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research-article2014
MCRXXX10.1177/1077558714533825Medical Care Research and ReviewEllingson et al.
Empirical Research
Perspectives on Federal Funding for State Health Care–Associated Infection Programs: Achievements, Barriers, and Implications for Sustainability
Medical Care Research and Review 2014, Vol. 71(4) 402–415 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1077558714533825 mcr.sagepub.com
Katherine Ellingson1, Kelly McCormick1, Tiffanee Woodard1, Amanda Garcia-Williams1,2, Peter Mendel3, Katherine Kahn3, Clifford McDonald1, John Jernigan1, and Ronda Sinkowitz-Cochran1
Abstract In September 2009, federal funding for health care–associated infection (HAI) program development was dispersed through a cooperative agreement to 51 state and territorial health departments. From July to September 2011, 69 stakeholders from six states—including state health department employees, representatives from partner organizations, and health care facility employees—were interviewed to assess state HAI program achievements, implementation barriers, and strategies for sustainability. Respondents most frequently cited enhanced HAI surveillance as a program achievement and resource constraints as an implementation barrier. To sustain programs, respondents recommended ongoing support for HAI prevention activities, improved surveillance processes, and maintenance of partnerships. Findings suggest that state-level HAI program growth was achieved during the cooperative agreement but that maintenance of programs faces challenges. This article, submitted to Medical Care Research and Review on October 28, 2013, was revised and accepted for publication on March 3, 2014. 1Centers
for Disease Control and Prevention, Atlanta, GA, USA Rollins School of Public Health, Atlanta, GA, USA 3RAND Corporation, Santa Monica, CA, USA 2Emory
Corresponding Author: Ronda Sinkowitz-Cochran, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30333, USA. Email: [email protected]
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Ellingson et al. Keywords health care–associated infections, qualitative research, federal funding
Introduction Health care–associated infections (HAIs) lead to substantial morbidity, mortality, and increased health care spending for the U.S. population (Klevens et al., 2007; Scott, 2009). Over the past decade, the burden of HAIs has been increasingly recognized as a preventable public health problem, and stakeholders, including federal agencies, have recommended and supported a coordinated, accountability-driven approach (Cardo et al., 2010; Frieden, 2010). In 2008, the U. S. Department of Health & Human Services (HHS) developed an Action Plan to Prevent HAIs, which emphasized aligning HAI stakeholder efforts, promoting standardized metrics for HAI surveillance, and targeting reductions in device-associated, procedure-associated, and multidrug resistant HAIs (U.S. Department of Health & Human Services, 2009). The Centers for Disease Control and Prevention (CDC) designated HAIs as one of seven Winnable Battles, with explicit goals for increasing adherence to infection prevention guidelines, improving surveillance, and enhancing capacity at state health departments (CDC, 2013). In step with these federal agency missions, the American Recovery and Reinvestment Act of 2009, Pub. L. No. 111-5 (ARRA), appropriated funds to health departments for HAI prevention in September 2009 through the CDC’s Epidemiology and Laboratory Capacity (ELC) Cooperative Agreement (CDC, 2012a). In an effort to better integrate public health and the health care delivery system, this novel federal funding program dedicated to HAI prevention strategies was intended to support progress toward the national targets for HAI incidence reduction established in the HHS Action Plan. The goal of this cooperative agreement was to enhance the role of the state and territorial health departments in executing the HHS Action Plan while furthering CDC’s mandate to improve HAI prevention capacity at the state level. Through this ELC cooperative agreement, approximately $35.8 million in federal Recovery Act funds for state-level HAI prevention programs was dispersed to 51 health department grantees in 49 states, the District of Columbia, and Puerto Rico. The ELC Recovery Act cooperative agreement ended in December 2011. The ELC Recovery Act cooperative agreement awarded federal funding to health departments in three HAI domains: infrastructure, surveillance, and prevention. Those receiving funding in the infrastructure domain (n = 48) were expected to financially support staff time dedicated to HAI activities, promote strategic partnerships through regular assembly of a multidisciplinary advisory group of HAI stakeholders, and provide training and technical assistance to health care facilities. Those awarded funding under the surveillance domain (n = 31) were expected to enhance the quality of HAI surveillance through the National Healthcare Safety Network (NHSN) Surveillance System and to work toward active use of NHSN data to inform decision making and motivate prevention. The 28 health departments awarded funds for prevention collaborative implementation were expected to lead or support multifacility prevention initiatives targeting HAI reductions through systematic implementation of evidence-based
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practices, data feedback, and culture change strategies (CDC, 2005, 2010; Pronovost et al., 2006). Funding awards varied, with state health departments receiving anywhere from $174,000 to $2,600,000 depending on whether funding was granted in one or more domains; the 17 health departments granted funding for only infrastructure received an average of $210,000, whereas the 22 health departments granted funding in all three domains received an average of $1.1 million.
New Contributions A quantitative evaluation of the ELC Recovery Act HAI cooperative agreement showed that funding amount was significantly associated with HAI program capacity enhancements, specifically staffing, partnerships, training, technical assistance, surveillance, and prevention; this quantitative evaluation also showed that states funded for prevention collaborative implementation demonstrated greater infection reduction than states without funding for prevention collaboratives (Ellingson et al., 2014). To complement this quantitative component of the evaluation, a qualitative assessment was undertaken by CDC in collaboration with contracted evaluation experts from IMPAQ International and RAND Corporation (IMPAQ/RAND) to gain a more indepth perspective from state-level stakeholders on the implementation of HAI programs. Qualitative research has become increasingly common in health services and health policy research because qualitative methods describe phenomena within a realworld context that is useful for understanding new programs and planning future implementation (Bradley, Curry, & Devers, 2007). The specific aims of this qualitative study were to describe state-level HAI stakeholder perspectives on (a) greatest program achievements since receipt of federal funds through the ELC Recovery Act cooperative agreement and facilitators attributed to success, (b) barriers to implementing state HAI programs, and (c) strategies for sustainability of state HAI programs.
Conceptual Framework A conceptual program model was developed by CDC and guided the evaluation serving as the basis for expectations related to health department functioning and performance (Ellingson et al., 2014). The purpose of this model was to elucidate the pathway between the funding distributed to state health departments for HAI prevention and the desired outcome of safer health care. The goal of the ELC Recovery Act HAI program was to make patients safer by increasing state health department capacity for sustained HAI prevention. The various program inputs were distributed to the state health departments to support the development or expansion of state HAI programmatic activities. This program model was the conceptual basis for the issues assessed in this qualitative evaluation. An exploratory evaluation was conducted using an inductive process of constant comparison for coding and thematic analysis. In an effort to detect patterns and regularities in responses, no a priori assumptions, hypotheses, or predefined themes were anticipated prior to immersion and qualitative analysis.
