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HEALTHCARE ASSOCIATED INFECTIONS (G BEARMAN AND D MORGAN, SECTION

EDITORS)

Hospital-Acquired Infections Under Pay-for-Performance Systems:
an Administrative Perspective on Management and Change

Rebecca A. Vokes1 & Gonzalo Bearman2
& Gloria J. Bazzoli1

Published online: 26 July 2018
# Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract
Purpose of Review The purpose of this review is to explore the impact of hospital-acquired infection on payment under pay-for-
performance systems, and provide perspective on the role of administrators in infection prevention.
Recent Findings Hospital-acquired infections continue to pose a serious threat to patient safety and to the fiscal viability of healthcare
facilities under pay-for-performance systems. There is mixed evidence that use of pay-for-performance systems leads to prevention of
hospital-acquired conditions. Use of evidence-based guidelines has been shown to reduce hospital-acquired infections.
Summary Increasing use of pay-for-performance (PFP) systems results in potential loss of reimbursement for healthcare orga-
nizations that fail to prevent hospital-acquired infections (HAI). Healthcare administrators must work with front-line providers
and infection control staff to establish and maintain evidence-based infection prevention policy. Additionally, infection control
policy should be regularly updated to reflect best practices, and proper change management techniques should be employed in
order to mobilize and empower staff to increase their ability to prevent hospital-acquired infections.

Keywords Hospital-acquired infection . Change management . Pay for performance . Healthcare administration . Healthcare
management . Alternative payment models . Hospital-acquired condition . CMS . Medicare reimbursement . Medicaid
reimbursement . Hospital reimbursement . Nosocomial condition . CLABSI . Kotter method . Kotter change management .

Preventing hospital infection . Infection prevention . Hospital management . Organizational change . CMS payment .

Infection prevention program . Horizontal vs vertical intervention . Horizontal infection control . Vertical infection control

Introduction

The implementation of pay-for-performance (PFP) systems in
healthcare means opportunity and challenge for administrators
and clinicians seeking to improve healthcare delivery. In many

systems, the prevention of hospital-acquired infections (HAI) is
an increasing focus of research and resources, not only to prevent
adverse patient outcomes but to avoid financial penalization un-
der new PFP systems. This article discusses the current PFP
environment, the importance of hospital infection prevention
(HIP) programs, the five most common HAIs, use of vertical
and horizontal interventions, and the role of administration in
establishing andmaintaining evidence-based policies to optimize
clinical care and financial performance in an inpatient setting.
Finally, we will provide an example of a new infection preven-
tion technology with corresponding sample change implementa-
tion plan following the Kotter Change Management Model [1•].

Background

Hospital-acquired infections (HAI) represent a public health
issue across the continuum of care, and are a particularly cost-
ly problem in an inpatient hospital setting. Studies estimate an

This article is part of the Topical Collection on Healthcare Associated
Infections

* Rebecca A. Vokes
ravokes@vcu.edu

Gonzalo Bearman
Gonzalo.bearman@vcuhealth.org

Gloria J. Bazzoli
gjbazzol@vcu.edu

1 Department of Health Administration, Virginia Commonwealth
University, Richmond, VA, USA

2 VCU Health, Richmond, VA, USA

Current Infectious Disease Reports (2018) 20: 35
https://doi.org/10.1007/s11908-018-0638-5

http://crossmark.crossref.org/dialog/?doi=10.1007/s11908-018-0638-5&domain=pdf

mailto:ravokes@vcu.edu

incidence of approximately 440,000 HAIs per year in an adult
inpatient population with an associated annual cost of $9.8
billion [2••]. Out of all patients hospitalized on any given
day, roughly 1 in 25 will contract a hospital-acquired infection
[3•]. The problem is pervasive, and research suggests the ma-
jority of these infections are preventable. Hospital administra-
tors play a pivotal role in reducing HAIs given their manage-
rial responsibilities to allocate resources and establish goals
for their facilities. In an increasingly complex healthcare en-
vironment, it is important for hospital administrators to work
closely with clinicians and epidemiologists to ensure the im-
plementation of current evidence-based guidelines and to
maintain strong infection control programming.

