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Reducing HealthcareAssociated Infections

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Title: Reducing HealthcareAssociated Infections


1
ReducingHealthcare-Associated Infections
Don Wright, MD, MPH L Clifford McDonald, MD,
FACP Barry M Straube, MD William B Munier, MD, MBA
OPHS CDC CMS AHRQ
AHRQ 2009 Annual Conference September 14, 2009
2
Presentation Overview
  • Introduction
  • DHHS overview
  • CDC initiatives
  • CMS role in HAI reduction
  • AHRQ HAI portfolio
  • Discussion

3
Participants
  • Don Wright, MD, MPH
  • Principal Deputy Assistant Secretary for Health,
    Office of Public Health Science
  • L Clifford McDonald, MD
  • Chief, Prevention and Response Branch, Division
    of Healthcare Quality Promotion, CDC
  • Barry M Straube, MD
  • CMS Chief Medical Officer, Director, Office of
    Clinical Standards Quality, CMS
  • William B Munier, MD, MBA
  • Director, Center for Quality Improvement
    Patient Safety, AHRQ

4
DHHS Overview
5
HHS Efforts to PreventHealthcare-Associated
Infections
  • Don Wright, M.D. M.P.H.
  • Principal Deputy Assistant Secretary
  • for Health
  • AHRQ Annual Conference
  • Rockville, MD
  • Monday, September 14, 2009

6
Presentation Overview
  • HHS Action Plan Development and Implementation
  • State Action Plans States Adopt National Plan
  • Recovery Act Funds Targeting HAIs
  • Future Direction in Reducing HAIs Tier 2
  • Healthy People 2020
  • Questions

7
Healthcare-Associated Infections (HAIs)
  • What are they?
  • Bloodstream infections, urinary tract infections,
    pneumonia, surgical site infections
  • The Problem
  • 1.7 million HAIs in hospitalsunknown burden in
    other healthcare settings
  • 99,000 deaths per year
  • 28-33 billion in added healthcare costs
  • HAI Prevention
  • Implementing what we know for prevention can lead
    to up to a 70 or more reduction in HAIs

8
HHS Action Plan to Prevent Healthcare-Associated
Infections Development and Implementation
9
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10
GAO ReportRecommendations for HHS
  • Improve central coordination of HHS-supported
    prevention and surveillance strategies
  • Identify priorities among CDC guidelines to
  • Promote implementation of high priority practices
  • Establish greater consistency and compatibility
    of HAI-related data across HHS systems to
  • Increase reliable national estimates of HAIs

11
HHS Steering Committee for the Prevention of HAI
  • Charge
  • Develop an Action Plan to reduce, prevent, and
    ultimately eliminate HAIs
  • Plan will
  • Establish national goals for reducing HAIs
  • Include short- and long-term benchmarks
  • Outline opportunities for collaboration with
    external stakeholders
  • Coordinate and leverage HHS resources to
    accelerate and maximize impact

12
Tier One Priorities
  • HAI Priority Areas
  • Catheter-Associated Urinary Tract Infection
  • Central Line-Associated Blood Stream Infection
  • Surgical Site Infection
  • Ventilator-Associated Pneumonia
  • MRSA
  • Clostridium difficile
  • Implementation Focus
  • Hospitals

Tier Two will address other types of healthcare
facilities
13
Steering Committee Working Group Structure
14
Stakeholder Public Engagement
  • Hold five stakeholder/public engagement meetings
  • Washington, DC Tuesday, June 30 (National
    Level)
  • Denver, CO Saturday, July 25 (Regional/State
    Level)
  • Chicago, IL Thursday, July 30 (Regional/State
    Level)
  • Seattle, WA Thursday, Aug 27 (Regional/State
    Level)
  • Chicago, IL Tuesday, Sept 22 (Regional/State
    Level)
  • Engage professional and public stakeholders in
    the HHS Action Plan
  • Request input on priorities and strategies

15
State Action Plans
16
State Action Plans
  • State plans will
  • Be consistent with the HHS Action Plan
  • Contain measurable 5-year goals and interim
    milestones for preventing HAIs

