates back to participating hospitals.21 CDC noted that hospitals that monitored HAIs demonstrated a marked reduction in bloodstream infection (BSI) rates in intensive care units (ICUs).22 The Society for Healthcare Epidemiology held 2 major consensus panels addressing, respectively, the inpatient and out-of-hospital requirements for infrastructure and essential activities of infection control and epidemiology.23,24 Subsequently, HICPAC implemented its meticulous process of developing evidence-based guidelines for infection control, and multiple evidence-based guidelines for the prevention of HAIs were published with support by the national epidemiological and infection control communities.25–33 In 2008, a task force of leading experts from Society for Healthcare Epidemiology and the Infectious Disease Society of America compiled a compendium of HAI prevention strategies for use in acute care hospitals.34
Another critical element relevant to the context for research and prevention practice adoption was the evolving patient safety movement. Although advances in infection control were progressing, the national patient safety movement was also developing and emphasizing the need to distinguish practices based upon sufficient high-quality evidence. Methods emerged to support evidence-based practices, including advances in matching study designs with research questions, systematic evaluation of the quality of research literature using synthesis and summary techniques, quantitative evaluation of the strength of evidence to support valued outcomes, and explicit identification of gaps in evidence.35–37 In response to the call for improved patient safety, the IOM recommended the prevention of HAIs as one of 20 priority areas on which the US Department of Health and Human Services (HHS) and other public and private sectors should focus.38 The Leapfrog Group,8 Consumer Reports,39 and the Institute for Healthcare Improvement9 developed recommendations and/or tools for how professionals and consumers could contribute to HAI prevention.40 The Agency for Healthcare Research and Quality (AHRQ), the federal agency with the largest budget for patient safety, developed a major focus on HAIs41 and the CDC’s Division of Healtchare Quality Promotion supplemented its longstanding focus on epidemiology and HAI prevention with renewed efforts to engage states and local stakeholders in HAI prevention.42
AHRQ requested that the National Quality Forum use a consensus process to define best practices, and commissioned an Evidence-based Practice Center to evaluate safety practices according to evidence.43 In 2001, the first Critical Analysis of Patient Safety Practices was published, presenting 11 practices, including 4 related to HAIs, with the strongest supporting evidence for interventions that decrease the risk for hospitalization, critical care, or surgery.44 The report noted evidence gaps for system-level interventions, patient safety practices beyond hospital settings, and potential or actual contributions from engineering, information technology, and management—3 disciplines with particular relevance to improving HAI prevention practices. A subsequent AHRQ Evidence Report specifically focused on the effects of quality-improvement strategies on promoting adherence to interventions to reduce HAIs.45 This report noted that, overall, the methodological quality of studies was poor, such that authors were unable to reach firm conclusions about actionable quality-improvement strategies to prevent HAIs. They suggested an urgent need for studies of quality-improvement strategies for HAI prevention.44
As this brief history indicates, there was a solid foundation of research and prevention practices upon which Action Plan leaders could build. However, there were concerns that agencies might be funding some duplicative studies and, in the area of prevention, that there were too many recommended practices. In 2008 the Government Accounting Office criticized HHS’s approach to the HAI epidemic, citing among other findings, >1200 Centers for Disease Prevention and Control (CDC)-recommended practices for preventing HAIs, with >500 being “strongly recommended” for implementation.46 Thus, a key task for the Action Plan’s developers was to determine which existing research and activities to prioritize, which to deemphasize, and where new efforts were needed.
In the following sections, we discuss results from the evaluation of Action Plan goals, inputs, and implementation processes, first, for research, and then for prevention practice adoption.
The Action Plan’s selection of goals and objectives was responsive to the need to better coordinate research efforts and prioritize research topics that would address knowledge gaps. In the initial release of the Action Plan in 2009, the Research Working Group of the Steering Committee identified several objectives for the work group: coordination and prioritization of research efforts to reduce HAIs nationwide, design of a plan and metrics for evaluating HAI progress within the research domain, and serving as a contact point to communicate to stakeholders so that HHS’s efforts would be coordinated and linked to a broader national coalition. The Research Working Group identified 4 core research domains: the basic science underlying HAIs, the epidemiology of HAIs, the investigation of infection control interventions, and implementation science for interventions to prevent HAIs. In 2012, the Research Working Group also emphasized the value across these domains of research of the role of data and monitoring and technology in promoting HAI prevention. The Research Working Grop noted the importance ofincentives for changing uptake and implementation. It also added new implementation science goals emphasizing the importance of linking “discovery science” with practice-based research conducted in the context of ongoing clinical care.47,48 Finally, the 2012 Action Plan introduced research specifically related to ambulatory surgical centers (ASCs) and influenza vaccinations among healthcare personnel, consistent with the focus on expanding research to venues beyond hospitals (Table 1).