Pay-for-Performance in Healthcare

Pay-for-performance programs use financial consequences to
incentivize or deter behaviors of healthcare providers and fa-
cilities. The PFP system links each payment to the perfor-
mance of a healthcare facility, commonly in comparison to
established benchmarks in quality and safety. PFP is on a
spectrum of new payment systems known as alternative pay-
ment methods (APM). These APMs continue the departure
from traditional fee-for-service (FFS), increasingly shifting
financial risk to hospitals for each episode of care. The goal
of PFP programs, and other APMs such as capitation and
bundled payments, is to focus providers on the health out-
comes of patients rather than on the rate of services provided.
As pointed out by Kondo and his colleagues in their 2016
paper, Implementation processes and pay for performance in
healthcare: a systematic review, “APMs are intended to mo-
tivate high value care and improved patient outcomes whereas
FFS primarily promotes higher service volume.” [4].

The Center for Medicare and Medicaid Services (CMS) con-
tinues to enact payment policies tying reimbursement to quality
through three programs affecting payment for inpatient ser-
vices—the hospital readmissions reduction program, the Value-
Based Purchasing (VBP) Program, and the Hospital-Acquired
Condition (HAC) Reduction Program. These payment policies
further support the strategy of rewarding providers for the quality
of care through the use of financial incentives and disincentives.
The VBP program adjusts inpatient hospital payments based on
performance over a range of different measures related to patient
outcomes, processes of care, patient experience, and costs of
care. The HAC program reduces reimbursement by 1% for those
hospitals with performance falling in the worst 25% of hospitals
for identified HAC metrics [5].

Some success in PFP programing has been observed when
targeting HAIs. For example, hospitals participating in PFP pro-
grams for four or more years have on average 3.13 fewer central
line-associated bloodstream infections (CLABSIs) per year
compared to those participating for less than 4 years [6].
Waters and colleagues also found that an initial 2008 version

of CMS’s HAC penalty program resulted in the reduction of
CLASBI and catheter-associated urinary tract infection
(CAUTI) occurrences, but a similar study that examined this
CMS policy on a smaller sample of hospitals did not find com-
parable results [7•, 8]. This points to inconsistency in PFP’s
reported effectiveness in producing better outcomes in
healthcare. Although more evidence is needed to support the
effectiveness of PFP, it is likely that reimbursement methodswill
continue to include incentives intended to reward high-quality
care and penalize hospitals for preventable adverse events.

Introduction to Hospital Infection Prevention
Programming

Although limited evidence exists on the influence of PFP on
HAIs, the goal of reducing hospital-acquired infections reso-
nates with hospital administrators and clinicians as they seek to
manage the costs of healthcare delivery and improve patient
outcomes from care. To meet the expectations of safety and
quality in a complex and challenging healthcare delivery envi-
ronment, an adequately-staffed hospital infection prevention
program is necessary. A major development in hospital infec-
tion prevention was the paradigm shift from HAIs as inevitable
consequences of hospitalization to the view that every HAI is
potentially preventable [9]. Further, there has been a shift from
the descriptive and analytic practice of infection control to the
more active and process-driven goal of infection prevention.

Following the development of surveillance and outbreak
response systems, hospital infection control programs have
significantly expanded in depth and scope over the last
30 years. Critical elements of modern, academic infection pre-
vention programs include advancing the signs of infection
prevention, wide-scale implementation of best practices, man-
datory public reporting, emergency preparedness, and antimi-
crobial stewardship [10]. To accomplish these goals, infection
prevention programs require adequate staffing, robust infor-
mation technology, and proper funding. Funding must not
only cover all essential elements of infection prevention pro-
grams, but should also shield physician epidemiologists from
the competing pressure of clinical revenue generation [10].
Last, robust infection prevention programs must be backed
by hospital senior leadership so that interventions and process
changes are implemented with reliability and accountability.