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Method Selection of States Six of the 51 states or territories with health departments receiving ELC Recovery Act funding were selected for in-depth stakeholder interviews conducted by evaluation experts external to CDC at IMPAQ/RAND. Selection criteria for states included funding domain, state population size, and progress toward HAI program goals as of early 2011. States were sorted by population size according to U.S. Census and then categorized as small (lowest third), medium (middle third), or large (highest third). The final selection criterion—initial progress toward HAI program goals—was determined by semistructured interviews of CDC-based public health analysts assigned to each state in order to provide program administration support and technical assistance; interviews were conducted by IMPAQ/RAND. The CDC public health analysts were asked to rank their assigned states as “exceptional” (i.e., serves as an example to other states in terms of program achievements and progress toward HAI prevention), “steadily improving” (i.e., on a positive trajectory with improvements since distribution of federal funding), or “slow moving” (i.e., overall progress in HAI prevention has been slow, negligible, or even negative since distribution of federal funds). Based on the funding domain, population size, and initial progress toward HAI program goals, the IMPAQ/RAND evaluation team recommended six states for stakeholder interviews: three “exceptional” and three “steadily improving” states. No “slow-moving” states were selected for this evaluation because, at the time, there had been ample follow-up with slow-moving states to elucidate and address barriers; it was less clear, however, what characteristics and dynamics led to successful implementation of ELC Recovery Act HAI programs. Thus, the evaluators decided to sample three states each from the exceptional and steadily improving categories. The CDC public health analysts assisted IMPAQ/RAND with recruitment of approximately 12 stakeholders each from the six states; the state health department’s HAI coordinator was contacted first and assisted with enumerating lists of key stakeholders. Stakeholders recruited from the state health department included the HAI coordinator, a senior executive and/or policy director, the HAI surveillance data analyst, and the infection prevention liaison. Other stakeholders included medical professionals and infection preventionists from facilities across each state as well as state-level partners such as representatives from the quality improvement organizations, hospital associations, and consumer groups. Distribution of each stakeholder group interviewed varied by state due to differences in state HAI program, size, and operations.
Development of Interview Guide and Interview Implementation The CDC and IMPAQ/RAND collaborated to develop a standardized interview guide, which was then tailored slightly by stakeholder type through the use of prespecified probes. The interview guide included detailed directions with sections for demographics and experience of respondent, previous activities related to HAIs prior to federal funding, implementation of HAI activities during the cooperative agreement,
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achievements, barriers to program implementation, and questions about lessons learned and sustainability. Interview guides were piloted in spring of 2011 on two HAI coordinators in states not selected for interviews; revisions were made, and institutional review board approval was obtained by RAND Corporation in June 2011. In August and September of 2011, three trained interviewers from IMPAQ International interviewed 69 stakeholders in the six selected states, either by phone or in person. In an effort to minimize any systematic differences across the two modes of administration, all interviews used the same standardized script, directions, probes, and prompts and were conducted using uniform procedures. All interviews were recorded with consent from stakeholders. Each interview was transcribed, identifying information was removed or redacted, and transcripts were sent to CDC for analysis.
Qualitative Coding and Analysis All transcripts were reviewed and assessed for completeness. The evaluation team within CDC’s Division of Healthcare Quality Promotion—including an epidemiologist, a behavioral scientist, a program evaluator, and a doctoral student in public health—read transcripts prior to coding following standard qualitative “immersion” methodology to comprehend scope and meaning within the entire context of the interview (Crabtree & Miller, 1999). Next, members of the team independently ascribed codes (i.e., tags or labels assigned to segments of the transcript to catalogue key concepts) to the transcripts. An inductive coding approach was used, allowing independent team members to ascribe codes without forcing any type of predetermined structure. The team met regularly to review and compare codes; this method of “constant comparison” allowed iterative refinement of existing codes as well as identification of new codes (Bradley et al., 2007; Glaser & Strauss, 1967). When all possible themes were identified and refined (i.e., the point of “theoretical saturation”), the team reassigned the set of standardized, refined codes back to the transcript. Routine conference calls between CDC and IMPAQ/RAND were used to answer any questions and clarify scripts and qualitative data as needed. The focus for this analysis was on questions related to achievements during the ELC Recovery Act cooperative agreement, barriers to HAI program implementation, as well as strategies for sustainability of state HAI programs. All transcripts were imported into MAXQDA (Version 10, Amtsgericht Berlin Charlottenburg, Germany) and assigned standardized codes. The resulting data set included a taxonomy of codes to describe achievements, barriers, and strategies for sustainability. These taxonomies were assessed by the frequency of occurrence in the transcript and stratified by stakeholder type as well as state status on initial progress (i.e., exceptional vs. steadily improving).
Results A total of 69 stakeholders were interviewed from six states, including 26 state health department employees with roles relevant to HAI, 15 representatives from state-level partner organizations focused on HAI, and 28 health care facility employees. Health
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department stakeholders included HAI coordinators (n = 5),1 HAI data analysts or surveillance leads (n = 8), infection prevention liaisons (n = 4), and policy executives (n = 9). State-level partners included representatives from state quality improvement organizations (n = 6), state hospital associations (n = 5), and consumers or patient advocate groups (n = 4). Employees from health care facilities included infection preventionists (n = 19) and physicians (n = 9). Respondents reported a range of 1 to 25 years of experience working in their current position and 0 to 40 years of experience in infection prevention and control. Staff from IMPAQ International interviewed 9 to 16 respondents from each state dependent on stakeholder availability and coordination.
Achievements and Attributions Respondents described 142 state HAI program achievements occurring during the ELC Recovery Act cooperative agreement, which were categorized into 20 independent themes. The most frequently assigned theme (assigned to 33/142 or 23% of achievements described) was enhanced HAI surveillance. Respondents specified surveillance-related achievements in terms of data validation activities, technical assistance received from the state health department for NHSN enrollment, and the ability to use data for action. As one infection preventionist explained, “The major [achievement] is getting everybody enrolled in NHSN, using standard definitions, training, and validating our consistency in data.” State health department respondents emphasized the importance of HAI surveillance enhancements in light of public reporting of HAI rates and the need to maintain data integrity and credibility; this perceived importance of validation relative to reporting was also recognized at the facility level. According to one physician: “If we hadn’t had the ARRA-funded validators coming around to validate the public reporting of central line-associated bloodstream infections, I don’t think the hospitals would have been quite as ‘honest.’” The second most commonly described program achievement during the cooperative agreement was HAI rate reduction (19/142 or 13% of achievements described). Such reductions were reported to be achieved either through federally funded prevention collaboratives or through partnerships and initiatives built between health care facilities and state-level partners including health departments, quality improvement organizations, and hospital associations. In the words of a consumer advocate, There’s significant progress on lowering the rates of central line infection and a really thorough working partnership among a variety of influential stakeholders involved in infection control . . . so there is a foundation to take on other forms of HAI that need attention.
Enhanced collaboration and partnerships (15/142, 11%), which were described by a state hospital association representative as “the collaborative nature of our work, where it’s seen as a true partnership between the public and private sector to eliminate HAIs,” and enhanced education and training (12/142, 8%) of “all the players” from health care providers to patients to public health staff throughout the state were also
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Table 1. Greatest Achievements Described by Respondents for HAI Programs During the 2-Year ELC Recovery Act Cooperative Agreement, Listed in Order of Overall Frequency. Theme rank stratified by respondent type Theme Enhanced HAI surveillance HAI rate reduction Enhanced collaboration and partnerships Enhanced training and education Advancements in public reporting
Theme rank, overall SHDa
Partners
Theme rank stratified by state’s initial progress toward program goalsb
Health care facilities Exceptional
Steadily improving
1
1
3
1
2
1
2
2
2
3
1
5
3
3
1
>5
3
4
4
>5
4
2
5
3
4
4
2
>5
4
>5
Note. HAI = health care–associated infection; ELC = Epidemiology and Laboratory Capacity. a. State health department stakeholders. b. Determined by interviews with Centers for Disease Control and Prevention public health analysts prior to data collection.
