Perspectives on federal funding for state health care-associated infection programs: Achievements, barriers, and implications for sustainability

Katherine Ellingson; Kelly McCormick; Tiffanee Woodard; Amanda Garcia-Williams; Peter Mendel; Katherine Kahn; Clifford McDonald; John Jernigan; Ronda Sinkowitz-Cochran

doi:10.1177/1077558714533825

Perspectives on federal funding for state health care-associated infection programs: Achievements, barriers, and implications for sustainability

Katherine Ellingson, Kelly McCormick, Tiffanee Woodard, Amanda Garcia-Williams, Peter Mendel, Katherine Kahn, Clifford McDonald, John Jernigan, Ronda Sinkowitz-Cochran

Research output: Contribution to journal › Review article › peer-review

1 Scopus citations

Abstract

In September 2009, federal funding for health care-associated infection (HAI) program development was dispersed through a cooperative agreement to 51 state and territorial health departments. From July to September 2011, 69 stakeholders from six states - including state health department employees, representatives from partner organizations, and health care facility employees - were interviewed to assess state HAI program achievements, implementation barriers, and strategies for sustainability. Respondents most frequently cited enhanced HAI surveillance as a program achievement and resource constraints as an implementation barrier. To sustain programs, respondents recommended ongoing support for HAI prevention activities, improved surveillance processes, and maintenance of partnerships. Findings suggest that state-level HAI program growth was achieved during the cooperative agreement but that maintenance of programs faces challenges.

Original language	English (US)
Pages (from-to)	402-415
Number of pages	14
Journal	Medical Care Research and Review
Volume	71
Issue number	4
DOIs	https://doi.org/10.1177/1077558714533825
State	Published - Aug 2014
Externally published	Yes

Keywords

federal funding
health care-associated infections
qualitative research

ASJC Scopus subject areas

Health Policy

Access to Document

10.1177/1077558714533825

Cite this

Ellingson, K., McCormick, K., Woodard, T., Garcia-Williams, A., Mendel, P., Kahn, K., McDonald, C., Jernigan, J., & Sinkowitz-Cochran, R. (2014). Perspectives on federal funding for state health care-associated infection programs: Achievements, barriers, and implications for sustainability. Medical Care Research and Review, 71(4), 402-415. https://doi.org/10.1177/1077558714533825

Ellingson, K, McCormick, K, Woodard, T, Garcia-Williams, A, Mendel, P, Kahn, K, McDonald, C, Jernigan, J & Sinkowitz-Cochran, R 2014, 'Perspectives on federal funding for state health care-associated infection programs: Achievements, barriers, and implications for sustainability', Medical Care Research and Review, vol. 71, no. 4, pp. 402-415. https://doi.org/10.1177/1077558714533825

@article{a96c39f233ba401d9588058d2341dc24,

title = "Perspectives on federal funding for state health care-associated infection programs: Achievements, barriers, and implications for sustainability",

abstract = "In September 2009, federal funding for health care-associated infection (HAI) program development was dispersed through a cooperative agreement to 51 state and territorial health departments. From July to September 2011, 69 stakeholders from six states - including state health department employees, representatives from partner organizations, and health care facility employees - were interviewed to assess state HAI program achievements, implementation barriers, and strategies for sustainability. Respondents most frequently cited enhanced HAI surveillance as a program achievement and resource constraints as an implementation barrier. To sustain programs, respondents recommended ongoing support for HAI prevention activities, improved surveillance processes, and maintenance of partnerships. Findings suggest that state-level HAI program growth was achieved during the cooperative agreement but that maintenance of programs faces challenges.",

keywords = "federal funding, health care-associated infections, qualitative research",

author = "Katherine Ellingson and Kelly McCormick and Tiffanee Woodard and Amanda Garcia-Williams and Peter Mendel and Katherine Kahn and Clifford McDonald and John Jernigan and Ronda Sinkowitz-Cochran",

