Form 1 Interview Protocol for Acute Care Settings

Interview Guide- Acute Care Setting (Phase I)

Phase II of a Longitudinal Program Evaluation of HHS Healthcare Associated Infections (HAI) National Action Plan

Interview Guide – Acute Care Settings (Phase I)

Interviewee Name:

Title:

Organization:

Interview Date and Time:

Interviewer:

Note taker:

Introduction and Consent

Hello, my name is [interviewer name] from [Insight, RAND, or IMPAQ]. Thank you again for agreeing to talk with me today about your involvement in preventing healthcare-associated infections and patient safety. I’m joined today by [names and affiliations of other team members, if applicable] and [note-taker name] from [Insight], who will be taking notes for the interview.

We’re part of a team from Insight, RAND, and IMPAQ hired by the Department of Health and Human Services (HHS) to conduct a longitudinal program evaluation of the HHS Action Plan to Prevent Healthcare-Associated Infections. This year we’re focusing on the following topics that we’ll be asking you about today:

• What are the current major priorities in HAI prevention and how are various federal prevention and safety initiatives addressing these priorities?

• What are some of the main challenges facing HAI prevention in different healthcare settings?

• What are some of the key lessons that can be learned from (insert QI program person represents) about what works in HAI prevention?

• How can federal agencies best promote coordination of infection prevention efforts across different safety initiatives and healthcare settings?

Review informed consent:

Let me also take a minute to review the informed consent for the interview and how we’ll handle the information you provide:

• We will use the information you share with us for research purposes only.

• All of your responses will be kept confidential.

• No one, except the Insight/RAND/IMPAQ research team, will have access to the information you provide, and we will only produce summaries from our collective set of interviews.

• We will not report information in any way that identifies you or the organization you are affiliated with to anyone outside the research team, except with your permission or as required by law.

• We will destroy all information that identifies you after the end of the study.

• We’d also like to emphasize that your participation is completely voluntary:

  • Your participation or nonparticipation will not be reported to anyone.

  • You can stop the interview at any time for any reason, and you should feel free to decline to discuss any topic that we raise.

You should have received an attachment to the email confirmation for the interview that covers this information. That sheet also includes contact information for the project director if you have questions about the study, as well as for RAND’s Human Subjects Protection Committee if you have questions about your rights as a research participant. Do you recall seeing that sheet?

[IF NO] We’ll send you that document again so you have a written copy of this information.

[IF YES] Great.

Do you agree to be interviewed?

With your permission, we’d also like to audio-record the interview to ensure we record and analyze your remarks accurately. Only the IMPAQ/RAND team will have access to the recording, and the recording will be destroyed at the end of the project. Would it be okay to audio-record the interview?

Do you have any questions about the interview before we begin?

[IF YES, answer any questions]

The first set of questions asks about your perspective on current HAI prevention priorities and activities in the acute care hospital setting.

1. What do you see as the current major priorities in HAI prevention for the acute care hospital setting?

a. How are cross-setting infections (e.g. infected or colonized patients bringing infectious organisms into acute care from other settings) affecting HAI prevention priorities?

2. Have there been any major achievements or milestones in hospital HAI prevention over the past year? If so, what are they?

Probe:

• What has been the role of federal agencies in these achievements or milestones?

3. What currently are the main challenges facing HAI improvement efforts in the hospital setting?

Probe:

• In which areas has progress on HAI outcomes been slower than anticipated, and why?

4. The HHS Action Plan to prevent HAIs recently established new HAI goals for 2020 to reduce CLABSI and MRSA infections by 75% in acute care hospitals.

1. Do these goals seem reasonable?

2. What will it take to achieve those goals?

5. What types of multi-drug resistant organism (MDR-O) infections are emerging in the acute care setting at this time?

Probe:

• Are you seeing emerging infections such as KPC and CRE in the acute care setting?

1. How are healthcare professionals in the acute care setting addressing these infections in terms of both treatment and prevention?