frequently cited achievements. Other achievements included advancements in public reporting (12/142, 8%), described by a health department policy executive as “the regular reporting of information about hospitals for people to see with transparency function and better information”; increased awareness and focus on HAIs (11/142, 8%); and information dissemination (11/142, 8%) through multiple communications such as “webinar series and conference calls (that facilitated) dialogue and sharing” related to HAI surveillance and prevention. Across respondent types, the reporting of main achievements was relatively consistent (Table 1). However, state partners cited enhanced collaboration and partnerships as the main achievement more often than other respondents; respondents from health care facilities cited enhanced education and training more frequently than other respondents (Table 1). Additionally, respondents from states categorized as “exceptional” in terms of progress toward program goals most often cited HAI rate reductions as the greatest achievements, whereas “steadily improving states” more often cited enhanced HAI surveillance. Respondents described 136 attributions for which they credited their program achievements; these then were categorized into 21 distinct themes. Regardless of the type of achievements cited, respondents most often described “collaboration, relationship building, and teamwork” (31/136 or 23% of all attributions described) as the primary facilitator for success. Said one state HAI coordinator, “If we just had the
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funds, but not the partnerships it wouldn’t work nearly as well.” Similarly, a representative from a state hospital association attributed success to: understanding the complementary strengths of the various organizations and how we make the most of the resources we have . . . by working in collaboration. The old model was everybody working in silos. And we no longer can afford to do that.
Another common theme assigned to attributions for achievement was the provision of the federal funding (18/136, 13%); according to one policy executive at a state health department, “You’ve got to have the dollars to do it. If you don’t have the dollars to do it, forget it. It can’t happen.” Other themes assigned to attributions for program achievement included enhanced alignment of stakeholder activities and goals (10/136, 7%), engagement and buy-in (9/136, 7%) from staff and leadership at both health care facilities and public health organizations within and across states, and the presence of dedicated HAI coordinators in each state (8/136, 6%). Regarding alignment of initiatives as an important contributor to program success, one state hospital association representative noted, “We’ve tried to align so we’re not overwhelming our hospitals . . . to fold [various initiatives] together so [hospitals] really just see it as one initiative so that they don’t have unnecessary duplicative work.” Attributions for which they credited their program achievements were similar across respondent type and state status in terms of initial progress toward program goals.
Barriers to Implementing Federal Funding for HAI Prevention Respondents described 324 barriers to program implementation, which were categorized by 24 themes. The most common theme assigned was resource constraints (99/324 or 31% of barriers noted by respondents), including lack of funding, human capital, consistent staffing, and information technology support. From the hospital perspective, one infection preventionist explained, “Hospitals are under extreme funding reductions, and it’s challenging to get additional man hours.” Similarly at the state health department, respondents noted resource barriers to hiring and maintaining staff when consistent staffing is needed to meet HAI reporting requirements. Difficulties in retaining qualified personnel at state health departments were also a concern, particularly to infection prevention liaisons: “One of our biggest challenges right now is uncertainty . . . and so we have lost staff because they don’t know what’s going to happen after ARRA finishes.” Respondents noted other barriers categorized as “problematic data or metrics,” including challenges with HAI data collection, reporting, and interpretation (58/324, 18%). Both infection preventionists at the facility level and health department employees described additional work related to NHSN data collection and challenges learning to access the data collected: “The biggest problem for us is then getting the data back out, so that we know what’s happening in our hospitals, so that we can then target our actions.” Another commonly reported challenge included competing priorities (26/324, 8%); a quality improvement organization respondent described this phenomenon in
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Table 2. Greatest Barriers Described by Respondents for Health Care–Associated Infection Programs During the 2-Year ELC Recovery Act Cooperative Agreement, Listed in Order of Overall Frequency. Theme rank stratified by respondent type Theme Lack of resources Problematic data or metrics Competing priorities Lack of buy-in/ engagement Lack of education/ training
Theme rank stratified by state’s initial progress toward program goalsa
Theme rank, State health Health care overall department Partners facilities Exceptional
Steadily improving
1
1
1
1
1
1
2
2
3
2
2
2
3
5
4
4
3
3
4
>5
2
5
3
4
5
>5
5
3
>5
4
Note. ELC = Epidemiology and Laboratory Capacity. a. Determined by interviews with Centers for Disease Control and Prevention Public Health Analysts prior to data collection.
terms of “a lot of projects that hospitals are requested to participate in . . . so it’s been a barrier at times, to get the attention of the hospitals and get their ongoing commitment to participate.” Other prominent but less frequently cited barriers to HAI program success were lack of buy-in and engagement (25/324, 8%) and lack of sufficient education and training on HAIs (22/324, 7%), most notably for infection preventionists and other health care providers but also for administrators, policy makers, and consumers. Lack of effective coordination and role differentiation among partners (19/324, 6%) was also reported and described by a consumer: There could be better coordination . . . the various efforts work somewhat in silos . . . organizations have territories and turfs . . . we could do a better job of (working) collectively for the benefit of the whole.
The frequency of barrier themes described by respondents was consistent across respondent type and state progress toward program goals in that all strata reported “lack of resources” as the number one barrier to success. State HAI partners more often reported barriers related to lack of buy-in and engagement compared to problematic data issues, whereas respondents from health departments and health care facilities cited problematic data or metrics as a barrier more often than buy-in or engagement (Table 2).
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Strategies for Sustainability When asked about strategies to sustain HAI-related activities after the ELC Recovery Act cooperative agreement ends, respondents described 111 strategies, which were categorized into 24 themes. The most common theme assigned to respondent strategies for sustainability was “long-term funding for HAI programs” (39/111 responses or 35% of all strategies described). As stated by an HAI coordinator, “Having longterm sustainable, stable funding is absolutely critical . . . you don’t want to dismantle existing programs, because you will never get them back.” Other frequently assigned themes for respondent’s suggested strategies for sustainability included surveillance and data improvements such as streamlining reporting, validation, and using data for action (15/111, 14%); maintaining partnerships (10/111, 9%); expansion of focus to diverse HAIs and settings including emerging pathogens and special settings (7/111, 6%); and practical and flexible HAI reporting requirements at the state level (7/111, 6%) through “enforcement of legislation” and “development of recommendations [by HAI subject matter experts] for what is efficient to report.” As noted by a state hospital association representative with regard to surveillance and data improvements, “The biggest piece on sustainability, in terms of actually making a difference, is making sure that the measurement process (surveillance) remains viable and not overwhelming for the performance improvement efforts.” Although respondents from health departments and health care facilities most commonly reported sustained resources as a critical strategy for sustainability, state-level partners most frequently reported maintenance of partnerships as a critical strategy. State health department and health care facility respondents also more frequently described improved HAI surveillance as critical to sustainability than did state-level partners (Table 3). There were no differences in respondent reporting of strategies for sustainability by states’ categorization in terms of progress toward program goals.
Discussion This qualitative study of perceived achievements, barriers, and strategies for program sustainability among stakeholders in states receiving Recovery Act funds through the ELC cooperative agreement for HAI program development elucidated the importance of sustained and dedicated resources (specifically financial and human capital); the widespread adoption, validation, and functionality of HAI surveillance; and relationship building and alignment among partners. Although respondents noted an array of program achievements resulting directly or indirectly from federal funding, there were concerns across respondent types about the ability of these programs to persist once the ELC Recovery Act cooperative agreement ended. From the health department perspective, the potential loss or reduction of federal funds to continue programming meant the inability to maintain qualified staff. From the facility perspective, less funding meant more burden on hospitals to train staff and coordinate prevention initiatives in an environment with many competing priorities and fiscal constraints.