17
State Action Plans
  • Fiscal Year 2009 Omnibus Appropriations Act
  • Requires states receiving Preventive Health and
    Health Services (PHHS) Block Grant funds to
    certify that they will submit a plan to the
    Secretary of HHS not later than January 1, 2010
  • Authorizes CDC to withhold 25 of states
    allocated funds until this certification is
    submitted
  • All states have submitted a certification
  • Be reviewed by the Secretary of HHS with a report
    submitted to Congress by June 1, 2010
  • Technical assistance sessions and calls will be
    planned to assist states in plan development
  • CDC has created a template to assist states in
    plan development

18
American Reinvestment and Recovery Act Funds
Preventing Healthcare-Associated Infections
19
Building State Programsto Prevent HAIs
  • Project Description
  • Create and expand state-based HAI prevention
    collaboratives
  • Build a public health HAI workforce in states
  • Enhance states abilities to assess where HAIs are
    occurring
  • Agency Lead CDC
  • Collaborating Agencies AHRQ and CMS
  • Funds Source Amount American Reinvestment and
    Recovery Act Funds (40 million)
  • CDC HAI Recovery Act Website
  • www.cdc.gov/nhsn/ra

20
New Ambulatory Surgery Center Infection Instrument
  • Project Description
  • Nationwide application of a new infection control
    survey instrument (designed by CMS CDC)
  • Use of new tracer methodology
  • Use of multiple-person teams for ASCs over a
    certain size or complexity
  • Greater inspection frequency than the current
    10-year average inspection frequency (Goal 3
    years)
  • Funds Source Amount 2-year funding with ARRA
    grant dollars of 1 million in FY09 and the
    remaining
  • 9 million in FY10

21
Future Direction
22
HHS Commitment to Reducing Healthcare-Associated
Infections Tier 2
23
Tier Two Priorities
  • Ambulatory Surgical Centers
  • Dialysis Centers

24
Growth in Outpatient Care
  • Shift in healthcare delivery from acute care
    settings to ambulatory care, long term care and
    free standing specialty care sites
  • Infection control oversight often lacking
  • Approximately 1.2 billion outpatient visits /
    year
  • Number of Dialysis Centers
  • 2008 4,950 (72 increase since 1996)
  • Number of Ambulatory Surgical Centers
  • 2008 5,100 (240 increase since 1996)
  • 2007 more that 6 million surgeries performed in
    ASC and paid by Medicare

25
Surgical Procedures Movingto Outpatient Setting
All Outpatient Settings
Procedures (millions)
Hospital Inpatient
Source Avalere Health analysis of Verispans
Diagnostic Imaging Center Profiling Solution,
2004, and American Hospital Association Annual
Survey data for community hospitals,
1981-2004. 2005 values are estimates.
26
Healthy People 2020Defining the Nations Health
Objectives
27
Healthy PeopleWhat is it Now?
  • A comprehensive set of national ten-year health
    objectives
  • A framework for public health priorities and
    actions
  • Guided health policy decisions for 3 decades
  • www.healthypeople.gov

28
Healthy People 2020 Phase IINew Topic Areas
  • Access to Health Services
  • Adolescent Health
  • Childrens Health
  • Genomics
  • Global Health
  • Older Adults
  • Healthcare-Associated Infections
  • Quality of Life
  • Social Determinants of Health
  • Blood Disorders and Blood Safety
  • Healthy Places
  • Preparedness

29
Points of Contact Links
  • HHS Action Plan to
  • Prevent Healthcare-Associated Infections
  • Stakeholder Meeting Information
  • www.hhs.gov/ophs/initiatives/hai

30
CDC Initiatives
31
CDC Approach to Eliminating Healthcare-associated
Infections
  • L. Clifford McDonald, MD, FACP
  • Chief, Prevention and Response Branch
  • Division of Healthcare Quality Promotion
  • Centers for Disease Control and Prevention

The findings and conclusions in this presentation
are those of the author and do not necessarily
represent the views of the Centers for Disease
Control and Prevention No Conflicts of Interest
to Disclose
32
Patient Safety within CDCs Division of
Healthcare Quality Promotion (DHQP)
Healthcare Safety
Transfusion/Transplant Safety
Healthcare-associated Infections
Antimicrobial Resistance
Adverse Drug Events
Immunization Safety
Healthcare Preparedness
  • Outbreak Investigations
  • Surveillance
  • Prevention Recommendations
  • Intervention Implementation
  • Extramural Research
  • Laboratory Research and Support

