Impact of Mandatory Reporting and Nonpayment Policies on Hospital Patient Safety Practices and HAI Rates

Background: In 2008, California enacted legislation mandating that hospitals report specific rates of hospital-acquired infections (HAI) to the Department of Public Health beginning January 2009.  In addition, the Centers for Medicare and Medicaid Services (CMS) identified three HAI as “never events”, the additional costs for which they would no longer pay beginning October 2008.

Objective: The objective of this research was to assess changes in hospital organizational behaviors and HAI rates approximately one year following implementation of state and federal policy affecting mandatory reporting and nonpayment for specific HAI.

Methods: Two statewide surveys of California’s general acute care hospitals were conducted in Fall 2008 (Wave 1), and Summer 2010 (Wave 2). Response rates were 78% and 74%, respectively.  Changes in organizational behaviors for patient safety and specific HAI rates were analyzed for a cohort of 183 hospitals that responded to both waves of the survey (Wave 2 – Wave 1). Data on five HAI were collected: central line-associated blood stream infections (CLABSI)/1000 central line days; catheter associated urinary tract infections (CAUTI)/1000 urinary catheter days; ventilator-associated pneumonia (VAP)/1000 ventilator days; MRSA/1000 inpatient days; Cholostridum Difficile (C. Diff) percent of inpatient days, and on three process outcomes: hand hygiene, contact precautions, and surgical care improvement practices (SCIP).

Results: In the 15 months since mandatory reporting and 18 months since the CMS nonpayment policies took effect, California’s hospitals have made significant improvements in implementation of evidence-based practices for patient safety (n=183; p=0.03).  They increased implementation of evidence-based practices for CAUTI (p=0.0001) and C. Diff (p=0.001), as well as contact precautions (p=0.001), and SCIP (p=0.025). The hospitals also reported a decline in the “fear of blame” (p=0.0001) component of the culture of patient safety.  In addition, rates of CAUTI (n=57; p=0.005) declined from 4.38 to 1.34 per 1000 urinary catheter days, and VAP (n=106; p=0.029) declined from 1.88 to 1.12 per 1000 ventilator days. Finally, rates of appropriate hand hygiene increased from 72% to 91% (n=16; p=0.035) and rates of contact precautions from 49% to 86% (n=24; p=0.0001).

Conclusions: California’s general acute care hospitals have made significant improvements in the implementation of evidence-based practices for patient safety since the start of mandatory reporting and the CMS nonpayment policy for never events.  In addition, rates for CAUTI, which are subject to the CMS nonpayment policy, declined significantly, as did VAP rates, which are subject to state mandatory reporting.  The findings suggest that regulations and financial incentives for reducing HAI may improve patient safety practices and reduce HAI rates in general acute care hospitals.