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Table 3. Strategies for HAI Program Sustainability Described by Respondents, Listed in Order of Overall Frequency. Theme rank stratified by respondent type Response Sustained HAI resources Surveillance and data improvements Maintain partnerships Expand prevention across settings/ infections Practical/ progressive reporting requirements
Theme rank stratified by state’s initial progress toward program goalsa
Theme rank, State health Health care overall department Partners facilities Exceptional
Steadily improving
1
1
2
1
1
1
2
2
4
2
2
2
3
4
1
4
3
3
4
4
4
3
4
4
4
3
3
5
4
4
Note. HAI = health care–associated infection. a. Determined by interviews with Centers for disease control and prevention public health analysts prior to data collection.
The Recovery Act funds dispersed through the ELC cooperative agreement for HAI program development totaled $35.8 million for all grantees and $4.1 million in the six states participating in this study. Since the six states in this evaluation were purposely selected as “exceptional” or “steadily improving” in terms of HAI program progress, it is likely that the barriers to program implementation and sustainability challenges encountered by these states affect all 51 states and territories that received health department funding for HAI program development. Conversely, the achievements made in these six states represent what is possible in lower performing states if they can build and sustain HAI programs. Respondents from exceptional states most frequently cited HAI reductions as the greatest achievement during the ELC Recovery Act cooperative agreement, whereas respondents from steadily improving states most frequently cited enhanced HAI surveillance, suggesting that progress toward patient safety (fewer HAIs) exists on a continuum and that building surveillance infrastructure is a key component along this pathway. Among different stakeholder types (health department, representatives from partner organizations, and employees at health care facilities), the primary difference was in reported achievements; respondents from health departments and health care facilities emphasized data-related achievements, whereas respondents from partner agencies (e.g.,
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quality improvement organizations, Hospital Associations, and consumers) emphasized the strengthened relationships with stakeholders throughout the states and alignment of multiple HAI program initiatives. State health department employees, state-level partners, and health care facility employees commonly shared the perception that health care facilities were underfunded to do the HAI surveillance and prevention work expected of them. An infection preventionist noted, “You can collect all the data you want, but if you don’t have time to do the interventions, you’re not going to influence the outcomes.” Respondents’ most frequently noted achievement was improvement in HAI surveillance infrastructure, but challenges with the infrastructure for HAI surveillance were also mentioned frequently as barriers to program success. Furthermore, respondents noted that improved systems for entering data into NHSN and streamlined feedback and reporting of data were critical to the sustainability of state HAI programs. During the ELC Recovery Act cooperative agreement, NHSN enrollment increased across the country in large part due to Centers for Medicare and Medicaid Services incentives, whereas state mandates also motivated facilities to enroll in NHSN (Centers for Medicare and Medicaid Services, 2013). The state HAI programs were able to provide technical assistance to facilities for enrollment, getting started with reporting, and more than 55 validation projects (Ellingson et al., 2014). Despite gains made throughout the cooperative agreement relative to surveillance, all respondent types described the need for enhancements. Although respondents noted reductions in infections due to both federally funded and non–federally funded prevention initiatives ongoing throughout the ELC Recovery Act cooperative agreement time period, the prevailing paradigm was that there are still great strides to be made in using HAI surveillance data toward its maximum prevention potential. A policy executive articulated the importance of partnerships in reducing rates of infection through maximizing prevention efforts: We have shown a tremendous improvement in HAIs and central line associated bloodstream infections . . . that was something to be very, very proud of . . . again, I think it comes from everybody working together . . . I think that hospitals are safer as a result.
A key component of the HHS Action Plan was aligning various HAI initiatives supported by local, state, regional, and federal partners. When asked to what the program successes during the ELC Recovery Act cooperative agreement could be attributed, all respondent types reported enhanced collaboration, relationship building, and teamwork as the primary reason for program success. A state health department policy executive attributed achievement to “the fact that [hospitals] know that we’re all in the same game . . . we’re all looking for the welfare of our people in terms of reducing infections at these health care facilities.” A quality improvement organization representative also attributed success to collaborating and presenting a united front to hospitals: “We’ve realized that our hospitals really want to see alignment between the different organizations that are working on HAIs. They do not want there to be the appearance of multiple slightly different projects.” Maintaining partnerships—including convening key stakeholders and leveraging partnerships in tight financial times— was also noted by respondents as a critical factor in sustaining state HAI programs.
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This qualitative evaluation is subject to some limitations. First, all results reported are generated from self-report where respondents individually interpreted each question based on their own contextual experience and cognitive processing. Respondents were interviewed during the summer of 2011 prior to the end of the ELC Recovery Act cooperative agreement on December 31, 2011, and therefore responses may not have encompassed the entire funding period. Additionally, findings from respondents in these six states are not generalizable to all states, particularly because states were deliberately selected as exceptional or steadily improving states. Furthermore, findings may underrepresent barriers experienced by states categorized as “slow moving” since they were not included in the sample. Because this study was sponsored by CDC, responses might also have been influenced by social desirability bias. To minimize this potential bias, all recruiting and interviewing were conducted by associates at IMPAQ/RAND. Respondents were informed that their responses were confidential, and all transcripts were deidentified before being sent to CDC for qualitative analysis. From the perspective of state-level stakeholders interviewed in this evaluation, ongoing funding is seen as critical to maintain and expand HAI prevention efforts, especially as state health departments face budget cuts and staffing shortages that affect all public health activities (CDC, 2012b). This funding has in part materialized through the Prevention and Public Health Fund created by the Affordable Care Act, which helped sustain an HAI coordinator in every state health department and funded targeted prevention projects in certain states. Based on responses from this multistate, multistakeholder qualitative evaluation, maintaining partnerships to align activities and streamlining surveillance will also be critical to helping states build and sustain HAI prevention efforts. Authors’ Note The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
Note 1. The HAI coordinator for one state worked at the state’s quality improvement organization and therefore was considered as a state-level partner for the analysis rather than a state health department employee.