33
CDCs Role in HAI Elimination
  • Provide technical support to states, local health
    agencies, and healthcare facilities
  • Field investigations, consultations, training
  • Define the scope of the problem and impact of
    interventions
  • National Healthcare Safety Network (NHSN)
  • Population-based surveillance systems
  • Identify best practices
  • Work with partners to promote prevention
  • Complement other HHS agencies and support
    state/local health departments

34
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35
DHQP Field Investigations of Healthcare
Associated Outbreaks, United States, 2004-2009
PR
n 61, as of July 2009 DHQP
DVH DFBMD
36
Epidemic Clostridium difficile InfectionsDetecti
on, Understanding, Surveillance, and Prevention
Emerg Infect Dis. 200612(3)409-15
Infect Control Hosp Epidemiol 2009 30264-272
37
Nevada Field Investigation of Hepatitis C
Transmission in Ambulatory Surgery Centers
  • Discovered reuse of syringes and single dose
    vials
  • Resulted in massive patient notification risks
    of bloodborne viral infections due to unsafe
    injection practices

38
  • 33 outbreaks in 15 states
  • Outpatient clinics, n12
  • Dialysis centers, n6
  • Long term care, n15

Thompson et al. Ann Intern Med. 200915033-39.
39
Implementation Challenge ? Awareness and
Adherence
MMWR May 16, 2008 5719
40
Injection Safety Campaign
41
Collaboration with CMS
  • Improve infection control in survey and
    certification process for ASCs
  • Advise on the adoption of infectious Hospital
    Acquired Conditions for reduced reimbursement
  • Part of the Deficit Reduction Act (DRA)
  • Collaborate on HAI reduction through QIOs
  • MRSA in the 9th Scope of Work
  • Pilot for the 10th Scope of Work
  • Hospital Compare
  • Role for NHSN

42
Surveillance
43
National Healthcare Safety Network (NHSN)
  • Voluntary, secure, internet-based surveillance
    system
  • Includes information about infections,
    microorganisms, and practices for HAI prevention
  • Over 2200 hospitals from 50 States currently
    report to NHSN 21 States mandate the use of NHSN
    for HAI reporting

44
States Mandating NHSN for Reporting (as of August
2009)
WA
Jul-2008
VT
ME
Feb
-
2007
MT
ND
OR
MN
Jan-2009
ID
NH Jan-2009
NY
SD
WI
Jan-2007
MA Jul-2008
MI
WY
RI
PA
CT Jan-2008
IA
Feb-2008
NE
NJ Jan-2009
NV May 2009
OH
IL
IN
CA
UT
WV
DE Feb-2008
Sept-2008
CO
Jan-2008
Jul-2009
MD Jul-2008
VA
Jan-2008
DC
Jul-2008
MO
KS
KY
NC
TN
OK
Jan
-
2008
AZ
SC
AR
NM
Jul-2008
Jul-2007
GA
AL
MS
Mandates NHSN for public reporting
LA
TX Aug-2009
FL
AK
HI

6/30/2008
45
NHSN eSurveillance Moving Towards the Future
NHSN
Component Biovigilance
Component Healthcare Personnel Safety
Component Patient Safety
Component Research and Development
Modules Hemovigilance
  • Events Modules
  • Device Associated
  • Procedure Assoc.
  • Medication Assoc.
  • MDRO and CDAD
  • High Risk Inpatient
  • Influenza Vaccination
  • eSurveillance
  • HL7 CDA
  • HL7 Messages
  • Prevention research

HL7 Health Level Seven CDA Clinical Document
Architecture
Data Transmission Standards
- Structured documents for infection reports,
denominators, and process of care measures -
Messages for laboratory results,
admission/discharge/transfer, and pharmacy data
MDRO Multidrug-resistant
organism CDAD Clostridium difficile
associated disease
46
NHSN Data for Action
  • Data for local action
  • Outcomes, adherence, analysis
  • Compare trends and benchmark
  • Data for regional/state action
  • Data for national metrics from HHS plan

47
HICPACThe Healthcare Infection Control
Practices Advisory Committee
  • Guideline production
  • Revised, systematic rapid-cycle evidence analysis
  • Urgent infection prevention recommendations for
    emerging threats (e.g., SARS)
  • June 2008, HHS Charge to HICPAC in response to
    findings of the GAO investigation
  • Prioritization of recommendations from HICPAC
    guidelines
  • Identification of major infection prevention
    strategies for Department-wide promotion