This next section focuses on the influence of and interaction between the HAI National Action Plan and other federal safety improvement efforts.

We’re interested in how several other specific federally-sponsored safety initiatives contribute to HAI prevention and relate to the Action Plan. I’d like to start by asking you a question about each one.

[Interviewer Note: for this question, it’s OK if respondent says they don’t enough about a safety program to answer. It’s also OK if respondent only has information on how one affects the other but not vice versa. Just note and go to next question.]

[Interviewer Instruction: Ask the following question for each of the following Safety Programs:]

• CUSP, the Comprehensive Unit-based Safety Program, which began with CLABSI and has been adapted for other HAIs, like CAUTI, VAP, and SSI.

• TeamSTEPPS program developed by AHRQ and the Department of Defense

• CMS’ Quality Improvement Organizations (QIO) program

• CMS’ Value-based Purchasing program

• Partnership for Patients initiative

6. If you’re familiar with [Safety Program]…

1. What do you see as its current major contribution to HAI prevention in the hospital setting?

One of the goals of the Action Plan is to promote alignment and coordination between quality improvement programs the Action Plan. In your opinion have there been any changes in coordination and alignment since the Action Plan was first implemented? Can you share an example or examples that illustrate that change?

[Note: Repeat above question for each of the Safety Programs.]

7. What are your suggestions for how the various federal safety efforts can best be coordinated and aligned to support HAI improvement in the hospital setting?

1. What specific roles do you see for the Action Plan and the other programs in HAI prevention and improvement going forward? In an ideal world, how would these programs work together? What would need to be done for that to happen?

8. What are some of the key lessons from HAI improvement in the hospital setting that are applicable to other settings being addressed by the Action Plan? Namely:

1. Ambulatory Surgery Centers?

2. End-stage Renal Disease Centers?

3. Long-term Care facilities?

9. What opportunities do you see for HAI interventions that span across multiple settings such as these?

• Probes: What are the most important cross-setting interventions? What is needed to make them happen?

10. [For Value-based Purchasing only] What do you think the effect of CMS public reporting and value-based payment incentives has been during the past year?

• How have healthcare organizations and providers responded to these incentives?

• Have there been any noticeable unintended consequences?

• Are HAI prevention activities sufficiently resourced?

11. What other major quality improvement initiatives – aside from the 5 that we mentioned – do you see contributing to or impacting HAI prevention?

Our next section explores specific issues around HAI Data and Monitoring. This refers to the development, collection, validation, and use of HAI data for quality improvement and outcomes monitoring.

[Note: some of the specific questions in this section may have already been discussed above. If so, either skip the particular question or use this opportunity to find out more about the issue.]

12. Can you describe progress, if any, in HAI data systems, measures, or surveillance over the past year?

Probes:

• What progress has there been in the validation of HAI surveillance data used for public reporting and payment incentives?

• What progress has there been in automation of HAI surveillance using EHR, lab, or other provider data systems?

13. What currently are the biggest challenges in HAI data systems, measures, and surveillance?

Probes:

• What do federal agencies or other stakeholders need to do to address those challenges?

• How well coordinated are the federal government’s HAI data and monitoring systems? What do you think would help improve this coordination?

14. How has the development of the new definition for Ventilator-Associated Events (VAE) affected HAI measurement and surveillance?

15. One of the recommendations in the 2009 GAO report focused on better integration and coordination of HAI data systems within HHS. What progress has there been in reducing friction or silos between HAI data systems in different HHS agencies?

The next section focuses on what we call “Knowledge Development” which refers to the full spectrum of HAI-related research.

16. What have been major accomplishments or findings in HAI-related research over the past year?

17. Can you identify any major gaps in the HAI knowledge base?

Probe:

• What evidence do you think would most impact provider behavior to promote HAI prevention practices?

18. Have there been any changes during the past year in how federal agencies have coordinated their HAI research programs?

Probes:

• How could coordination be improved?

• A past issue has been coordination between basic science (such as NIH’s work) and other HAI research priorities. Has that changed at all?