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Bradley, E. H., Curry, L. A., & Devers, K. J. (2007). Qualitative data analysis for health services research: Developing taxonomy, themes, and theory. Health Services Research, 42, 1758-1772. Cardo, D., Dennehy, P. H., Halverson, P., Fishman, N., Kohn, M., Murphy, C. L., . . . HAI Elimination White Paper Writing Group. (2010). Moving toward elimination of healthcare-associated infections: A call to action. American Journal of Infection Control, 38, 671-675. Centers for Disease Control and Prevention. (2005). Reduction in central line-associated bloodstream infections among patients in intensive care units–Pennsylvania, April 2001-March 2005. Morbidity and Mortality Weekly Report, 54, 1013-1016. Centers for Disease Control and Prevention. (2010). Collaboration primer: Establishing HAI prevention collaboratives. Retrieved from http://www.cdc.gov/hai/toolkits/collaborationPrimer.html Centers for Disease Control and Prevention. (2012a). Healthcare-associated infections: Recovery Act. Retrieved from http://www.cdc.gov/HAI/recoveryact/index.html Centers for Disease Control and Prevention. (2012b). The epidemiology workforce in state and local health departments-United States, 2010. Morbidity and Mortality Weekly Report, 61, 205-208. Centers for Disease Control and Prevention. (2013). Winnable battles: Progress. Retrieved from http://www.cdc.gov/winnablebattles/goals.html Centers for Medicare and Medicaid Services. (2013). Acute care hospital inpatient prospective payment system: Payment system fact sheet series. Retrieved from http://www.cms.gov/ Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/ AcutePaymtSysfctsht.pdf Crabtree, B., & Miller, W. (1999). Doing qualitative research (2nd ed.). Thousand Oaks, CA: Sage. Ellingson, K., McCormick, K., Sinkowitz-Cochran, R., Woodard, T., Jernigan, J., Srinivasan, A., . . .Rask, K. (2014). Enhance ment of health department capacity for healthcare-associated infection prevention enhanced through Recovery Act-funded programs. American Journal of Public Health, 104(4), e27-e33. Frieden, T. R. (2010). Maximizing infection prevention in the next decade: Defining the unacceptable. Infection Control and Hospital Epidemiology, 31(Suppl. 1), S1-S3. Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded research: Strategies for qualitative research. New York, NY: Aldine De Gruyter. Klevens, R. M., Edwards, J. R., Richards, C. L., Jr., Horan, T. C., Gaynes, R. P., Pollock, D. A., & Cardo, D. M. (2007). Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Reports, 122, 160-166. Pronovost, P., Needham, D., Berenholtz, S., Sinopoli, D., Chu, H., Cosgrove, S., . . . Goeschel, C. (2006). An intervention to decrease catheter-related bloodstream infections in the ICU. New England Journal of Medicine, 355, 2725-2732. Scott, R. D. (2009). The direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of prevention. Retrieved from http://www.cdc.gov/HAI/pdfs/hai/ Scott_CostPaper.pdf U.S. Department of Health & Human Services. (2009). Action plan to prevent healthcareassociated infections. Retrieved from http://www.hhs.gov/ash/initiatives/hai/actionplan/ hhs_hai_action_plan_final_06222009.pdf
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research-article2014
MCRXXX10.1177/1077558714533825Medical Care Research and ReviewEllingson et al.
Empirical Research
Perspectives on Federal Funding for State Health Care–Associated Infection Programs: Achievements, Barriers, and Implications for Sustainability
Medical Care Research and Review 2014, Vol. 71(4) 402–415 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1077558714533825 mcr.sagepub.com
Katherine Ellingson1, Kelly McCormick1, Tiffanee Woodard1, Amanda Garcia-Williams1,2, Peter Mendel3, Katherine Kahn3, Clifford McDonald1, John Jernigan1, and Ronda Sinkowitz-Cochran1
Abstract In September 2009, federal funding for health care–associated infection (HAI) program development was dispersed through a cooperative agreement to 51 state and territorial health departments. From July to September 2011, 69 stakeholders from six states—including state health department employees, representatives from partner organizations, and health care facility employees—were interviewed to assess state HAI program achievements, implementation barriers, and strategies for sustainability. Respondents most frequently cited enhanced HAI surveillance as a program achievement and resource constraints as an implementation barrier. To sustain programs, respondents recommended ongoing support for HAI prevention activities, improved surveillance processes, and maintenance of partnerships. Findings suggest that state-level HAI program growth was achieved during the cooperative agreement but that maintenance of programs faces challenges. This article, submitted to Medical Care Research and Review on October 28, 2013, was revised and accepted for publication on March 3, 2014. 1Centers
for Disease Control and Prevention, Atlanta, GA, USA Rollins School of Public Health, Atlanta, GA, USA 3RAND Corporation, Santa Monica, CA, USA 2Emory
Corresponding Author: Ronda Sinkowitz-Cochran, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30333, USA. Email: [email protected]
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Ellingson et al. Keywords health care–associated infections, qualitative research, federal funding
Introduction Health care–associated infections (HAIs) lead to substantial morbidity, mortality, and increased health care spending for the U.S. population (Klevens et al., 2007; Scott, 2009). Over the past decade, the burden of HAIs has been increasingly recognized as a preventable public health problem, and stakeholders, including federal agencies, have recommended and supported a coordinated, accountability-driven approach (Cardo et al., 2010; Frieden, 2010). In 2008, the U. S. Department of Health & Human Services (HHS) developed an Action Plan to Prevent HAIs, which emphasized aligning HAI stakeholder efforts, promoting standardized metrics for HAI surveillance, and targeting reductions in device-associated, procedure-associated, and multidrug resistant HAIs (U.S. Department of Health & Human Services, 2009). The Centers for Disease Control and Prevention (CDC) designated HAIs as one of seven Winnable Battles, with explicit goals for increasing adherence to infection prevention guidelines, improving surveillance, and enhancing capacity at state health departments (CDC, 2013). In step with these federal agency missions, the American Recovery and Reinvestment Act of 2009, Pub. L. No. 111-5 (ARRA), appropriated funds to health departments for HAI prevention in September 2009 through the CDC’s Epidemiology and Laboratory Capacity (ELC) Cooperative Agreement (CDC, 2012a). In an effort to better integrate public health and the health care delivery system, this novel federal funding program dedicated to HAI prevention strategies was intended to support progress toward the national targets for HAI incidence reduction established in the HHS Action Plan. The goal of this cooperative agreement was to enhance the role of the state and territorial health departments in executing the HHS Action Plan while furthering CDC’s mandate to improve HAI prevention capacity at the state level. Through this ELC cooperative agreement, approximately $35.8 million in federal Recovery Act funds for state-level HAI prevention programs was dispersed to 51 health department grantees in 49 states, the District of Columbia, and Puerto Rico. The ELC Recovery Act cooperative agreement ended in December 2011. The ELC Recovery Act cooperative agreement awarded federal funding to health departments in three HAI domains: infrastructure, surveillance, and prevention. Those receiving funding in the infrastructure domain (n = 48) were expected to financially support staff time dedicated to HAI activities, promote strategic partnerships through regular assembly of a multidisciplinary advisory group of HAI stakeholders, and provide training and technical assistance to health care facilities. Those awarded funding under the surveillance domain (n = 31) were expected to enhance the quality of HAI surveillance through the National Healthcare Safety Network (NHSN) Surveillance System and to work toward active use of NHSN data to inform decision making and motivate prevention. The 28 health departments awarded funds for prevention collaborative implementation were expected to lead or support multifacility prevention initiatives targeting HAI reductions through systematic implementation of evidence-based
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practices, data feedback, and culture change strategies (CDC, 2005, 2010; Pronovost et al., 2006). Funding awards varied, with state health departments receiving anywhere from $174,000 to $2,600,000 depending on whether funding was granted in one or more domains; the 17 health departments granted funding for only infrastructure received an average of $210,000, whereas the 22 health departments granted funding in all three domains received an average of $1.1 million.
New Contributions A quantitative evaluation of the ELC Recovery Act HAI cooperative agreement showed that funding amount was significantly associated with HAI program capacity enhancements, specifically staffing, partnerships, training, technical assistance, surveillance, and prevention; this quantitative evaluation also showed that states funded for prevention collaborative implementation demonstrated greater infection reduction than states without funding for prevention collaboratives (Ellingson et al., 2014). To complement this quantitative component of the evaluation, a qualitative assessment was undertaken by CDC in collaboration with contracted evaluation experts from IMPAQ International and RAND Corporation (IMPAQ/RAND) to gain a more indepth perspective from state-level stakeholders on the implementation of HAI programs. Qualitative research has become increasingly common in health services and health policy research because qualitative methods describe phenomena within a realworld context that is useful for understanding new programs and planning future implementation (Bradley, Curry, & Devers, 2007). The specific aims of this qualitative study were to describe state-level HAI stakeholder perspectives on (a) greatest program achievements since receipt of federal funds through the ELC Recovery Act cooperative agreement and facilitators attributed to success, (b) barriers to implementing state HAI programs, and (c) strategies for sustainability of state HAI programs.
Conceptual Framework A conceptual program model was developed by CDC and guided the evaluation serving as the basis for expectations related to health department functioning and performance (Ellingson et al., 2014). The purpose of this model was to elucidate the pathway between the funding distributed to state health departments for HAI prevention and the desired outcome of safer health care. The goal of the ELC Recovery Act HAI program was to make patients safer by increasing state health department capacity for sustained HAI prevention. The various program inputs were distributed to the state health departments to support the development or expansion of state HAI programmatic activities. This program model was the conceptual basis for the issues assessed in this qualitative evaluation. An exploratory evaluation was conducted using an inductive process of constant comparison for coding and thematic analysis. In an effort to detect patterns and regularities in responses, no a priori assumptions, hypotheses, or predefined themes were anticipated prior to immersion and qualitative analysis.
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Method Selection of States Six of the 51 states or territories with health departments receiving ELC Recovery Act funding were selected for in-depth stakeholder interviews conducted by evaluation experts external to CDC at IMPAQ/RAND. Selection criteria for states included funding domain, state population size, and progress toward HAI program goals as of early 2011. States were sorted by population size according to U.S. Census and then categorized as small (lowest third), medium (middle third), or large (highest third). The final selection criterion—initial progress toward HAI program goals—was determined by semistructured interviews of CDC-based public health analysts assigned to each state in order to provide program administration support and technical assistance; interviews were conducted by IMPAQ/RAND. The CDC public health analysts were asked to rank their assigned states as “exceptional” (i.e., serves as an example to other states in terms of program achievements and progress toward HAI prevention), “steadily improving” (i.e., on a positive trajectory with improvements since distribution of federal funding), or “slow moving” (i.e., overall progress in HAI prevention has been slow, negligible, or even negative since distribution of federal funds). Based on the funding domain, population size, and initial progress toward HAI program goals, the IMPAQ/RAND evaluation team recommended six states for stakeholder interviews: three “exceptional” and three “steadily improving” states. No “slow-moving” states were selected for this evaluation because, at the time, there had been ample follow-up with slow-moving states to elucidate and address barriers; it was less clear, however, what characteristics and dynamics led to successful implementation of ELC Recovery Act HAI programs. Thus, the evaluators decided to sample three states each from the exceptional and steadily improving categories. The CDC public health analysts assisted IMPAQ/RAND with recruitment of approximately 12 stakeholders each from the six states; the state health department’s HAI coordinator was contacted first and assisted with enumerating lists of key stakeholders. Stakeholders recruited from the state health department included the HAI coordinator, a senior executive and/or policy director, the HAI surveillance data analyst, and the infection prevention liaison. Other stakeholders included medical professionals and infection preventionists from facilities across each state as well as state-level partners such as representatives from the quality improvement organizations, hospital associations, and consumer groups. Distribution of each stakeholder group interviewed varied by state due to differences in state HAI program, size, and operations.
Development of Interview Guide and Interview Implementation The CDC and IMPAQ/RAND collaborated to develop a standardized interview guide, which was then tailored slightly by stakeholder type through the use of prespecified probes. The interview guide included detailed directions with sections for demographics and experience of respondent, previous activities related to HAIs prior to federal funding, implementation of HAI activities during the cooperative agreement,
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achievements, barriers to program implementation, and questions about lessons learned and sustainability. Interview guides were piloted in spring of 2011 on two HAI coordinators in states not selected for interviews; revisions were made, and institutional review board approval was obtained by RAND Corporation in June 2011. In August and September of 2011, three trained interviewers from IMPAQ International interviewed 69 stakeholders in the six selected states, either by phone or in person. In an effort to minimize any systematic differences across the two modes of administration, all interviews used the same standardized script, directions, probes, and prompts and were conducted using uniform procedures. All interviews were recorded with consent from stakeholders. Each interview was transcribed, identifying information was removed or redacted, and transcripts were sent to CDC for analysis.
Qualitative Coding and Analysis All transcripts were reviewed and assessed for completeness. The evaluation team within CDC’s Division of Healthcare Quality Promotion—including an epidemiologist, a behavioral scientist, a program evaluator, and a doctoral student in public health—read transcripts prior to coding following standard qualitative “immersion” methodology to comprehend scope and meaning within the entire context of the interview (Crabtree & Miller, 1999). Next, members of the team independently ascribed codes (i.e., tags or labels assigned to segments of the transcript to catalogue key concepts) to the transcripts. An inductive coding approach was used, allowing independent team members to ascribe codes without forcing any type of predetermined structure. The team met regularly to review and compare codes; this method of “constant comparison” allowed iterative refinement of existing codes as well as identification of new codes (Bradley et al., 2007; Glaser & Strauss, 1967). When all possible themes were identified and refined (i.e., the point of “theoretical saturation”), the team reassigned the set of standardized, refined codes back to the transcript. Routine conference calls between CDC and IMPAQ/RAND were used to answer any questions and clarify scripts and qualitative data as needed. The focus for this analysis was on questions related to achievements during the ELC Recovery Act cooperative agreement, barriers to HAI program implementation, as well as strategies for sustainability of state HAI programs. All transcripts were imported into MAXQDA (Version 10, Amtsgericht Berlin Charlottenburg, Germany) and assigned standardized codes. The resulting data set included a taxonomy of codes to describe achievements, barriers, and strategies for sustainability. These taxonomies were assessed by the frequency of occurrence in the transcript and stratified by stakeholder type as well as state status on initial progress (i.e., exceptional vs. steadily improving).
Results A total of 69 stakeholders were interviewed from six states, including 26 state health department employees with roles relevant to HAI, 15 representatives from state-level partner organizations focused on HAI, and 28 health care facility employees. Health
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department stakeholders included HAI coordinators (n = 5),1 HAI data analysts or surveillance leads (n = 8), infection prevention liaisons (n = 4), and policy executives (n = 9). State-level partners included representatives from state quality improvement organizations (n = 6), state hospital associations (n = 5), and consumers or patient advocate groups (n = 4). Employees from health care facilities included infection preventionists (n = 19) and physicians (n = 9). Respondents reported a range of 1 to 25 years of experience working in their current position and 0 to 40 years of experience in infection prevention and control. Staff from IMPAQ International interviewed 9 to 16 respondents from each state dependent on stakeholder availability and coordination.
Achievements and Attributions Respondents described 142 state HAI program achievements occurring during the ELC Recovery Act cooperative agreement, which were categorized into 20 independent themes. The most frequently assigned theme (assigned to 33/142 or 23% of achievements described) was enhanced HAI surveillance. Respondents specified surveillance-related achievements in terms of data validation activities, technical assistance received from the state health department for NHSN enrollment, and the ability to use data for action. As one infection preventionist explained, “The major [achievement] is getting everybody enrolled in NHSN, using standard definitions, training, and validating our consistency in data.” State health department respondents emphasized the importance of HAI surveillance enhancements in light of public reporting of HAI rates and the need to maintain data integrity and credibility; this perceived importance of validation relative to reporting was also recognized at the facility level. According to one physician: “If we hadn’t had the ARRA-funded validators coming around to validate the public reporting of central line-associated bloodstream infections, I don’t think the hospitals would have been quite as ‘honest.’” The second most commonly described program achievement during the cooperative agreement was HAI rate reduction (19/142 or 13% of achievements described). Such reductions were reported to be achieved either through federally funded prevention collaboratives or through partnerships and initiatives built between health care facilities and state-level partners including health departments, quality improvement organizations, and hospital associations. In the words of a consumer advocate, There’s significant progress on lowering the rates of central line infection and a really thorough working partnership among a variety of influential stakeholders involved in infection control . . . so there is a foundation to take on other forms of HAI that need attention.