note = "Funding Information: This qualitative study of perceived achievements, barriers, and strategies for program sustainability among stakeholders in states receiving Recovery Act funds through the ELC cooperative agreement for HAI program development elucidated the importance of sustained and dedicated resources (specifically financial and human capital); the widespread adoption, validation, and functionality of HAI surveillance; and relationship building and alignment among partners. Although respondents noted an array of program achievements resulting directly or indirectly from federal funding, there were concerns across respondent types about the ability of these programs to persist once the ELC Recovery Act cooperative agreement ended. From the health department perspective, the potential loss or reduction of federal funds to continue programming meant the inability to maintain qualified staff. From the facility perspective, less funding meant more burden on hospitals to train staff and coordinate prevention initiatives in an environment with many competing priorities and fiscal constraints. The Recovery Act funds dispersed through the ELC cooperative agreement for HAI program development totaled $35.8 million for all grantees and $4.1 million in the six states participating in this study. Since the six states in this evaluation were purposely selected as “exceptional” or “steadily improving” in terms of HAI program progress, it is likely that the barriers to program implementation and sustainability challenges encountered by these states affect all 51 states and territories that received health department funding for HAI program development. Conversely, the achievements made in these six states represent what is possible in lower performing states if they can build and sustain HAI programs. Respondents from exceptional states most frequently cited HAI reductions as the greatest achievement during the ELC Recovery Act cooperative agreement, whereas respondents from steadily improving states most frequently cited enhanced HAI surveillance, suggesting that progress toward patient safety (fewer HAIs) exists on a continuum and that building surveillance infrastructure is a key component along this pathway. Among different stakeholder types (health department, representatives from partner organizations, and employees at health care facilities), the primary difference was in reported achievements; respondents from health departments and health care facilities emphasized data-related achievements, whereas respondents from partner agencies (e.g., quality improvement organizations, Hospital Associations, and consumers) emphasized the strengthened relationships with stakeholders throughout the states and alignment of multiple HAI program initiatives. State health department employees, state-level partners, and health care facility employees commonly shared the perception that health care facilities were underfunded to do the HAI surveillance and prevention work expected of them. An infection preventionist noted, “You can collect all the data you want, but if you don{\textquoteright}t have time to do the interventions, you{\textquoteright}re not going to influence the outcomes.” Respondents{\textquoteright} most frequently noted achievement was improvement in HAI surveillance infrastructure, but challenges with the infrastructure for HAI surveillance were also mentioned frequently as barriers to program success. Furthermore, respondents noted that improved systems for entering data into NHSN and streamlined feedback and reporting of data were critical to the sustainability of state HAI programs. During the ELC Recovery Act cooperative agreement, NHSN enrollment increased across the country in large part due to Centers for Medicare and Medicaid Services incentives, whereas state mandates also motivated facilities to enroll in NHSN ( Centers for Medicare and Medicaid Services, 2013 ). The state HAI programs were able to provide technical assistance to facilities for enrollment, getting started with reporting, and more than 55 validation projects ( Ellingson et al., 2014 ). Despite gains made throughout the cooperative agreement relative to surveillance, all respondent types described the need for enhancements. Although respondents noted reductions in infections due to both federally funded and non–federally funded prevention initiatives ongoing throughout the ELC Recovery Act cooperative agreement time period, the prevailing paradigm was that there are still great strides to be made in using HAI surveillance data toward its maximum prevention potential. A policy executive articulated the importance of partnerships in reducing rates of infection through maximizing prevention efforts: We have shown a tremendous improvement in HAIs and central line associated bloodstream infections . . . that was something to be very, very proud of . . . again, I think it comes from everybody working together . . . I think that hospitals are safer as a result. A key component of the HHS Action Plan was aligning various HAI initiatives supported by local, state, regional, and federal partners. When asked to what the program successes during the ELC Recovery Act cooperative agreement could be attributed, all respondent types reported enhanced collaboration, relationship building, and teamwork as the primary reason for program success. A state health department policy executive attributed achievement to “the fact that [hospitals] know that we{\textquoteright}re all in the same game . . . we{\textquoteright}re all looking for the welfare of our people in terms of reducing infections at these health care facilities.” A quality improvement organization representative also attributed success to collaborating and presenting a united front to hospitals: “We{\textquoteright}ve realized that our hospitals really want to see alignment between the different organizations that are working on HAIs. They do not want there to be the appearance of multiple slightly different projects.” Maintaining partnerships—including convening key stakeholders and leveraging partnerships in tight financial times—was also noted by respondents as a critical factor in sustaining state HAI programs. This qualitative evaluation is subject to some limitations. First, all results reported are generated from self-report where respondents individually interpreted each question based on their own contextual experience and cognitive processing. Respondents were interviewed during the summer of 2011 prior to the end of the ELC Recovery Act cooperative agreement on December 31, 2011, and therefore responses may not have encompassed the entire funding period. Additionally, findings from respondents in these six states are not generalizable to all states, particularly because states were deliberately selected as exceptional or steadily improving states. Furthermore, findings may underrepresent barriers experienced by states categorized as “slow moving” since they were not included in the sample. Because this study was sponsored by CDC, responses might also have been influenced by social desirability bias. To minimize this potential bias, all recruiting and interviewing were conducted by associates at IMPAQ/RAND. Respondents were informed that their responses were confidential, and all transcripts were deidentified before being sent to CDC for qualitative analysis. From the perspective of state-level stakeholders interviewed in this evaluation, ongoing funding is seen as critical to maintain and expand HAI prevention efforts, especially as state health departments face budget cuts and staffing shortages that affect all public health activities ( CDC, 2012b ). This funding has in part materialized through the Prevention and Public Health Fund created by the Affordable Care Act, which helped sustain an HAI coordinator in every state health department and funded targeted prevention projects in certain states. Based on responses from this multistate, multistakeholder qualitative evaluation, maintaining partnerships to align activities and streamlining surveillance will also be critical to helping states build and sustain HAI prevention efforts. Authors{\textquoteright} Note The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) received no financial support for the research, authorship, and/or publication of this article. 1. The HAI coordinator for one state worked at the state{\textquoteright}s quality improvement organization and therefore was considered as a state-level partner for the analysis rather than a state health department employee. ",

