Benchmarking quality to fight hospital infections

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Abstract

As part of the new programme to reduce hospital acquired infections, the Ministry of Health decided to benchmark hospitals. A first ranking of hospitals by their capacity to fight against hospital infections was published in February 2006. The indicator used does not take into account infection rates, but a number of dimensions which are deemed important for reducing infections. All hospitals will have to provide publicly available information on the selected benchmark indicators by 2007.

Purpose of health policy or idea

Hospital acquired infections, also called nosocomial infections (NI), cover infections which occur in patients who have been hospitalised and which were not present or incubating on admission. About 7% of patients admitted to health care facilities in France develop a hospital acquired infection. Four-yearly national programmes set priority areas and actions for reducing hospital acquired infections in France, with an objective to strengthen and monitor infection control and to improve the quality of care provided in health care institutions. Benchmarking is presented as one of the major drivers of the 2005-2008 national programme where five indicators are defined to measure the progress in specific areas. The collection of data and diffusion of information to the public on these became obligatory both for public and private institutions.

The indicators selected for benchmarking are:

1) ICALIN, a composite index of activities for fighting against nosocomial infections (NI). The indicator has three dimensions (resources allocated to reduce NI, organisational structure and activities carried out) which consist of about 30 items,

2) Yearly consumption of antiseptic hand-wash products for 1000 hospital days,

3) Incidence rates of methicillin resistant Staphylococcus aureus,

4) Incidence rates of surgical site infections,

5) Monitoring antibiotic consumption.

The scores for ICALIN were published in February 2006. Each provider is given a rank from A (best) to E (worst), by comparing its score with the average score of providers in a given class/category. 13 classes of providers are defined by taking into account size (less/more then 100/300 beds), public/private status and type of care provided (acute care, rehabilitative care, long term care, hospital at home, cancer treatment centres, etc.). The two following indicators on the list (second and third) are supposed to be available for all institutions before the end of 2006, and the last two before the end of 2007. All together they would provide a more complete picture of the situation.

The Ministry of Health is also carrying out a pilot project for generalising other benchmark indicators to compare the quality of care in hospitals (satisfaction rates, waiting times for emergency room, etc.) in about 40 hospitals participating on a voluntary basis.

Main points

Main objectives

The major objectives of the national programme are to reduce nosocomial infection rates and to improve the overall management of activities to fight hospital acquired infections. Improving the treatment of infected patients and providing better information to health care users on quality were also amongst the stated goals.

The stated objective for benchmarking is encouraging health care providers to measure their efforts and results in terms of reducing hospital acquired infections. Benchmarking is presented as a tool which would lead to improvements in the quality of care through continuous monitoring and comparison of providers.

More generally, improving the transparency of hospital care and providing better information to the public has been a major preoccupation for the current government since it is introducing a new activity based payment system for hospitals where the quality of care is becoming a major issue.

Type of incentives

Benchmarking is a non-financial incentive. However, each indicator corresponds to a number of specific activities, and a number of financial and regulatory incentives have been introduced over the past ten years linked to these activities.

Groups affected

Health care institutions, Patients

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral

Political and economic background

The first national programme to fight against hospital acquired infections dates from 1994. Since then, progress has been made in terms of monitoring and organisation of activities for reducing hospital infections. Since 1999, all public and private providers are required to have a specific committee (CLIN) responsible for developing yearly action plans for reducing NI as well as a specific team for monitoring the quality of hygiene in the institution. At the regional level there are 5 regional networks (C.CLIN) co-ordinating the monitoring and data collection on hospital infections, and which produce guidelines for good practice for improving hospital hygiene. A technical committee at the national level (CTIN) sets the priority areas and provides technical recommendations for organising individual networks and for the implementation of necessary actions.  

About 68 million Euros, mostly for creating more than 700 new positions, have been devoted to the prevention of nosocomial infections in the past six years (numbers from the Ministry of Health).

Despite all the measures for improving the monitoring and management of nosocomial infections, there is still no information available to the public on the actual infection levels of specific providers.  The organisation of data monitoring and dissemination has been largely based on voluntary participation. While data on prevalence/incidence of specific types of infections are available through regional infection centres (CCLIN), it is not possible to have individualised data on infection rates for a given health care provider.

At the same time, there is a legitimate demand from health care users for more information on the care quality in hospitals. A recent survey showed that 63% of the people questioned believed that the number of hospital acquired infections is increasing, when in fact on the whole infection rates in public hospitals have been declining over the past two years.

 

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Origins of health policy idea

Hospital acquired infections have been a public health priority since 1998 by the National health conference which brings together different parties in the health sector such as the government, health insurers, representatives of medical professionals. 