Our next section focuses on Infrastructure Development to support improvement efforts and prevention of HAIs. Some examples of infrastructure activities include: HAI-specific regulation and oversight, new funding and payment systems, creating dissemination mechanisms, and technical assistance and support.

19. Have there been any major policy, legislative, or regulatory changes related to HAI prevention during the past year? What were they? What have been their effects?

Probe:

• Has external attention or pressure for HAI improvement changed among the public, media, or policymakers? Has it increased or decreased? Why?

20. Besides Value –based Purchasing, what major changes in funding and payment systems affecting HAI prevention have occurred over the past year?

• How have healthcare organizations and providers responded to these incentives?

• Have there been any noticeable unintended consequences?

• Are HAI prevention activities sufficiently resourced?

21. Can you comment on any improvements in quality and safety culture around HAI prevention that you think are due to Action Plan activities?

Probe:

• Which specific activities of any federal agencies might have contributed to this type of culture change?

[Note: quality and safety culture can be at any level of the healthcare system, including within healthcare delivery organizations, as well as among policy-makers, public opinion, and healthcare professionals more generally.]

22. What progress have you seen, if any, in expanding dissemination and training on HAI prevention practices and strategies? What could improve that?

23. How well have HHS agencies coordinated infrastructure for HAI prevention (regulation, payment systems, dissemination and technical assistance programs)? Any specific issues or examples?

Probes:

• How well has infrastructure for HAI prevention been coordinated between the Action Plan and the other federally supported quality improvement efforts? Any specific issues or examples?

• In what ways, if any, has HHS fostered coordination among other related efforts, public or private?

24. Can you comment on the alignment of federal efforts with state and local HAI prevention efforts?

Probes:

• How could federal and state HAI efforts be better aligned?

• Are state HAI plans being updated? Used?

• Has there been any increase in relative role of local health departments in promoting HAI improvement (for example, in HAI prevention training, or coordinating local community HAI efforts and interventions across settings of care)?

The final section reviews Adoption of HAI Prevention and Patient Safety Practices. This includes activities that help encourage health care organizations or providers to adopt, use, and sustain patient safety practices related to HAIs.

25. What’s your assessment of how well HAI prevention practices overall have been adopted by healthcare organizations and providers in the US?

Probes:

• What’s been the role of federal agencies?

• What are the major challenges in adoption and use of HAI prevention practices? How can that be improved? Who needs to do it?

26. Has there been any noticeable change in ‘implementation burden’ on healthcare organizations and providers as the Action Plan and HAI prevention efforts have expanded? If that is a problem, how could it be addressed?

27. For CLABSI in particular, evidence seems to point to overall improvement in adoption of CLABSI practices and national rates. However, we’re also interested in whether there are pockets of facilities within the hospital setting that are still lagging behind the benchmarks for improvement, such as documented reduction of rates or adherence to infection surveillance on all central lines:

1. How extensive is the proportion of facilities that are lagging behind the benchmarks for CLABSI improvement?

2. What characteristics, if any, might distinguish these facilities?

3. What strategies might be required to help these facilities improve in their CLABSI rates?

28. Has there been any change (positive or negative) in the sustainability of HAI prevention practices, and rooting of HAI prevention in the work routine and culture in healthcare organizations?  Does this differ by HAI condition or healthcare setting? Which ones?

29. How do you think healthcare organizations and providers view the Federal efforts that we’ve talked about, specifically in terms of coordination and coherency?

Future Directions

30. Now that the Action Plan is in its fifth year, how would you characterize the overall momentum of the initiative?

    • Speeding up, slowing down, about the same?

    • Momentum in hospitals (Phase I) versus ASC, ESRDC, and LTC settings (Phases II & III)?

31. Would it make sense for the Action Plan to expand its focus to any new healthcare settings or HAI topics? If so, which ones?

Thank You

Thanks again for giving us your time and insights. We look forward to summarizing the perspectives from across our interviews and feeding back the information to HHS.

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