year = "2014",

month = aug,

doi = "10.1177/1077558714533825",

language = "English (US)",

volume = "71",

pages = "402--415",

journal = "Medical Care Research and Review",

issn = "1077-5587",

publisher = "SAGE Publications Inc.",

number = "4",

}

TY - JOUR

T1 - Perspectives on federal funding for state health care-associated infection programs

T2 - Achievements, barriers, and implications for sustainability

AU - Ellingson, Katherine

AU - McCormick, Kelly

AU - Woodard, Tiffanee

AU - Garcia-Williams, Amanda

AU - Mendel, Peter

AU - Kahn, Katherine

AU - McDonald, Clifford

AU - Jernigan, John

AU - Sinkowitz-Cochran, Ronda

N1 - Funding Information: This qualitative study of perceived achievements, barriers, and strategies for program sustainability among stakeholders in states receiving Recovery Act funds through the ELC cooperative agreement for HAI program development elucidated the importance of sustained and dedicated resources (specifically financial and human capital); the widespread adoption, validation, and functionality of HAI surveillance; and relationship building and alignment among partners. Although respondents noted an array of program achievements resulting directly or indirectly from federal funding, there were concerns across respondent types about the ability of these programs to persist once the ELC Recovery Act cooperative agreement ended. From the health department perspective, the potential loss or reduction of federal funds to continue programming meant the inability to maintain qualified staff. From the facility perspective, less funding meant more burden on hospitals to train staff and coordinate prevention initiatives in an environment with many competing priorities and fiscal constraints. The Recovery Act funds dispersed through the ELC cooperative agreement for HAI program development totaled $35.8 million for all grantees and $4.1 million in the six states participating in this study. Since the six states in this evaluation were purposely selected as “exceptional” or “steadily improving” in terms of HAI program progress, it is likely that the barriers to program implementation and sustainability challenges encountered by these states affect all 51 states and territories that received health department funding for HAI program development. Conversely, the achievements made in these six states represent what is possible in lower performing states if they can build and sustain HAI programs. Respondents from exceptional states most frequently cited HAI reductions as the greatest achievement during the ELC Recovery Act cooperative agreement, whereas respondents from steadily improving states most frequently cited enhanced HAI surveillance, suggesting that progress toward patient safety (fewer HAIs) exists on a continuum and that building surveillance infrastructure is a key component along this pathway. Among different stakeholder types (health department, representatives from partner organizations, and employees at health care facilities), the primary difference was in reported achievements; respondents from health departments and health care facilities emphasized data-related achievements, whereas respondents from partner agencies (e.g., quality improvement organizations, Hospital Associations, and consumers) emphasized the strengthened relationships with stakeholders throughout the states and alignment of multiple HAI program initiatives. State health department employees, state-level partners, and health care facility employees commonly shared the perception that health care facilities were underfunded to do the HAI surveillance and prevention work expected of them. An infection preventionist noted, “You can collect all the data you want, but if you don’t have time to do the interventions, you’re not going to influence the outcomes.” Respondents’ most frequently noted achievement was improvement in HAI surveillance infrastructure, but challenges with the infrastructure for HAI surveillance were also mentioned frequently as barriers to program success. Furthermore, respondents noted that improved systems for entering data into NHSN and streamlined feedback and reporting of data were critical to the sustainability of state HAI programs. During the ELC Recovery Act cooperative agreement, NHSN enrollment increased across the country in large part due to Centers for Medicare and Medicaid Services incentives, whereas state mandates also motivated facilities to enroll in NHSN ( Centers for Medicare and Medicaid Services, 2013 ). The state HAI programs were able to provide technical assistance to facilities for enrollment, getting started with reporting, and more than 55 validation projects ( Ellingson et al., 2014 ). Despite gains made throughout the cooperative agreement relative to surveillance, all respondent types described the need for enhancements. Although respondents noted reductions in infections due to both federally funded and non–federally funded prevention initiatives ongoing throughout the ELC Recovery Act cooperative agreement time period, the prevailing paradigm was that there are still great strides to be made in using HAI surveillance data toward its maximum prevention potential. A policy executive articulated the importance of partnerships in reducing rates of infection through maximizing prevention efforts: We have shown a tremendous improvement in HAIs and central line associated bloodstream infections . . . that was something to be very, very proud of . . . again, I think it comes from everybody working together . . . I think that hospitals are safer as a result. A key component of the HHS Action Plan was aligning various HAI initiatives supported by local, state, regional, and federal partners. When asked to what the program successes during the ELC Recovery Act cooperative agreement could be attributed, all respondent types reported enhanced collaboration, relationship building, and teamwork as the primary reason for program success. A state health department policy executive attributed achievement to “the fact that [hospitals] know that we’re all in the same game . . . we’re all looking for the welfare of our people in terms of reducing infections at these health care facilities.” A quality improvement organization representative also attributed success to collaborating and presenting a united front to hospitals: “We’ve realized that our hospitals really want to see alignment between the different organizations that are working on HAIs. They do not want there to be the appearance of multiple slightly different projects.” Maintaining partnerships—including convening key stakeholders and leveraging partnerships in tight financial times—was also noted by respondents as a critical factor in sustaining state HAI programs. This qualitative evaluation is subject to some limitations. First, all results reported are generated from self-report where respondents individually interpreted each question based on their own contextual experience and cognitive processing. Respondents were interviewed during the summer of 2011 prior to the end of the ELC Recovery Act cooperative agreement on December 31, 2011, and therefore responses may not have encompassed the entire funding period. Additionally, findings from respondents in these six states are not generalizable to all states, particularly because states were deliberately selected as exceptional or steadily improving states. Furthermore, findings may underrepresent barriers experienced by states categorized as “slow moving” since they were not included in the sample. Because this study was sponsored by CDC, responses might also have been influenced by social desirability bias. To minimize this potential bias, all recruiting and interviewing were conducted by associates at IMPAQ/RAND. Respondents were informed that their responses were confidential, and all transcripts were deidentified before being sent to CDC for qualitative analysis. From the perspective of state-level stakeholders interviewed in this evaluation, ongoing funding is seen as critical to maintain and expand HAI prevention efforts, especially as state health departments face budget cuts and staffing shortages that affect all public health activities ( CDC, 2012b ). This funding has in part materialized through the Prevention and Public Health Fund created by the Affordable Care Act, which helped sustain an HAI coordinator in every state health department and funded targeted prevention projects in certain states. Based on responses from this multistate, multistakeholder qualitative evaluation, maintaining partnerships to align activities and streamlining surveillance will also be critical to helping states build and sustain HAI prevention efforts. Authors’ Note The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) received no financial support for the research, authorship, and/or publication of this article. 1. The HAI coordinator for one state worked at the state’s quality improvement organization and therefore was considered as a state-level partner for the analysis rather than a state health department employee.