Introduction to Five HAIs Tracked by CMS

The CMS HAC Reduction Program assigns scores to partici-
pating facilities based on established criteria used in reporting
hospital quality indicators through Hospital Compare on-line
reports. The five HAIs assessed by CMS are CLABSI,
CAUTI, Surgical Site Infection (SSI), Methicillin-resistant
Staphylococcus aureus (MRSA) bacteremia, and Clostridium
difficile Infection (CDIF). These five HAIs are given

35 Page 2 of 7 Curr Infect Dis Rep (2018) 20: 35

considerable weight in determining hospital reimbursement un-
der PFP. Additionally, the failure to manage these five HAIs
results in preventable costs to the hospital and, most important-
ly, preventable harm to the patient.

CLABSIs are among the costliest HAIs to treat at approxi-
mately $45,814 per case [2••]. CLABSI results in prolonged hos-
pital stays, significant morbidity, and increased risk of mortality
[11]. As noted above, CLASBI is also one of the indicators mon-
itored byCMSand, thus, can negatively affect hospital reimburse-
ment for associated services performed during an episode of care.

CAUTIs are the most common HAI, and over 75% of all
urinary tract infections detected in a hospital may be traced to
the use of a catheter [3•]. Over 13,000 deaths per year are
associated with CAUTIs, and the occurrence of these infections
is associated with increased costs of care, complications, and
length of stay [5]. Estimates of the average attributable costs of
CAUTI range from $749 to $832 per case [3•]. On an aggregate
national basis, CAUTIs are estimated to contribute $390 mil-
lion to $450 million annually to US hospital costs [12].

SSIs also contribute significantly to morbidity and mortality,
and their economic impact is substantial. The costs attributable to
SSI are $11,087 to $29,443 per case and these infections make
up the largest percentage of total HAI costs at 33.7% per year, in
aggregate approximately $3450 million per year [2••, 3•].

Hospital-acquired CDIF infection also has a substantial
effect on patient outcomes and hospital costs. CDIF results
in significantly prolonged hospital length of stay independent
of baseline risk of mortality. Additionally, CDIF cases add
approximately $9118–$13,574 of costs per case, can be chal-
lenging to treat, and are prone to relapse [13].

The discussion below examines key clinical guidelines,
policies, and procedures that administrators and clinicians
could implement to reduce incidence of HAIs in their hospi-
tals so as to avoid preventable costs and improve healthcare
outcomes for patients.

Central Line-Associated Bloodstream
Infection

The prevention of central line-associated infections is backed by
high-quality data in favor of a bundled risk reduction approach
[14••]. The creation of a central line insertion checklist, which
assures standardization in catheter insertion has resulted in sig-
nificant CLABSI risk reduction [15, 16]. Standardization in cath-
eter maintenance through the use of chlorhexidine-impregnated
catheter dressings and the use of alcohol-impregnated port pro-
tectors (AIPP) has further reduced the risk of CLABSI [14••, 17].

In addition, the employment of patient bathing with chlor-
hexidine gluconate results in a therapeutic intervention which
decreases patient bacterial bioburden and further decreases the
risk of CLABSI. One survey of US hospitals found daily
bathing with chlorhexidine-impregnated washcloths

significantly reduced the risks of acquisition of MDROs and
development of hospital-acquired bloodstream infections
[18]. Hospital administration plays an important role in
supporting the education, systems, structures, and account-
ability needed to implement and sustain CLABSI risk reduc-
tion mechanisms. In the “Change Implementation” section of
this article, an example of one unit’s switch from manual dis-
infection to AIPP illustrates the importance of organized
change management in preventing infection.

Catheter-Associated Urinary Tract Infection

Much like CLABSI reduction, minimizing the risk of catheter-
associated urinary tract infection requires a standardized ap-
proach. Best practices for CAUTI risk reduction are summa-
rized in the Centers for Disease Control (CDC)/Society of
Healthcare Epidemiology of America (SHEA) compendium
of strategies to prevent healthcare-associated infections in
acute care hospitals [14••].