48
From Guidelines to Checklist
49
Following CDC Guidelines Reduces
Healthcare-associated Infections in
States-Examples of Success Pennsylvania, Michigan
ICUs at 103 Michigan hospitals, 18 months
BSIs/1,000 catheter days
Pronovost P. New Engl J Med 20063552725-32.
MMWR 2005541013-16
50
Hospitals Participating in NHSN are Preventing
MRSA Bloodstream Infections
Trends in Bloodstream Infections by ICU Type,
NHSN hospitals, 1997-2007
9
8
7
6
5
Pooled Mean Annual CLABSI Rate per 1,000 Central
Line Days
4
3
2
1
0
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
Year
51
Prevent Infection
Bundles (sets of infection control
recommendations) to prevent infection when
inserting devices or performing procedures.
52
Prevent Transmission
Hand Hygiene, Isolation, Environmental Cleaning,
etc
53
(No Transcript)
54
CDCs MRSA Prevention Initiatives
National
Region
  • VA Pilot
  • 17 hospitals,
    multiple states
  • MarylandInitiative
  • 15 hospitals
  • National VA Initiative
  • 150 hospitals
  • nationwide
  • CMS
  • 9th Scope of Work

Facility
Unit
Hospital-wide VA Pittsburgh
ICUVA Pittsburgh
  • RWJ Initiative
  • 6 hospitals, 4 states

gt60 Reduction in MRSA
National
Local
55
CDC and AHRQ collaborating to prevent MRSA/HAIs
  • AHRQ receiving supplemental funds for MRSA/HAI
    research
  • CDC and AHRQ are collaborating on MRSA/HAI
    prevention research in a healthcare system,
    including acute care hospitals and long-term
    facilities
  • CDC provides technical expertise into what
    research questions need answering
  • CDC will put research results into action, and
    use results to
  • Update existing recommendations as appropriate
  • Advise prevention implementation campaigns on how
    best to prevent HAIs

56
CDC Works with Healthcare Facilities and States
  • Technical and direct support (e.g. field
    investigations and consultation)
  • Data for action (e.g., NHSN, emerging infections
    program)
  • Training and tools
  • Funding with accountability (e.g., epidemiology
    and laboratory capacity)

57
CDC Successfully Collaborates with States to
Prevent Healthcare-associated Infections
  • New York CDC guidelines basis for prevention
    implementation initiatives
  • Greater New York Hospital Association prevention
    initiative
  • Collaborative partnership with 46 hospitals
  • Focused on incrementally building infrastructure
    needed for BSI and other future prevention
    initiatives (e.g. C. difficile)
  • Communications to share best practices
  • Culture of accountability
  • CEO to support staff levels involved
  • Site visits, monthly reporting
  • Adopted bundles of practices


58
Preventing Healthcare-associated Infections the
Time is NOW
  • Problem is critical and costly but preventable
  • Interventions can have an immediate national
    impact
  • Interventions can be cost savings
  • Ongoing efforts are needed to address changes in
    healthcare

59
Keys for the Elimination of Healthcare-associated
Infections
  • Collect data and disseminate results
  • Communication with consumers
  • Evaluate how were doing
  • Full adherence to best practices
  • Recognize excellence
  • Identify and respond to emerging threats
  • Improve science for prevention through research

60
Public Health Continuum
Evaluate Impact Of Policy and Prevention

Translate Proven Strategies into Practice
61
Increasing Needs for Public Health Approach
Across the Continuum of Care
Acute Care Facility
Home Care
Outpatient/ Ambulatory Facility
Long Term Care Facility
62
INFECTION PREVENTION IS EVERYONES RESPONSIBILITY!
  • http//www.cdc.gov/ncidod/dhqp/

63
Save the DateFifth DecennialInternational
Conference onHealthcare AssociatedInfectionsMa
rch 18-22, 2010Hyatt Regency AtlantaAtlanta,
Georgiahttp//www.decennial2010.com
Co-organized by
64
CMS Role in HAI Reduction
65
Healthcare Acquired InfectionsCMS Driving
Improvement
  • Barry M. Straube, M.D.
  • CMS Chief Medical Officer
  • Director, Office of Clinical Standards Quality
  • Centers for Medicare Medicaid Services (CMS)