PY - 2014/8

Y1 - 2014/8

N2 - In September 2009, federal funding for health care-associated infection (HAI) program development was dispersed through a cooperative agreement to 51 state and territorial health departments. From July to September 2011, 69 stakeholders from six states - including state health department employees, representatives from partner organizations, and health care facility employees - were interviewed to assess state HAI program achievements, implementation barriers, and strategies for sustainability. Respondents most frequently cited enhanced HAI surveillance as a program achievement and resource constraints as an implementation barrier. To sustain programs, respondents recommended ongoing support for HAI prevention activities, improved surveillance processes, and maintenance of partnerships. Findings suggest that state-level HAI program growth was achieved during the cooperative agreement but that maintenance of programs faces challenges.

AB - In September 2009, federal funding for health care-associated infection (HAI) program development was dispersed through a cooperative agreement to 51 state and territorial health departments. From July to September 2011, 69 stakeholders from six states - including state health department employees, representatives from partner organizations, and health care facility employees - were interviewed to assess state HAI program achievements, implementation barriers, and strategies for sustainability. Respondents most frequently cited enhanced HAI surveillance as a program achievement and resource constraints as an implementation barrier. To sustain programs, respondents recommended ongoing support for HAI prevention activities, improved surveillance processes, and maintenance of partnerships. Findings suggest that state-level HAI program growth was achieved during the cooperative agreement but that maintenance of programs faces challenges.

KW - federal funding

KW - health care-associated infections

KW - qualitative research

UR - http://www.scopus.com/inward/record.url?scp=84903840000&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84903840000&partnerID=8YFLogxK

U2 - 10.1177/1077558714533825

DO - 10.1177/1077558714533825

M3 - Review article

C2 - 24806265

AN - SCOPUS:84903840000

SN - 1077-5587

VL - 71

SP - 402

EP - 415

JO - Medical Care Research and Review

JF - Medical Care Research and Review

IS - 4

ER -

Perspectives on federal funding for state health care-associated infection programs: Achievements, barriers, and implications for sustainability

Abstract

Keywords

ASJC Scopus subject areas

Access to Document

Other files and links

Fingerprint

Cite this