In addition to standardized processes for catheter insertion and
maintenance, limiting the unnecessary use of urinary catheters
results in a significant reduction in CAUTIs. A key strategy for
reducing unnecessary catheter use involves daily charting of
catheter use and the use of the electronic medical record to gen-
erate automatic 48 or 72 h discontinuation orders that must be
formally overridden by the medical team [19]. In addition, the
use of biocide impregnated urinary catheters, such as silver-
coated or nitrofurazone-impregnated urinary catheters, may fur-
ther decrease risk of CAUTI [20]. Investments in information
technology, along with the development of processes and mech-
anisms for standardization and reliability in catheter insertion,
maintenance, and discontinuation are critical.

Surgical Site Infections

The reduction of surgical site infections requires broad collab-
oration across the disciplines of infection prevention, surgery,
anesthesia, and perioperative nursing. Key interventions in-
clude administering antimicrobial prophylaxis according to
evidence-based standards and guidelines, not removing hair
at the operative site unless the presence of hair will interfere
with the operation, using clippers instead of razors when hair
removal is necessary, controlling perioperative blood glucose,
maintaining perioperative normothermia, optimizing tissue
oxygenation by administering supplemental oxygen during
and immediately following surgical procedures, using
alcohol-containing preoperative skin preparatory agents if no
contraindication exists, using impervious plastic wound pro-
tectors for gastrointestinal and biliary tract surgery, using a
checklist based on the WHO checklist to ensure compliance
with best practices for surgical patient safety, and performing

Curr Infect Dis Rep (2018) 20: 35 Page 3 of 7 35

surveillance with feedback for SSI and risk factor reduction-
related process of care measures [14••].

Health administration plays a key role in partnering with
both infection prevention and practitioners in the operating
room to support systems and policies that allow for high reli-
ability in risk factor mitigation.

Methicillin-Resistant Staphylococcus aureus

Strategies to decrease the risk of hospital-acquired MRSA infec-
tions are broad and diverse and are not neatly categorized into
simple technical interventions or safety checklists. As summa-
rized in the CDC/SHEA compendium of strategies to prevent
healthcare-associated infections, key interventions include
conducting a MRSA risk assessment, implementation of a
MRSA monitoring program, compliance with hand hygiene,
the use contact precautions for MRSA-colonized and MRSA-
infected patients, cleaning and disinfection of equipment and
the environment, implementing a laboratory-based alert system
for MRSA-colonized or MRSA-infected patients on admission
or transfer, and providing MRSA data and outcome measures to
key stakeholders, including senior leadership, physicians, nurs-
ing staff, and others. Active surveillance through microbial
screening and isolation of patients is also a component of some
MRSA infection prevention programs [14••].

Recently, the added value of isolating patients with endem-
ic MRSA and VRE infection or colonization has become in-
creasingly controversial, with some US healthcare systems
reporting ongoingMRSA reduction without the use of contact
precautions [21, 22]. Healthcare administration plays a vital
role in securing the vital resources and promoting policies and
mechanisms for MRSA reduction strategies that answer to
both legal/regulatory mandates and local need.

Clostridium difficile Infection

Much like MRSA risk reduction, minimizing C. difficile infec-
tions requires a broad, multifaceted approach. No one single
intervention fully minimizes the risk of hospital-acquired C.
difficile infection. Key interventions include developing a CDIF
surveillance and reporting system, antimicrobial stewardship, the
use of contact precautions for suspected or in infectedC. difficile
patients, the use of single occupancy rooms, heightened daily and
terminal cleaning of the inanimate environment including an
assessment mechanism for the adequacy of cleaning, the imple-
mentation of a laboratory-based alert system to provide immedi-
ate notification to infection prevention and control and clinical
personnel about newly diagnosed CDI patients, promoting and
assessing adequate hand hygiene, and educating healthcare pro-
fessionals, environmental service personnel, and hospital admin-
istration about CDIF [14••].