66
Ensuring Quality ValueCMS Strategies
  • Traditional Quality Improvement
  • Transparency Public Reporting Data Sharing
  • Incentives
  • Financial Value-Based Purchasing
  • Non-financial
  • Regulatory vehicles
  • Demonstrations, pilots, research
  • Leveraging efforts with other HHS components,
    state/federal agencies private sector

67
Traditional QI
  • Prioritization of potential topics
  • Evidence-based metrics and interventions
  • Accountability Administrative financial
  • Attribution of interventions to outcomes
  • Scientific evaluation of outcomes as well as
    cost-benefit analysis of each initiative
  • Continue, build, retire or new direction?

68
Traditional QI
  • QIO Program 9th SOW
  • August 1, 2008 July 31, 2011
  • Four themes
  • Patient Safety
  • Prevention
  • Care Transitions
  • Beneficiary Protection
  • Cross-cutting issues
  • HIT adoption and use
  • Health Disparities
  • Value in Healthcare

69
Traditional QI
  • QIO Program 9th SOW
  • HAIs under patient safety theme
  • Reduction of MRSA infections in 440 hospitals
    nationwide
  • CDC National Healthcare Safety Network (NHSN)
  • AHRQ TeamSTEPPS methodology
  • Pilot programs ? 10th SOW inclusion
  • C. difficile infection reduction
  • Urinary tract catheter infection reduction

70
Traditional QI
  • ESRD Network Program QI activities
  • Individual ESRD Networks have included activities
    to address infections in vascular access as well
    as other infection control issues, including
    facility-acquired infections (dialysis facilities
    and some hospitals)
  • Collaboration with other HHS agencies, other
    state/federal agencies, private sector
    organizations

71
Transparency
  • Hospital Compare Website as prototype
  • 27 quality process measures (all patients)
  • 6 quality outcomes measures (Medicare only)
  • HCAHPS survey for experience of care (all)
  • Medicare payment and volume (Medicare only)
  • Several infection-related quality measures
  • Influenza and pneumonia vaccinations
  • Therapeutic and prophylactic antibiotics
  • Pre-op hair removal, blood cultures, etc.

72
Transparency
  • Additional reporting of HAI measures
  • Considering for future Hospital Compare updates
  • Requires NQF endorsement and Hospital Quality
    Alliance and other stakeholder input
  • Expand to other provider sites, starting with
  • Ambulatory surgery centers
  • Dialysis facilities
  • Link to transitions of care and episodes of care

73
Transparency
  • The White House, the Secretary and HHS have
    prioritized the concept of HHS making its data
    available to all healthcare stakeholders
  • http//www.data.gov development and expansion
  • CMS has now added the concept that as part of its
    public health agency role, collecting, reporting
    and making healthcare data available is a core
    competency/mission

74
Incentives
  • Value-based Purchasing (VBP)
  • Hospital VBP Report to Congress (Nov 2007)
  • Physician VBP RTC due May 2010
  • ESRD Quality Incentive Program to be implemented
    by January 1, 2012
  • All other settings with plans
  • Healthcare Reform debate may define better
  • HAI focus may be included in all

75
Incentives Hospital Acquired Conditions
  • DRA Section 5001(c) authorized this approach
  • Beginning October 1, 2007, IPPS hospitals were
    required to submit data on their claims for
    payment indicating whether diagnoses were present
    on admission (POA)
  • Beginning October 1, 2008, CMS stopped assigning
    a case to a higher DRG based on the occurrence of
    one of the selected conditions, if that condition
    was acquired during the hospitalization

76
Incentives HACs
  • By statute CMS had to select conditions that are
  • High cost, high volume, or both
  • Assigned to a higher paying DRG when present as a
    secondary diagnosis
  • Reasonably preventable through the application of
    evidence-based guidelines
  • CMS and CDC convened an internal workgroup to
    select the HACs

77
Incentives HACs
  • Almost all HACs might have indirect relationship
    to potential HAIs
  • HACs clearly linked to HAIs
  • Catheter-associated UTI
  • Vascular catheter associated infection
  • Surgical site infections
  • Mediastinitis after CABG
  • Certain orthopedic surgeries
  • Bariatric surgery for obesity

78
Incentives HACs
  • HAC payment policies currently relate to outlier
    payments under Medicare Part A
  • Could consider expansion of payment to more than
    the outlier portion
  • In some cases can supplement payment policy
    restrictions with Coverage Policy via National
    Coverage Decisions (NCDs)
  • Affects not only Part A (hospitals), but Part B
    (physicians, clinicians, suppliers, etc.)

79
Conditions of Participation
  • COPs are minimum health and safety standards set
    by CMS for facilities that may receive Medicare
    payments
  • Current Infection Control COPs generally address
    reduction of HAIs
  • Expansion possibilities for COPs
  • Require facilities to incorporate specific
    standards of practice or guidelines set by the
    Secretary
  • Require that infection control be part of the
    QAPI program

80
Conditions of Participation
  • Infection control regulations already
    strengthened
  • Conditions for Coverage for ESRD facilities
    (April 15, 2008)
  • CfC for Ambulatory Surgery Centers (ASCs)
    (November 18, 2008)
  • Other current considerations
  • Omnibus COP/CfC Rule for HAIs
  • Individual setting strengthening of current regs

81
Survey Certification
  • All U.S. healthcare facilities certified by
    Medicare are expected to be in compliance with
    all current regulations, as well as applicable
    state laws
  • SC process uses interpretive guidelines to
    assess compliance with regulations
  • Focus on HAIs can be prioritized
  • Surveyor training has included HAI emphasis
  • Web-based training surveyor tools being
    developed
  • Interpretive guidelines for 2010 to include QAPI
    opportunities for hospitals

82
Other
  • Demonstrations, pilots, research
  • ARRA funding and other funding sources should
    also focus on HAIs as they fall under
  • Comparative Effectiveness Research
  • Prevention, Wellness, Patient Safety
  • CMS will incorporate HAI topics into its demos,
    when appropriate
  • Cross Agency HHS collaboration (a priority for
    all issues from the Secretary), as well as with
    other federal/state agencies, private sector

83
Contact Information
  • Barry M. Straube, M.D.
  • CMS Chief Medical Officer,
  • Director, Office of Clinical Standards Quality
  • Centers for Medicare Medicaid Services
  • 7500 Security Boulevard
  • Baltimore, MD 21244
  • Email Barry.Straube_at_cms.hhs.gov
  • Phone (410) 786-6841

84
AHRQ HAI Portfolio
85
Overview
  • Background
  • Current Initiatives
  • Future Directions

86
Background
  • General AHRQ approach
  • Keystone ICU Project 2003
  • First major AHRQ HAI project 454,000
  • Enormously successful in reducing central line
    infections in ICUs in Michigan
  • Barriers and Challenges for Preventing HAIs in 34
    Hospitals Initiative 2007
  • 5 ACTION networks 2 million

87
MRSA 2008
  • 5 million in appropriated funds
  • Coordinated with CDC CMS
  • Funded 7 projects, e.g.,
  • Implementation of MRSA-reducing practices
  • Contribution of community LTC to rising
    occurrence of MRSA in hospital patients
  • Rapid-cycle state and national estimates
  • Understanding MRSA reservoirs

88
MRSA CUSP 2009
  • 17 million in appropriated funds
  • 8 million for MRSA gt 7 MRSA projects
  • 9 million for CUSP gt 6 CUSP projects
  • Included projects also directed at
  • C. difficile
  • KPC-producing organisms
  • Urinary tract infections
  • Surgical site infections
  • Antibiotic usage
  • Hemodialysis

89
AHRQ HAI Investments
CUSP Comprehensive Unit-based Safety
Program Includes other related infections
90
Current Efforts
  • Roll-out of CLABSI initiative in all 50 states,
    in cooperation with private sector
  • Commencement of numerous new projects addressing
    effective implementation of known techniques
    research on better methods of prevention of HAIs
    by organism by infection site

91
Future Plans
  • Maintain alignment with DHHS
  • Continue rollout of CLABSI nationwide
  • Promote best practices research findings via
    proven techniques
  • Align HAI efforts with those of Patient Safety
    Organizations (PSOs), which are collecting data
    on adverse events using AHRQs Common Formats

92
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93
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