Table 2 shows the mechanisms by which these 4 domains are likely to improve HAI outcomes (the “product” or final “P” in the CIPP model). The Action Plan’s research goals focused on 4 core domains; this choice was responsive to mounting evidence concerning the importance of expertise in these distinct research areas, whereas the emphasis on linkages across these 4 core domains was responsive to mounting evidence about the importance of translation from basic to population science.49 The expanded focus from the hospital to other venues highlighted the growing importance of transitions in care settings for the spread of multidrug-resistant organisms and HAIs.
Research Inputs and Implementation Processes
Key research inputs (the “I” in the CIPP model) included individual research projects funded by the core agencies involved in the Action Plan, as well as a broader HAI research agenda. Implementation processes (the first “P” in CIPP) focused on coordination and prioritization of research efforts, development of metrics to track research progress, and stakeholder engagement with the Action Plan. We discuss these issues next.
Decisions to Align the Research Agenda With Action Plan’s Goals
The establishment of an interagency Research Working Group was a useful tool for enhancing knowledge transfer, sharing content expertise, and developing a research agenda that could be shared across the 4 research domains and also across diverse stakeholders. The Research Working Group recognized the substantial contributions to HAI research of 4 federal agencies; these studies were important inputs to the Action Plan. At present, NIH is leading biomedical research to prevent, diagnose, and treat diseases; CDC is focused on population health and the role of state-based and community-based interventions to improve health; AHRQ is focused on long-term and system-wide improvement of healthcare safety, quality, and effectiveness. The Center for Medicare Services (CMS) is leading the effort toward value-based purchasing, and the Office of the Assistant Secretary for Health (OASH) is coordinating Action Plan efforts.
These agencies have been initiating important HAI research to address all 4 research domains. Basic science projects funded by NIH address the pathogenesis of device-associated infections and the development of strategies for preventing and/or eliminating biofilms associated with medical devices; epidemiology. Epidemiology projects funded by AHRQ and other HHS agencies include studies of the epidemiology of BSIs that occur outside of the hospital; studies to establish preventability of Clostridium difficile infection through a regional hospital collaborative intervention to reduce endemic rates through employment of tiered evidence-based recommendations50; studies to establish preventability of unnecessary antimicrobial use through multicenter collaborative interventions; and studies to establish the preventability of surgical site infections (SSIs) through a multicenter collaborative intervention to reduce rates. Intervention studies funded by AHRQ and HHS include a large, cluster-randomized study to assess whether ICU-wide application of a methicillin-resistant Staphyloccus aureus (MRSA) decolonization strategy was effective in reducing the transmission of HAIs and mortality compared with targeted decolonization strategy guided by active surveillance for MRSA colonization. Implementation studies include the support of (1) multidisciplinary investigation of the human cultural and organizational barriers at the unit and institutional levels that inhibit the successful implementation of prevention measures (AHRQ); (2) studies to develop and evaluate novel and potentially automatable strategies for measuring HAI transmission of epidemiologically important pathogens and related processes of care using electronic data sources routinely captured during the course of patient care (CMS); (3) studies to evaluate and validate standardized postdischarge surveillance methodology that can be used in both inpatient and ambulatory care settings using Healthcare Cost and Utilization Project (AHRQ); studies to identify and evaluate proxy measures for ventilator-associated pneumonia (VAP) (ie, acute lung injury) for interfacility comparisons that do not require stringent diagnostic approaches; and methodological studies to develop standardized methods (ie, performance methods) that are feasible, valid, and reliable for measuring and reporting compliance with broad-based HAI prevention practices that need to be practiced consistently by a large number of healthcare personnel (eg, hand hygiene, isolation precautions, environmental cleaning practices) (HHS).