Much like with other elements of infection prevention, in
collaboration with the hospital infection prevention program,
healthcare administration plays a vital role in securing the vital
resources and promoting policies and mechanisms for maxi-
mizing C. difficile reduction efforts.

Horizontal vs Vertical Interventions

Healthcare systems that focus resources on a single pathogen as a
sole approach to infection control are inherently flawed. The new
paradigm for infection prevention seeks multi-potent interven-
tions aimed at reducing risk from all pathogens transmitted
through the same mechanism contact [23]. The classic example
of a vertical intervention strategy is active detection in isolation of
MRSA for infection prevention. Horizontal infection prevention
programs are characterized by interventions such as hand hy-
giene, chlorhexidine bathing, central line insertion bundles, ven-
tilator bundle, and safety checklists which have broad risk reduc-
tion impact on most hospital-acquired pathogens transmitted by
contact [24]. Recently, advances in textiles and other technolo-
gies show promise for environmental bioburden reduction-
consistent with a horizontal infection prevention platform.
Patients in ICU rooms with copper alloy surfaces had a signifi-
cantly lower rate of incident HAI and/or colonization with
MRSA or VRE than did patients treated in standard rooms
[25]. The deployment of UVC-light “touchless” disinfecting ro-
bots may further decrease bioburden and infection risk [26].

Change Implementation

Implementing one or several strategies to reduce the incidence of
HAIs necessarily involves implementing new policies and pro-
cedures and, thus, organizational change. It is well understood
that change can be difficult not only because of its cost but also
because of the inertia that builds upwithin organizations and also
the need to obtain buy-in from managers and front-line staff. In
this section, we discuss a model for implementing change devel-
oped by Harvard Business School professor John B. Kotter,
PhD., and how it might be applied to implement HAI reduction
guidelines and policies.

Kotter Change Management Model

In 1998, Kotter published a short article previewing his book,
Leading Change. Since then, the Kotter Change Management
Model has been used successfully in healthcare to manage orga-
nizational change efforts. From improving nursing hand-offs [27]
to adopting new electronic health records [28], the Kotter model
provides a flexible and practical tool to organize and implement
new policies and procedures. The eight stages of Kotter’s
Change Management Model, the descriptions of the stages, and

35 Page 4 of 7 Curr Infect Dis Rep (2018) 20: 35

a case example regarding CLABSI reduction at an acute-care
hospital are provided in Table 1 of this article.

Conclusion

The adoption of pay-for-performance systems brings new
challenges to healthcare administrators as financial risks
continue to shift from insurer and patient, to provider and
facility. In the past 5 years, the HAIs discussed in this
paper have continued to present a threat to patient safety,

and to organizational survival in an increasingly competi-
tive healthcare market. Evidence-based infection control
guidelines continue to evolve, and these changes bring op-
portunities for healthcare administrators to partner with
clinical experts in change management. Hospital adminis-
tration must collaborate with content experts in infection
prevention and epidemiology so as to allow for the devel-
opment of an adequately supported infection prevention
program with resources, evidence-based policies, and plat-
forms that are methodically implemented to scale with
accountability.

Table 1 Kotter Organizational Change Management Model as Applied to CLASBI Reduction Initiative at VCU Health System

Stage Description Example

Establish a Sense
of Urgency

Define the problem (severity, scope, frequency, etc.)
and outline consequences of delayed action.
Ensure that the change is seen as less risky
than the current system.

The rate of CLABSI in the intensive care units (ICU)
is 4% per device day, 2 times higher than in other
similar facilities where AIPP is used. Each patient
in our care is at risk of CLABSI. Switching to AIPP
will present less risk to our patients than our current
caps.

Create a Guiding
Coalition

Enlist a group of employees with the right combination
of experience, leadership, skills, and credibility
to drive the change and influence others.