Enhanced collaboration and partnerships (15/142, 11%), which were described by a state hospital association representative as “the collaborative nature of our work, where it’s seen as a true partnership between the public and private sector to eliminate HAIs,” and enhanced education and training (12/142, 8%) of “all the players” from health care providers to patients to public health staff throughout the state were also
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Table 1. Greatest Achievements Described by Respondents for HAI Programs During the 2-Year ELC Recovery Act Cooperative Agreement, Listed in Order of Overall Frequency. Theme rank stratified by respondent type Theme Enhanced HAI surveillance HAI rate reduction Enhanced collaboration and partnerships Enhanced training and education Advancements in public reporting
Theme rank, overall SHDa
Partners
Theme rank stratified by state’s initial progress toward program goalsb
Health care facilities Exceptional
Steadily improving
1
1
3
1
2
1
2
2
2
3
1
5
3
3
1
>5
3
4
4
>5
4
2
5
3
4
4
2
>5
4
>5
Note. HAI = health care–associated infection; ELC = Epidemiology and Laboratory Capacity. a. State health department stakeholders. b. Determined by interviews with Centers for Disease Control and Prevention public health analysts prior to data collection.
frequently cited achievements. Other achievements included advancements in public reporting (12/142, 8%), described by a health department policy executive as “the regular reporting of information about hospitals for people to see with transparency function and better information”; increased awareness and focus on HAIs (11/142, 8%); and information dissemination (11/142, 8%) through multiple communications such as “webinar series and conference calls (that facilitated) dialogue and sharing” related to HAI surveillance and prevention. Across respondent types, the reporting of main achievements was relatively consistent (Table 1). However, state partners cited enhanced collaboration and partnerships as the main achievement more often than other respondents; respondents from health care facilities cited enhanced education and training more frequently than other respondents (Table 1). Additionally, respondents from states categorized as “exceptional” in terms of progress toward program goals most often cited HAI rate reductions as the greatest achievements, whereas “steadily improving states” more often cited enhanced HAI surveillance. Respondents described 136 attributions for which they credited their program achievements; these then were categorized into 21 distinct themes. Regardless of the type of achievements cited, respondents most often described “collaboration, relationship building, and teamwork” (31/136 or 23% of all attributions described) as the primary facilitator for success. Said one state HAI coordinator, “If we just had the
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funds, but not the partnerships it wouldn’t work nearly as well.” Similarly, a representative from a state hospital association attributed success to: understanding the complementary strengths of the various organizations and how we make the most of the resources we have . . . by working in collaboration. The old model was everybody working in silos. And we no longer can afford to do that.
Another common theme assigned to attributions for achievement was the provision of the federal funding (18/136, 13%); according to one policy executive at a state health department, “You’ve got to have the dollars to do it. If you don’t have the dollars to do it, forget it. It can’t happen.” Other themes assigned to attributions for program achievement included enhanced alignment of stakeholder activities and goals (10/136, 7%), engagement and buy-in (9/136, 7%) from staff and leadership at both health care facilities and public health organizations within and across states, and the presence of dedicated HAI coordinators in each state (8/136, 6%). Regarding alignment of initiatives as an important contributor to program success, one state hospital association representative noted, “We’ve tried to align so we’re not overwhelming our hospitals . . . to fold [various initiatives] together so [hospitals] really just see it as one initiative so that they don’t have unnecessary duplicative work.” Attributions for which they credited their program achievements were similar across respondent type and state status in terms of initial progress toward program goals.
Barriers to Implementing Federal Funding for HAI Prevention Respondents described 324 barriers to program implementation, which were categorized by 24 themes. The most common theme assigned was resource constraints (99/324 or 31% of barriers noted by respondents), including lack of funding, human capital, consistent staffing, and information technology support. From the hospital perspective, one infection preventionist explained, “Hospitals are under extreme funding reductions, and it’s challenging to get additional man hours.” Similarly at the state health department, respondents noted resource barriers to hiring and maintaining staff when consistent staffing is needed to meet HAI reporting requirements. Difficulties in retaining qualified personnel at state health departments were also a concern, particularly to infection prevention liaisons: “One of our biggest challenges right now is uncertainty . . . and so we have lost staff because they don’t know what’s going to happen after ARRA finishes.” Respondents noted other barriers categorized as “problematic data or metrics,” including challenges with HAI data collection, reporting, and interpretation (58/324, 18%). Both infection preventionists at the facility level and health department employees described additional work related to NHSN data collection and challenges learning to access the data collected: “The biggest problem for us is then getting the data back out, so that we know what’s happening in our hospitals, so that we can then target our actions.” Another commonly reported challenge included competing priorities (26/324, 8%); a quality improvement organization respondent described this phenomenon in
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Table 2. Greatest Barriers Described by Respondents for Health Care–Associated Infection Programs During the 2-Year ELC Recovery Act Cooperative Agreement, Listed in Order of Overall Frequency. Theme rank stratified by respondent type Theme Lack of resources Problematic data or metrics Competing priorities Lack of buy-in/ engagement Lack of education/ training
Theme rank stratified by state’s initial progress toward program goalsa
Theme rank, State health Health care overall department Partners facilities Exceptional
Steadily improving
1
1
1
1
1
1
2
2
3
2
2
2
3
5
4
4
3
3
4
>5
2
5
3
4
5
>5
5
3
>5
4
Note. ELC = Epidemiology and Laboratory Capacity. a. Determined by interviews with Centers for Disease Control and Prevention Public Health Analysts prior to data collection.
terms of “a lot of projects that hospitals are requested to participate in . . . so it’s been a barrier at times, to get the attention of the hospitals and get their ongoing commitment to participate.” Other prominent but less frequently cited barriers to HAI program success were lack of buy-in and engagement (25/324, 8%) and lack of sufficient education and training on HAIs (22/324, 7%), most notably for infection preventionists and other health care providers but also for administrators, policy makers, and consumers. Lack of effective coordination and role differentiation among partners (19/324, 6%) was also reported and described by a consumer: There could be better coordination . . . the various efforts work somewhat in silos . . . organizations have territories and turfs . . . we could do a better job of (working) collectively for the benefit of the whole.
The frequency of barrier themes described by respondents was consistent across respondent type and state progress toward program goals in that all strata reported “lack of resources” as the number one barrier to success. State HAI partners more often reported barriers related to lack of buy-in and engagement compared to problematic data issues, whereas respondents from health departments and health care facilities cited problematic data or metrics as a barrier more often than buy-in or engagement (Table 2).