The Research Working Group recognized the potential for synergies across these agencies to provide a comprehensive research agenda to prioritize, coordinate, and evaluate research efforts. For example, the Action Plan presented the example that if CDC finds a potential population with a risk factor or identifies a risk factor for an HAI, this information could help establish potential priorities for AHRQ-funded research on prevention or implementation of evidence-based practices.11 NIH could focus on basic science discoveries, and CMS could test how payment policies impact utilization of evidence-based practices. Research synergies emerging across agencies within and external to HHS would support coordination and alignment and stakeholder engagement, and reduce potential duplication and enhance the impact of each agency’s work.
Establishing and Implementing Criteria for Research Priorities
Another important input to the Action Plan was a set of criteria for prioritizing and funding research. The Research Working Group emphasized the importance of coordinating and prioritizing research efforts to reduce HAIs through the establishment of priorities for funding, the development of metrics for tracking research progress using these priorities, and the transparent communication of a coordinated HHS approach to research to the broader set of HAI stakeholders. Research was prioritized according to the proposed topic’s contribution to addressing research gaps, project feasibility and cost, and the anticipated impact on public health. The Research Working Group applied these criteria to research funded by the Interagency Research Working Group and identified, for each of the 4 core research domains, clinical and methodological gaps in knowledge and practice; some gaps were applicable across multiple HAIs, and some applicable only to specific HAIs, as shown in Table 2.
To evaluate progress made in the Action Plan’s research domain, the Research Working Group committed to conducting periodic assessments of the research programs and the projects it has specifically supported using a priori criteria for the evaluation with a plan for iterative evaluations. The Research Working Group recommended outcomes research metrics, including documented improvements in care, published articles, dissemination of findings through conferences or other means, or other research products. Importantly, the Research Working Group also committed in applying the results of these assessments to future prioritization efforts so that the Working Group’s ongoing program evaluation efforts would lead to adjustments to subsequent program iterations, an approach recommended by the evaluation team.12
The development of prioritization criteria is directly responsive to Government Accounting Office and Congressional concerns about the existence of too many “high-priority” prevention practices. As described in the 2012 Action Plan, the Research Working Group’s plans to iteratively involve representatives of the 4 lead HAI funding agencies in the application and evaluation of these criteria has potential to enhance the effectiveness of funded research as time passes and as the larger HAI research community becomes aware of these criteria.
Stakeholder Engagement With Knowledge Development
The collaborative style of Action Plan leadership supported engagement of key HHS agencies as well as of organizations and stakeholders external to the federal family. Our evaluation of the implementation processes used in the Action Plan’s knowledge development efforts considered the perspectives of stakeholders internal and external to HHS, including policymakers, providers, payers, state and local health departments, and patient representatives. Stakeholders interviewed by the evaluation team emphasized progress in HAI research across multiple areas and venues. They highlighted the importance of increased collaboration between NIH and other HHS agencies in efforts to increase the translation of research from basic research discovery to the development and dissemination of evidence-based prevention practices. They also emphasized progress in implementation-oriented research, highlighting the development and testing of HAI interventions for central line–associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), and MRSA and research on safety culture and organization change strategies for HAI improvement. Some stressed the importance of building the evidence base for changing practice behavior, by utilizing precise specification of terms relevant to physicians and other healthcare professionals. For example, a member of a professional group stated, “The fact that there are clear definitions, allows you to know what people are talking about; and there’s evidence. For physicians, evidence is key.”
Both internal and external stakeholders also emphasized the importance of all 4 research domains that the Action Plan emphasized (Table 2), noting some challenges coordinating federal research priorities across agencies. Interviewed stakeholders also highlighted the need for additional research to support the prioritization criteria for HAI prevention, for the specification of interventions to be adopted particularly in different contextual circumstances, and for specifying implementation details in driving practice change behavior. Interviews revealed interest in more research into the integration of new clinical microbiological molecular testing methods for HAI identification and validation; the impact of value-based purchasing on clinicians and staff who work with HAIs as well as on HAI rates, and the effectiveness of deploying antimicrobial stewardship strategies. Interview informants underscored the value of both quantitative and qualitative research.
HAI Research and Implementation Programs and Projects
The AHRQ, CDC, CMS, NIH, and OASH federal agencies account for the majority of federal research dollars expended to prevent HAIs. Our evaluation compiled a Program and Project Inventory (PAPI) to document the HAI prevention activities of these 5 agencies for fiscal year 2010 (the only year for which data were available for all participating agencies) in terms of system function addressed, HAI addressed, healthcare and hospital setting, and type of collaboration. The PAPI was important for understanding the extent to which research and prevention activities address key issues and for identifying gaps.