Form a guiding coalition with ICU Nurse Managers,
the Hospital Epidemiologist, the CNO, and an
experienced member of the nursing staff.

Develop a Clear
Shared Vision

Form clear, evidence-based solution. Solution must
have a roadmap of steps with a measurable goal.

“We will significantly reduce patient risk of CLABSI
on our units by using AIPP on all lines. This adoption
of AIPP on each unit will lead to use of AIPP
hospital-wide.”

Communicate the
Vision

Communicate the change convincingly, thoroughly,
and frequently. Ensure that multiple means
of communication are used (verbal and written
in different forms). Listen carefully to feedback,
and address concerns openly and honestly.

At monthly Champions in Infection Prevention Meetings
(CHIPs), where all units are represented by 1–2 nurses
empowered as infection prevention liaisons, the new
policy is introduced. It is also communicated in email
to all team members, and in laminated signs posted in
appropriate areas.

Empower Action Ensure that existing processes and procedures support
the change. Ensure that all resources and materials
to conduct the change are available. Identify potential
barriers to action and remove these barriers.
Empower each team member to contribute to the
change, and create fail-safes to guard against
mistakes during the learning process.

CHIPs nurse representatives enact an implementation plan
with their respective units. CHIPs develop educational
plans and reporting mechanisms for units, based on
infection control implementation plan. Staff are
encouraged to raise concerns and identify issues,
and CHIPs leaders are tasked with identifying potential
barriers.

Create Short-
Term Wins

Create benchmark goals during all phases of change
implementation, and reward their completion.
Broadcast successes and recognize team members
as early benchmarks are met.

Weekly assessment of AIPP is conducted, and feedback
is provided. The first week with full compliance of AIPP
use on any unit results in staff rewards (such as gift cards
provided for each staff member). At the end of the first
month, CHIPs leaders are recognized at an operations
meeting with hospital leadership.

Build on Gains
and Consolidate

Continue to examine successes, identify improvements,
and mitigate concerns. Continue to communicate
progress and celebrate small wins.

Hospital units with greatest improvement in AIPP use are
recognized and share experience with other unit managers.
Barriers to compliance are identified in weekly team
huddles, and then shared with CHIPs leaders.

Target is set for > 90% with AIPP use.

Institutionalize
the Change

Ensure that the change is institutionalized in policy,
procedure, and organizational culture. Pass
importance of change on to new team members
and leadership, and incorporate change into
orientation, training, peer-review, and performance
review.

Hospital policy for the maintenance of CVCs reflects
the use of AIPP.

Unit to unit compliance with use of alcohol-based
disinfecting CVC Caps is reported at the monthly
infection prevention committee as a standing agenda
item, results are shared with highest level of hospital
leadership.

Curr Infect Dis Rep (2018) 20: 35 Page 5 of 7 35

Acknowledgements The authors would like to thank Michele Fleming,
MSN, RN, CIC, for her review of this manuscript.

Compliance with Ethical Standards

Conflict of Interest The authors declare that they have no conflict of
interest.

Human and Animal Rights and Informed Consent This article does not
contain any studies with human or animal subjects performed by any of
the authors.

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Papers of particular interest, published recently, have been
highlighted as:
• Of importance
•• Of major importance

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Curr Infect Dis Rep (2018) 20: 35 Page 7 of 7 35

• Hospital-Acquired Infections Under Pay-for-Performance Systems: an Administrative Perspective on Management and Change

Abstract

Abstract

Abstract

Abstract

Introduction

Background

Pay-for-Performance in Healthcare

Introduction to Hospital Infection Prevention Programming

Introduction to Five HAIs Tracked by CMS

Central Line-Associated Bloodstream Infection

Catheter-Associated Urinary Tract Infection

Surgical Site Infections

Methicillin-Resistant Staphylococcus aureus

Clostridium difficile Infection

Horizontal vs Vertical Interventions

Change Implementation

Kotter Change Management Model

Conclusion

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance