Good enough is not good enough for infection prevention

By Walter Morrissey and Kenneth Kaufman

CMS has its ways of influencing clinical processes, and those ways generally involve payment—more for comparatively better performance and less for comparatively worse performance.

It is no surprise, then, that hospitals intently measure their performance with the metrics that CMS uses to determine payment rewards and penalties.

In the case of hospital-acquired infection, that metric is called a standardized infection ratio. This ratio compares the actual number to the predicted number of hospital-acquired infections. If your ratio is greater than 1.0, more hospital-acquired infections were observed than predicted; if the ratio is less than 1.0, fewer were observed than predicted.

CMS uses this ratio for five types of potential hospital-acquired infections as part of a hospital’s overall score for hospital-acquired conditions. Hospitals with a total score of hospital-acquired conditions greater than the 75th percentile have their CMS payments reduced.

This ratio, with its accompanying penalties, has proven to be a powerful tool. CMS and independent studies show measurable reduction in hospital-acquired infections as a result of the program. Also important, the ratio has provided excellent clarity within hospitals. Achieving a ratio of 1.0 or lower is an organizational focus—easy to understand and communicate, a clear target to celebrate if achieved and on which to renew focus if not achieved.

So, what’s the problem?

All this sounds good. And it is good. The problem is that it’s not good enough.

Among the hospitals we work with to improve clinical performance, we see a strong focus on achieving that lower-than-1.0 standardized infection ratio. A lot of diligence, skill and devotion goes into reaching that level of performance, all of which deserves commendation. It’s the right thing to do for patient safety and health, and it’s the right thing to do for hospital financial stability in a time of intense margin pressure.

The problem is that, perhaps naturally, this level of performance can become an end goal rather than a point on a continuum.

Having achieved this level of performance, hospitals may take their foot off the gas and turn their attention to other performance issues, rather than trying to get even better at preventing hospital-acquired infections.

The reasons to get even better are worthy of attention at the highest levels of the organization. A hospital may have fewer hospital-acquired infections than expected, but infections still occur. On any given day, one in 31 patients has a hospital-acquired infection.

With those infections come very real risks. For the organization, the risks range from unreimbursed expenses for unnecessary lengths of stay all the way to reputational damage for serious adverse events. For patients, the risks are far worse, from suffering to death.

Why aren’t we better?

Experts have been studying hospital infection prevention longer than anyone reading this blog has been alive.

In 1847, a Hungarian physician named Ignaz Semmelweis showed the relationship between unclean hands of physicians and maternal childbed fever in hospitals. In the 1950s, an epidemic of Staphylococcus aureus infections, particularly in hospital nurseries, gave rise to the first wave of epidemiological analysis of hospital-acquired infections. In 1965, the Centers for Disease Control and Prevention launched the Comprehensive Hospital Infections Project. In 1976, the Joint Commission established its first infection control standards.

Today, we have a solid understanding of the factors that increase the risk of infection in hospitals, and the clinical structures and processes that can reliably mitigate those factors. Yet patients still get infections within the walls of a hospital—at a rate that is greater than wanted.

Not surprisingly for anyone who has spent time in a hospital—or perhaps in any other complex organization—the barriers to getting better at infection prevention are generally not gaining knowledge but changing culture. The “easy” part is identifying the critical two or three process steps that contribute to a majority of infections. Culture is required to drive improvement in the critical process steps and then sustaining the improvements achieved. 

Consider one example.

Central line-associated bloodstream infection has the highest mortality rate among all healthcare-associated infections, from 12% to 25%. The CDC, supported by multiple studies, suggests a battery of practices to prevent these dangerous infections.

One recommendation concerns the site of catheter placement, with the CDC suggesting subclavian rather than jugular insertion when not contraindicated. Another practice concerns the type of catheter, with the CDC favoring a catheter with the fewest number of ports necessary. Use of the non-recommended practices heightens the need for vigilant nursing follow-up to prevent infection—an additional layer of complexity and burden for an already strained nursing staff.

Here is where culture enters the picture.

Physicians tend to use a site for, and a type of, central line catheter based on their training, experience and comfort. For many doctors, that means using a large-diameter catheter in the jugular vein. Conversations with physicians about this issue frequently elicit comments such as, “I do it the way I was taught.” Regarding post-procedural follow-up, it is often suggested that this responsibility can be effectively managed by nursing staff when in fact many lines are impossible to manage. In other words, an “upstream” cause leads to a “downstream” problem.

These responses are understandable. They are human nature. They are part of the hospital culture. And they are hard to overcome without a strong leadership directive.

What high-performing organizations do differently

The best organizations don’t wait for penalties or infections to tell them they have a problem.

• They target high-yield, upstream failure points, such as those in the preceding example, rather than diluting focus across dozens of metrics.
• They foster strong physician-nurse collaboration, ensuring that handoffs are accurate, and clinical decisions are transparent.
• They implement real-time rounding that not only identifies risk but demands immediate resolution.
• They embrace a daily learning culture where every missed opportunity is a shared lesson, not just an individual lapse.
• They instill a safety-first mindset where early decisions, especially line or catheter placements, are made with long-term consequences in mind.
• They consistently monitor process metrics using visual management tools. Process metrics, which can easily be collected daily or even every shift, offer real-time insights. High performance in these areas often directly correlates with reduced infection rates.

High-performing organizations know that sustainable safety is not achieved through compliance alone, but through a deep-rooted culture of vigilance, ownership and continuous improvement. And that culture starts with leadership commitment.

Making excellence a priority

For decades, the tool of choice among professionals seeking to improve hospital infection prevention has been comparative performance data. Clinicians are scientists, the truism goes. Show clinicians data about which processes are safer, and they will change their habits.

There is a great deal to recommend this approach. It creates a shared understanding among clinicians, and it can be a catalyst for incremental change. The problem is that the resulting change, after decades of focused effort, has not been enough.

Improvement in the prevention of infection will come more rapidly, more broadly and to a greater degree when it becomes a highly visible, highly vocal priority of the hospital’s CEO and board chair, standing shoulder to shoulder with the chief medical and nursing officers.

Even at high-performing hospitals, too many patients are getting infections that they did not enter the institution with. As a result, too many patients are suffering, and too many are dying.

For a hospital, this creates a financial burden at a time when hospitals are desperate for ways to improve their financial standing. It creates reputational risk that can undermine the community trust that is the basis of a hospital’s success and mission. And it undermines the very reason hospitals exist.

Among all the other priorities, initiatives and voices vying for the finite attention of hospital leadership, we respectfully suggest that achieving excellence in preventing hospital-acquired infections deserves to be first in line.