January 12, 2006

Representative Ann Pugh
Chair, House Committee on Human Services
Vermont House of Representatives
115 State Street
Montpelier, VT 05633-5201

Dear Representative Pugh:

In June of 2005, you sent a letter to Bea Grause, President and CEO of the Vermont Association of Hospitals and Health Systems, requesting that she "convene a working group of interested persons to develop a hospital infection rate reporting system appropriate to Vermont's needs."

We are pleased to report that we did convene such a working group, as a subcommittee of the larger Act 53 Hospital Community Report Work Group. Members of the Act 53 Infection Reporting Subcommittee include:

• W. Kemper Alston, MD, MPH, Hospital Epidemiologist, Fletcher Allen Health Care
• Dawn Bennett, Health Care Administrator, Vermont Department of Banking, Insurance, Securities and Health Care Administration
• Gene Cenci, Consumer
• Pat Jones, Director of Quality Assurance and Consumer Protection, Vermont Department of Banking, Insurance, Securities and Health Care Administration
• Cy Jordan, MD, Medical Director, Vermont Program for Quality in Health Care
• Jeanne Keller, MS, ARM, Health Care Consultant and Consumer Advocate
• Patty Launer, RN, Vermont Program for Quality in Health Care
• Cort Lohff, MD, State Epidemiologist, Vermont Department of Health
• Rich McCoy, Public Health Chief Statistics Chief, Vermont Department of Health
• Donna Morris, MLT, CIC, Infection Control Practitioner, Northeastern Vermont Regional Hospital
• Jill Olson, Vice President, Vermont Association of Hospitals and Health Systems
• Susan Page, MT, MS, CIC, Infection Control Practitioner, Fletcher Allen Health Care
• Wilma Salkin, RN, BSN, CIC, Infection Control Practitioner, Southwestern Vermont Medical Center

The subcommittee began meeting in September, and has convened four times. At the first meeting, the Vermont Program for Quality in Health Care presented their research and recommendations on infection reporting (see attached recommendations from VPQHC). At the second meeting, the group heard from the Missouri Department of Health and Senior Services and the Pennsylvania Health Care Cost Containment Council. Missouri will begin reporting hospital-specific infection measures in January of 2007, and Pennsylvania released a statewide report on infection rates in 2005. At the third meeting, Mary Andrus from the federal Centers for Disease Control and Prevention (CDC) provided an update on the CDC's proposed National Healthcare Safety Network (NHSN) surveillance system, which shows promise in measuring infection rates and infection control processes. NHSN is replacing the National Nosocomial Infections Surveillance (NNIS) system developed by the CDC in the early 1970's; NNIS was a voluntary reporting system and the only national system for tracking healthcare-associated infections. At the fourth meeting, the group heard about other state and national efforts from Lisa McGiffert of the Consumers Union. By hearing from these various experts, the subcommittee became well educated about the state of the art of infection measure specification and reporting.

Summary of Subcommittee Points of Consensus

The subcommittee has reached consensus and formulated recommendations in a number of areas, including mechanisms for identifying future measures, principles of public reporting of infection measures, criteria for potential measures, and a timeline for collecting data and publicly reporting measures. The following is a brief summary of these points of consensus; more in-depth discussion of each point is found below.

The subcommittee members agreed that:

• The already-existing Act 53 Hospital Community Report Work Group established to identify measures and formats for public reporting of quality information, along with the Work Group's Infection Reporting Subcommittee, should serve as the mechanism for identifying infection measures for public reporting.
• Adequate infrastructure, including adequate funding and a coordinating body with health data experience, is essential for BISHCA to implement effective public reporting of infection data at the individual hospital level.
• In order to ensure the best possible public reporting, a number of principles that are outlined by the national Healthcare Infection Control Practices Advisory Committee (HICPAC) should be followed by Vermont.
• There are a number of criteria that should be met by any publicly reported measure, in order to ensure the accuracy and relevance of the measures.
• An aggressive timeline should be adopted for public reporting of infection measures, as national specifications are developed and technical issues are resolved. During the next two years, the subcommittee recommends that public reporting be initiated for measures of surgical antimicrobial prophylaxis, central line (also known as central venous catheter) associated bloodstream infections in intensive care units, and surgical site infections following selected operations. Other measures should be added as specifications are developed.
• Because infection reporting measures are constantly being developed, updated and refined, specific measures should not be delineated in legislation.