Table 3 shows that 70% of 103 documented programs and projects included a focus on knowledge development, whereas 64% addressed adoption of prevention practices with some variability by agency. Although NIH research is foundational for much HAI research and informs much HAI prevention research conducted by other agencies, NIH research could not be included in this table because NIH uses a different system for categorizing research than the other agencies. Table 3 shows that compared with other agencies, CMS was more likely in 2010 to be involved in prevention practice adoption programs and projects than in research.
The PAPI showed that all 6 HAIs identified as high priority by the Action Plan were addressed by the agencies collectively and individually. Seventy-four percent (N=76) of programs or projects were described by agencies as addressing at least one of the 6 Action Plan HAIs; 39% addressed one of the target HAIs, 16% addressed 2, and 32% addressed all 6. AHRQ and OASH programs and projects were much more likely to address only 1 HAI, whereas CDC’s were more likely to address all 6 target HAIs. PAPI found that multiple efforts addressed hand hygiene and healthcare worker vaccinations. The inventory also showed that programs and projects span federal, regional, and state levels, and are distributed across a variety of inpatient and ambulatory settings. Overall, just under one third of programs or projects with available data were conducted with funds from their own funding agency, whereas more than one fourth involved collaboration with other HHS agencies; more than one third involved collaboration with other non-HHS agencies; and 7% involved both HHS and non-HHS collaborators. Given that each agency has its own mission, this distribution seems reasonable, allowing the uniqueness of each agency to be preserved while also illustrating substantial efforts across agencies to collaborate.
Prevention Practice Adoption Goals
Action Plan working groups collaborated to draw from the HAI evidence base derived from knowledge development and research to build support for the adoption of HAI prevention practices. Within the Action Plan working group structure, the Prevention and Implementation Working Group was tasked with prioritizing existing recommended clinical practices to facilitate implementation in healthcare organizations, the Incentives and Oversight Working Group explored opportunities for evaluating compliance with infection control practices in hospitals, and the Outreach and Messaging Working Group developed a coordinated plan for national messaging for HAI prevention.10,11 The overarching HAI Prevention Practice Adoption goal from the 2009 Action Plan was the identification of key HAI prevention strategies across healthcare settings where these strategies are needed and could be applied.10 Action Plan leaders recognized the importance of developing and testing interventions supported by research to increase adherence to recommended HAI practices. The Action Plan recommended applying implementation research to the subset of prevention practices supported by strong scientific evidence in an effort to accelerate adoption.
The 2012 Action Plan11 added new prevention practice adoption goals applicable to information system and technology and new venues, including ASCs and end-stage renal disease (ESRD) facilities,51–53 as well as to healthcare personnel.54
Prevention Practice Adoption Inputs and Implementation Processes
The key prevention practice input was the development of priority prevention recommendations and guidelines. Prioritization was supported by the development of a standardized approach for developing quality measures and a formal mechanism for assessing the quality of evidence and strength of recommendations. Important implementation processes included use of multiple strategies and toolkits to provide education and dissemination, support measurement, and provide incentives to stimulate adherence to prevention practices.
Development of Priority Recommendations
Action Plan leaders drew upon existing and emerging research to prioritize recommendations for CAUTI, SSI, CLABSI, and VAP prevention, using the multistep process presented in Table 4. CDC updated its process for identifying implementation priorities based upon supporting scientific evidence that a practice is effective/beneficial, associated with recognized gaps in current implementation, synergistic with other related practices, and has potential impact for achieving desired outcomes.10 A concise set of HAI-related guidelines emerged from these updates, including evidence tables with sections on implementation, auditing and prioritization, and with plans for regular guideline updates and the establishment of new strategies to address prevention gaps.56,57 CDC has also developed recommendations for infection prevention in ambulatory settings.58
Over time, CMS standardized its approach for developing quality measures and prioritized those measures with goals and objectives set forth by the Action Plan and the National Quality Strategy.59
Research to Define Effective Interventions
A strength of the Action Plan’s progress is that multiple Action Plan agencies have prioritized recommendations using rigorous systems, such as the tool for grading the quality of evidence and strength of recommendation developed by the international Grading of Recommendations Assessment, Development and Evaluation Working Group.60–62 In 2012, a follow-up AHRQ Evidence-based Practice Report presented new evidence regarding the effectiveness of interventions to increase adherence to prevention practices and/or to reduce HAIs.63 They reported moderate strength of evidence for adherence to evidence processes and infection rates for CLABSI, VAP, SSI, and CAUTI following exposure to combinations of interventions, including either audit and feedback plus provider reminder systems, or audit and feedback plus organizational change and provider education base strategies. However, when provider reminder systems were introduced alone, studies reported low strength of evidence for improved adherence to prevention methods and for reducing infection rates. They noted insufficient evidence for HAI reduction following interventions in out-of-hospital settings, for cost savings from quality-improvement strategies, and for including clinical contextual factors in specification of effective interventions. For the first time, a study addressing prevention of ambulatory HAIs was included, although only one.