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Strategies for Sustainability When asked about strategies to sustain HAI-related activities after the ELC Recovery Act cooperative agreement ends, respondents described 111 strategies, which were categorized into 24 themes. The most common theme assigned to respondent strategies for sustainability was “long-term funding for HAI programs” (39/111 responses or 35% of all strategies described). As stated by an HAI coordinator, “Having longterm sustainable, stable funding is absolutely critical . . . you don’t want to dismantle existing programs, because you will never get them back.” Other frequently assigned themes for respondent’s suggested strategies for sustainability included surveillance and data improvements such as streamlining reporting, validation, and using data for action (15/111, 14%); maintaining partnerships (10/111, 9%); expansion of focus to diverse HAIs and settings including emerging pathogens and special settings (7/111, 6%); and practical and flexible HAI reporting requirements at the state level (7/111, 6%) through “enforcement of legislation” and “development of recommendations [by HAI subject matter experts] for what is efficient to report.” As noted by a state hospital association representative with regard to surveillance and data improvements, “The biggest piece on sustainability, in terms of actually making a difference, is making sure that the measurement process (surveillance) remains viable and not overwhelming for the performance improvement efforts.” Although respondents from health departments and health care facilities most commonly reported sustained resources as a critical strategy for sustainability, state-level partners most frequently reported maintenance of partnerships as a critical strategy. State health department and health care facility respondents also more frequently described improved HAI surveillance as critical to sustainability than did state-level partners (Table 3). There were no differences in respondent reporting of strategies for sustainability by states’ categorization in terms of progress toward program goals.
Discussion This qualitative study of perceived achievements, barriers, and strategies for program sustainability among stakeholders in states receiving Recovery Act funds through the ELC cooperative agreement for HAI program development elucidated the importance of sustained and dedicated resources (specifically financial and human capital); the widespread adoption, validation, and functionality of HAI surveillance; and relationship building and alignment among partners. Although respondents noted an array of program achievements resulting directly or indirectly from federal funding, there were concerns across respondent types about the ability of these programs to persist once the ELC Recovery Act cooperative agreement ended. From the health department perspective, the potential loss or reduction of federal funds to continue programming meant the inability to maintain qualified staff. From the facility perspective, less funding meant more burden on hospitals to train staff and coordinate prevention initiatives in an environment with many competing priorities and fiscal constraints.
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Table 3. Strategies for HAI Program Sustainability Described by Respondents, Listed in Order of Overall Frequency. Theme rank stratified by respondent type Response Sustained HAI resources Surveillance and data improvements Maintain partnerships Expand prevention across settings/ infections Practical/ progressive reporting requirements
Theme rank stratified by state’s initial progress toward program goalsa
Theme rank, State health Health care overall department Partners facilities Exceptional
Steadily improving
1
1
2
1
1
1
2
2
4
2
2
2
3
4
1
4
3
3
4
4
4
3
4
4
4
3
3
5
4
4
Note. HAI = health care–associated infection. a. Determined by interviews with Centers for disease control and prevention public health analysts prior to data collection.
The Recovery Act funds dispersed through the ELC cooperative agreement for HAI program development totaled $35.8 million for all grantees and $4.1 million in the six states participating in this study. Since the six states in this evaluation were purposely selected as “exceptional” or “steadily improving” in terms of HAI program progress, it is likely that the barriers to program implementation and sustainability challenges encountered by these states affect all 51 states and territories that received health department funding for HAI program development. Conversely, the achievements made in these six states represent what is possible in lower performing states if they can build and sustain HAI programs. Respondents from exceptional states most frequently cited HAI reductions as the greatest achievement during the ELC Recovery Act cooperative agreement, whereas respondents from steadily improving states most frequently cited enhanced HAI surveillance, suggesting that progress toward patient safety (fewer HAIs) exists on a continuum and that building surveillance infrastructure is a key component along this pathway. Among different stakeholder types (health department, representatives from partner organizations, and employees at health care facilities), the primary difference was in reported achievements; respondents from health departments and health care facilities emphasized data-related achievements, whereas respondents from partner agencies (e.g.,
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quality improvement organizations, Hospital Associations, and consumers) emphasized the strengthened relationships with stakeholders throughout the states and alignment of multiple HAI program initiatives. State health department employees, state-level partners, and health care facility employees commonly shared the perception that health care facilities were underfunded to do the HAI surveillance and prevention work expected of them. An infection preventionist noted, “You can collect all the data you want, but if you don’t have time to do the interventions, you’re not going to influence the outcomes.” Respondents’ most frequently noted achievement was improvement in HAI surveillance infrastructure, but challenges with the infrastructure for HAI surveillance were also mentioned frequently as barriers to program success. Furthermore, respondents noted that improved systems for entering data into NHSN and streamlined feedback and reporting of data were critical to the sustainability of state HAI programs. During the ELC Recovery Act cooperative agreement, NHSN enrollment increased across the country in large part due to Centers for Medicare and Medicaid Services incentives, whereas state mandates also motivated facilities to enroll in NHSN (Centers for Medicare and Medicaid Services, 2013). The state HAI programs were able to provide technical assistance to facilities for enrollment, getting started with reporting, and more than 55 validation projects (Ellingson et al., 2014). Despite gains made throughout the cooperative agreement relative to surveillance, all respondent types described the need for enhancements. Although respondents noted reductions in infections due to both federally funded and non–federally funded prevention initiatives ongoing throughout the ELC Recovery Act cooperative agreement time period, the prevailing paradigm was that there are still great strides to be made in using HAI surveillance data toward its maximum prevention potential. A policy executive articulated the importance of partnerships in reducing rates of infection through maximizing prevention efforts: We have shown a tremendous improvement in HAIs and central line associated bloodstream infections . . . that was something to be very, very proud of . . . again, I think it comes from everybody working together . . . I think that hospitals are safer as a result.
A key component of the HHS Action Plan was aligning various HAI initiatives supported by local, state, regional, and federal partners. When asked to what the program successes during the ELC Recovery Act cooperative agreement could be attributed, all respondent types reported enhanced collaboration, relationship building, and teamwork as the primary reason for program success. A state health department policy executive attributed achievement to “the fact that [hospitals] know that we’re all in the same game . . . we’re all looking for the welfare of our people in terms of reducing infections at these health care facilities.” A quality improvement organization representative also attributed success to collaborating and presenting a united front to hospitals: “We’ve realized that our hospitals really want to see alignment between the different organizations that are working on HAIs. They do not want there to be the appearance of multiple slightly different projects.” Maintaining partnerships—including convening key stakeholders and leveraging partnerships in tight financial times— was also noted by respondents as a critical factor in sustaining state HAI programs.
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This qualitative evaluation is subject to some limitations. First, all results reported are generated from self-report where respondents individually interpreted each question based on their own contextual experience and cognitive processing. Respondents were interviewed during the summer of 2011 prior to the end of the ELC Recovery Act cooperative agreement on December 31, 2011, and therefore responses may not have encompassed the entire funding period. Additionally, findings from respondents in these six states are not generalizable to all states, particularly because states were deliberately selected as exceptional or steadily improving states. Furthermore, findings may underrepresent barriers experienced by states categorized as “slow moving” since they were not included in the sample. Because this study was sponsored by CDC, responses might also have been influenced by social desirability bias. To minimize this potential bias, all recruiting and interviewing were conducted by associates at IMPAQ/RAND. Respondents were informed that their responses were confidential, and all transcripts were deidentified before being sent to CDC for qualitative analysis. From the perspective of state-level stakeholders interviewed in this evaluation, ongoing funding is seen as critical to maintain and expand HAI prevention efforts, especially as state health departments face budget cuts and staffing shortages that affect all public health activities (CDC, 2012b). This funding has in part materialized through the Prevention and Public Health Fund created by the Affordable Care Act, which helped sustain an HAI coordinator in every state health department and funded targeted prevention projects in certain states. Based on responses from this multistate, multistakeholder qualitative evaluation, maintaining partnerships to align activities and streamlining surveillance will also be critical to helping states build and sustain HAI prevention efforts. Authors’ Note The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
Note 1. The HAI coordinator for one state worked at the state’s quality improvement organization and therefore was considered as a state-level partner for the analysis rather than a state health department employee.
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