Mechanisms for Identifying Infection Measures for Public Reporting

A broad-based Act 53 Hospital Community Report Work Group was convened in 2004 to identify measures and reporting formats for the first Act 53 hospital community reports. The Work Group consists of technical experts from the Vermont Program for Quality in Health Care, the Northeast Health Care Quality Foundation and the Vermont Department of Health. It also includes hospital representatives, consumers and BISHCA staff. This Work Group has proven effective in identifying measures, working through reporting issues, and developing formats for public reporting. The Work Group appointed an Infection Reporting Subcommittee based on the recommendations in your June 2005 letter. There was consensus that the Act 53 Hospital Community Report Work Group and the Infection Reporting Subcommittee should continue to advise BISHCA Commissioner John Crowley on measures and reporting formats for the Act 53 hospital community reports.

Infrastructure Needs

Public reporting of hospital quality and financial information is a major new initiative for state government in Vermont. Some infrastructure has been developed for hospital public reporting (e.g. the Act 53 Work Group and the use of analytic capability at the Northeast Health Care Quality Foundation and Press Ganey, Inc.), but more will be needed as Vermont's public reporting initiative ventures into more complex measures such as mortality rates, volumes of selected procedures, and infection rates. These measures rely on hospital discharge databases and other sources of data. They often require database verification to ensure accuracy, and risk adjustment in order to account for differences between hospitals in the severity of patient conditions. BISHCA will need to identify a coordinating body to perform this complex data analysis. Financial resources will be needed to support that analysis and to provide education and assistance to hospitals in collecting the data. Virtually every other state that has been charged with hospital public reporting has been provided with financial resources; as an example, the state of Missouri has been provided with an annual general fund allocation of $600,000 for its infection reporting initiative. While it remains to be determined exactly how much funding will be required for Vermont's initiative, it is unrealistic to assume that this initiative can be accomplished without additional resources and without the technical expertise that a coordinating body can provide.

Principles of Public Reporting of Infection Measures

VPQHC recommended that Vermont follow the recommendations included in a published document from the national Healthcare Infection Control Practices Advisory Committee (HICPAC). HICPAC is an advisory committee to the Centers for Disease Prevention and Control. The 2005 report, which is attached to this letter, is entitled "Guidance on Public Reporting of Healthcare-Associated Infections: Recommendations of the Healthcare Infection Control Practices Advisory Committee."

There are a number of principles outlined in the HICPAC document. They include:

• "Use established public health surveillance methods."
• "Involve people with infection control expertise in the process."
• "Track practices that prevent infections, in addition to measuring infection rates."
• "Provide regular and confidential feedback to healthcare providers."
• Phase in measures "to allow facilities to adapt and to permit ongoing evaluation of data validity."

The subcommittee recommends that these principles be used to guide the Vermont public reporting initiative.

Criteria for Potential Measures

Since its inception, the Act 53 Hospital Community Report Workgroup has worked to ensure that the data that is publicly reported is accurate, relevant, and can be collected. The following criteria for potential measures were agreed upon by the full Work Group, and have also been adopted by the Infection Reporting Subcommittee:

1. Reliability
2. Validity
3. Basis in scientific evidence
4. National consensus
5. Availability of relevant, reliable and valid external benchmarks
6. Well-developed specifications
7. Importance to consumers
8. Adequacy of case numbers
9. Cost of data collection

Applying these criteria to potential measures will ensure that consumers have access to the best possible data about health care quality and safety.

Timeline for Data Collection

The HICPAC document suggests the following potential initial measures for states committed to mandatory public reporting:

• Surgical antimicrobial prophylaxis
• Central line associated bloodstream infections in intensive care units
• Influenza vaccination among patients and healthcare professionals
• Surgical site infections following selected operations
• Central line insertion practices

The subcommittee has developed the following time frame for collecting and reporting information on these measures in Vermont, on a hospital-specific basis:

There will be significant technical issues that will need to be addressed in order to make the data accurate and comparable (e.g. - risk adjustment, small numbers, case finding, identification of patient populations, data validation, presentation of data). The Act 53 Work Group is convening a technical panel to address similar issues with other measures being considered for the hospital community reports. The Subcommittee recommends using the technical panel's expertise for infection reporting as well. Infection control practitioners should be included on the technical panel when it is addressing infection reporting issues.

Infection measurement and reporting is a rapidly evolving science. The Subcommittee recognizes that measures and reporting mechanisms will change over time, and recommends that Vermont be prepared to adapt to those changes and adjust reporting requirements accordingly. The Subcommittee and Work Group will aggressively seek to improve the transparency of public reporting of infection data and other health care quality and financial information.

Thank you for providing us the opportunity to report on our activities. We look forward to continuing a dialog with you and your committee regarding these important initiatives.

Sincerely,

John P. Crowley
Commissioner
Department of Banking, Insurance, Securities and Health Care Administration

M. Beatrice Grause, RN, J.D.
President and Chief Executive Officer
Vermont Association of Hospitals and Health Systems

Pat Jones (on behalf of the members of the Infection reporting Subcommittee)
Director of Quality Assurance and Consumer Protection
Department of Banking, Insurance, Securities and Health Care Administration