In 2013, an additional critical analysis of evidence for patient safety practices was reported, this time incorporating data and analyses about context, implementation, and unintended harms from patient safety effectiveness literature and from implementation studies.64 Six of the 10 patient safety strategies that were identified as having strength and quality of evidence for effectiveness and implementation (so that they were ready to be encouraged for adoption by healthcare providers) specifically related to HAI prevention.
In response to the recognition of challenges associated with implementing VAP metrics31 both the Research and Prevention Working Groups, and the Implementation Action Plan Working Groups aligned with CDC to identify the problems and plan a new and feasible alignment between research and the development of prevention practices.65 Multidisciplinary collaborative inputs from these experts were finally able to break the impasse in measuring HAI outcomes among users of mechanical ventilators by constructing a new ventilatory-associated events paradigm reflecting research advances in both clinical and implementation science.
Implementation of HAI Prevention Practices
Action Plan activities to enhance prioritization of prevention practices also addressed implementation and adoption. The Influenza Vaccination Working Group adopted practices recommended by the Advisory Committee on Immunization Practices to encourage influenza vaccination among healthcare personnel.66 These practices were complemented by toolkits and other strategies providing education, role modeling, improved access to vaccines, measurement and feedback of immunization rates, and by legislation and regulation endorsed by CDC, HICPAC, and AHRQ.66–68
The Action Plan also spurred progress in the dissemination of prevention practices through specific major initiatives, including AHRQ’s expansion of the Comprehensive Unit-based Safety Program (CUSP) system for reporting and reducing CLABSIs. Although CUSP began by aiming to increase the number of participating ICU in hospitals in 10 states to implement CUSP for CLABSI, it then expanded with open participation to all 50 states, Puerto Rico, and the District of Columbia, expanded CUSP into non-ICU hospital settings and to additional conditions, such as CAUTI.69,70 The Surgical Unit Safety Program is a patient safety program initiated in 2011 that also built on the success of CUSP for CLABSI.
CDC, with American Reinvestment and Recovery funding, has supported state health departments in convening stakeholders to focus on HAI prevention, established prioritized state-specific HAI prevention plans, and incorporated public health roles into existing and new HAI prevention work with local hospitals and developed collaborative networks to stimulate adherence to evidence-based prevention measures.71
CMS introduced value-based purchasing to stimulate adherence to prevention practices in hospital, ambulatory surgical, and ESRD settings through the development and tracking of prevention metrics and targets named in the HHS Action Plan.72,73 Furthermore, HHS federal agencies are increasingly collaborating in developing multifaceted programs to stimulate adoption of prevention practices. Value-based purchasing is applied nationally by CMS using hospital71,72 and dialysis center data74 collected and monitored using data sources specified by the Action Plan, at the state level as state laws have increasingly mandated public reporting of HAI rates,75 and as health plans have encouraged participation in statewide HAI collaboratives and research projects.76 Quality Improvement Organizations, in their ninth and 10th Scopes of Work have been required to form partnerships with national, state, and local stakeholders to broaden the impact of HAI reduction strategies generally, and to reduce CLABSI in particular.77 A field example shows CMS partnering with AHRQ and CDC to facilitate Quality Improvement Organization access to CUSP training sessions. This improved training for healthcare personnel played an active role in facilities’ enrollment and reporting in the National Healthcare Safety Network, thus aligning their resources with those channeled to states for HAI capacity improvement. In the ambulatory setting, progress has been made through CDC and CMS developing survey tools and training materials in ASCs to support implementation of recommended ambulatory guidelines.78 CMS is continuing to build its quality measurement and public reporting to include measurement in nursing homes, home health agencies, and physician offices as a supplement to hospitals and dialysis facilities.
Challenges to Adoption of Prevention Practices
Implementation burden and “campaign fatigue:” Although the Action Plan took steps to prioritize recommendations for HAI prevention practices, the implementation burden on healthcare providers and organizations was reported to have grown due to the proliferation of HAI prevention practices, policies, programs, and initiatives. This problem, referred to by 1 interview respondent as “campaign fatigue,” became especially notable as CMS introduced the Partnership for Patients’ initiative to accelerate improvements in quality, safety, and affordable healthcare for all Americans. Although leaders of the Partnership for Patients and the Action Plan took most of a year to intensively coordinate their approaches to HAI prevention, stakeholder interview respondents emphasized the need for greater integration and consolidation of core prevention strategies and functions across HAIs and other safety areas to make the work of healthcare organizations and providers more manageable. As one respondent commented: “There’s 5 or 10 different programs being rolled out without anybody overseeing how they work together. Partnership for Patients, for wound care, acronyms flying all over the place, I don’t quite see how it’s being pulled together. There’s no one line where it’s all going.”
Difficulty in implementing some practices: Stakeholders also noted several challenging areas for adoption of prevention practices. These include practices for addressing C. difficile and MRSA given the community transmission component of these HAIs, CLABSI outside ICU due to differences between ICU and other inpatient settings, and complexities associated with ensuring consistent hand washing adherence across venues and individuals. Stakeholders also emphasized the need for greater emphasis on development and dissemination of prevention strategies in ASCs and ESRD centers. An additional concern has been the extensive resources required by sites and states to staff and coordinate these multiple efforts. Concordance between areas needing further emphasis according to stakeholders internal and external to HHS and priority topics identified by the Research Working Group is notable.
Since the introduction of the Action Plan, HHS has made substantial progress in prioritizing research projects, translating findings from those projects into practice, and designing and implementing research projects in multisite practice settings. In both the areas of knowledge development and prevention practice adoption, the responsible Working Groups of the Action Plan (eg, Research, Prevention, and Implementation) sought not only to guide key funding efforts, but also to develop a prioritized approach with criteria that could be used to guide future decisions. Leading up to the release of the Action Plan and since that time, important activities by multiple federal and state agencies, as well as by researchers and practitioners, have built a growing awareness of the importance of HAIs as a major national epidemic, and of the need for a systematic and coordinated approach to stem the tide of the epidemic.79 Concomitantly, the methods, challenges, and opportunities associated with advancing the science of patient safety, and the application of safety principles to the goals of the Action Plan, continue to move forward.36,64,65,80,81
Engaging a Broad Coalition of Stakeholders
The most important role for HHS in research and prevention practice adoption lies its focused approach that engages a broad coalition of stakeholders. This approach can involve scientists across the 4 core research domains, building coordination and alignment across funding agencies and research teams, and thus identifying opportunities for accountability, incentives, and resource opportunities to efficiently respond to research gaps. Focusing on a broad coalition of stakeholders also facilitates the complex task of translating research findings into practice by establishing criteria for effective interventions that consider all 4 research domains and the linkages between them, applying criteria to available intervention options, and providing opportunities for endorsement by diverse key stakeholders, including those who implement the prevention practices and payers who can incentivize use of the interventions. Continuing to engage a broad range of stakeholders moving forward will be especially important, given the context of emerging research methods, new organizational structures and fiscal policies for supporting clinical and policy advances, changing specifications for valid processes and outcomes, updated guidelines, and a growing role for technology with HAI data and monitoring.
Emphasizing the Relationship Between Research and Prevention Practice Adoption
The broad translational view of research taken by the Action Plan which spans from bench to hospital to community ambulatory and long-term-care settings supports efficiencies by aligning research and prevention practice methods. Research and practice adoption relate to each other, with both depending upon the identification of key questions or challenges that can be informed through thoughtful analysis of quantitative and/or qualitative data. A better research evidence base is believed to lead to more effective practice adoption.48,82
Supporting Infrastructure and Accountability
In responding to the HAI epidemic, the Action Plan smartly recognized that federal efforts to support research and practice adoption down to the point of care would be most effective when supported by other system functions, including infrastructure development and data and monitoring. By involving key HHS agencies and a Steering Committee that includes a diverse set of organizations and stakeholders, and creating a process to link federal, regional, state, and local HAI prevention efforts, the Action Plan developed an infrastructure to support the research agenda and strategies for prioritizing prevention practices. Some major successes came with accountability measures that provided incentives to encourage more healthcare facilities to employ specific prevention practices; others came with the development of survey tools and training materials, and with the use of improved data and monitoring systems. Such efforts have likely contributed to stakeholders’ reported perceptions of greater momentum in HAI activities in federal, state, and private sectors as well as increased experience with implementation and adherence to HAI prevention practices, even if change in practice from these efforts is not yet clear.83 By identifying data and monitoring systems to support HAI-related metrics and targets, the Action Plan developed systems to support multisite research projects that can address external validity and reliability, thus providing important contextual inputs relevant for adoption of practices. Infrastructure and data and monitoring advances are likely to help build the research base, and in turn, to support evidence-based prevention practices. Benefits are likely to be gained from infrastructure, and from data and monitoring support for research and adoption strategies. Research and prevention practices are also likely to benefit from the basic, epidemiological, and implementation science communities having joined forces to better define mechanisms and responsibilities for translating HAI research into practice.
Improving Coordination, Prioritization, and Accountability
Furthermore, the Action Plan’s approach to knowledge development decisions and implementation strategies is supported by 5 system properties, which aim to support large-scale system change through prioritization, coordination and alignment, accountability and incentives, stakeholder engagement, and resources, as illustrated in Table 5. For example, the Action Plan’s introduction of an interagency Research Work Group placed a renewed focus on coordinating federal efforts, including those of NIH and other HHS agencies. Interviews have acknowledged this progress and coordination across agencies. If the translation of NIH basic science to bedside and community-wide implementation research and ultimately to evidence-based prevention practice adoption is to become a reality, these ongoing interagency collaborations must remain a priority.
Key to sustaining system capacity for research and practice adoption is to embed the identification and pursuit of research questions and prevention practices into routine work, systems, and culture, and to identify and develop core prevention practices that are common and easily learned across settings and HAI conditions.
Characterizing Goals, Strategies, and Outcomes of HAI Programs and Projects
Results of the PAPI of agency-sponsored projects demonstrate substantial coordination across federal and local initiatives for involving sites in research and adoption of prevention practices. However, although progress has been made, 1 strategy that could further support the coordination and integration of research and adoption efforts would be the development of a prospective PAPI to characterize the goals, strategies, and outcomes of federal, regional, and state HAI programs and projects. This was recommended by the Research Working Group. Although the PAPI developed by the evaluation team showed evidence of coordination and integration, its ability to identify opportunities for synergy and areas of redundancy and gaps was somewhat limited because each agency has its own system of tracking programs and projects. If HHS finds a systematic inventory of HAI programs and projects useful, efforts should be made so that agencies can agree in advance about terms that could generate a PAPI that is even more responsive to agency data structures and needs. A more centralized approach to tracking research and implementation of programs and projects could lead to a more centralized approach to resource allocation. It is difficult to know at this time whether a more centralized approach would be preferable to the current program that aims to, and increasingly is successful at, aligning the efforts of distinct agencies. Since the Action Plan has been introduced, these agencies have been collaborating in ways never before realized. This has been a learning process for interagency collaboration as each agency has been able to refine its own contributions, identify opportunities for new collaborations, avoid unnecessary redundancies, and identify areas for potential synergies.
Potential for Long-term Impact
Translation from basic science to dissemination of evidence prevention practice strategies is a complex activity, and history has shown the importance of time in allowing paradigm shifts in healthcare delivery to mature and disseminate.84,85 Efforts are being made to address ongoing challenges in applying findings from the evidence base to state and regional quality-improvement efforts.
Although we wait for time to reveal the effectiveness of the Action Plan’s longer-term impacts, it is fair to say now that we see evidence that research goals established by the Action Plan having been incorporated into resource and prioritization decisions. In parallel, we have seen an unprecedented flow of inputs and implementation strategies consistent with Action Plan goals that have resulted in the development of new prevention practice evidence,6 and a big push toward implementation spanning federal, regional, state, and local programs. It is important now to allow the current structure for research and prevention practices to mature by sustaining the coordinated approach to HAI prevention that the Action Plan has motivated.
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