More generally, over the past 10 years, the improvement of information systems on quality (as well as cost) of hospital care has become a priority both for implementing the proposed reforms on hospital funding and for satisfying the public's need for reliable information on quality.

In 1999, some journalists published a guide, Le guide des hôpitaux, showing for the first time comparisons of case-mix adjusted mortality rates for hospitals in France (and came close to being a best seller). Diffusion of this information to the public without any specific warning for interpretation provoked considerable adverse reaction from hospitals. Despite these initial reactions the mortality data is being increasingly used by the media to compare the performance of hospitals. These publications pushed the Ministry of Health to develop and implement a more solid framework to measure the performance of individual hospitals.

After a long period of indicator development, the Ministry of Health together with the High Health Authority (HAS, formerly ANAES), put in place a pilot project in 2003 to implement and test a number of indicators for benchmarking hospitals. This pilot project is supported by all the hospital federations (public and private) as well as the health insurance funds which participate in the validation process of each indicator to be used for benchmarking. About 40 hospitals have participated in the pilot project for the period 2003-2006 during which about 25 indicators have been "approved" for data collection in acute care hospitals. 

Initiators of idea/main actors

• Government

• Providers

• Payers

Approach of idea

The approach of the idea is described as:
new:

Stakeholder positions

The process of collaboration between the government and all other stakeholders, while slowing the process, made this exercise a peaceful one as all the stakeholders have been participating in the development and validation ofindicators.

Actors and positions

Government
Ministry of health	very supportive		strongly opposed
Providers
Public and private hospital federations	very supportive		strongly opposed
Payers
Sickness funds	very supportive		strongly opposed

Influences in policy making and legislation

The responsibilities of the health care institutions in monitoring and reducing hospital infections have been defined by law over the years.

In 1998, the health security article of the public health code re-defined the obligations and missions of individual health care providers giving them the responsibility for monitoring and organising activities to guarantee the safety of patients.

In 2000, the Ministry of Health defined by decree how the actions to reduce infections should be organised in each institution, determining the composition of specific teams, specific activities, etc.

Since 2001, reporting certain types of infections and sentinel events became obligatory (R711-1-14 of public health code). Hospitals are encouraged to put in place warning systems for sentinel events (several Decrees in 2003 and 2004).

Finally, an important piece of legislation for the patients was the modification of  public health code (article L.1142-1) in March 2002 to make hospitals responsible for any damages resulting from nosocomial infections. This means that patients who suffered from a NI can ask to be compensated without being obliged to prove that the institution was at fault, which was the case before. And unless the healthcare institution can prove that the origin of the infection was outside of the institution, it will be liable for compensation.

Legislative outcome

success

Actors and influence

Government
Ministry of health	very strong		none
Providers
Public and private hospital federations	very strong		none
Payers
Sickness funds	very strong		none

Positions and Influences at a glance

Adoption and implementation

See above.

Monitoring and evaluation

No specific evaluation of the impact of this benchmarking exercise on the health care providers has been carried out yet.

Dimensions of evaluation

Process

Expected outcome

There are quantified objectives for each indicator accompanied by an action plan. Concerning the composite indicator of the efforts put in place to reduce infections (ICALIN), the aim is that first all institutions collect and diffuse information on this (for about 13% of the hospitals there is no data yet) and second, by 2008 there is no more institution categorised as very bad (E class). Currently about six percent of the providers are in this class.

Moreover all the hospitals are asked to improve their score over this period whatever was their initial score.

• In terms of following up the recommendations on hand hygiene, it is estimated that 75% of the providers should double their consumption of antiseptic hand-wash products. It was announced that by 2008, every health care provider should use at least 20 litres of liquid solution for 1000 hospital days.
• As to the infection rates for methicillin resistant Staphylococcus aureus, the objective is to reduce the incidence rates by 25% at least in 75% of the hospitals in three years; for surgical site infections at the moment the aim is to be able to collect regular data from all the institutions by the end of 2007.
• Finally for the last indicator, antibiotic consumption, as over-consumption of  antibiotics is a real problem in France (very high resistance rates), the idea is to enforce the use of specific guidelines for appropriate antibiotic prescription. Hospitals are asked to develop strategies to reduce their prescription rates (following the guidelines).

The fact that benchmarking indicators are not focused only on "outcomes" but also on the process encourages harmonisation of procedures and resources. This is important in preventing perverse effects which may arise from benchmarking, such as a skewing of resources to meet narrowly defined targets in terms of outcomes.

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high

The estimated cost of hospital acquired infections is about 200 million Euros per year in France. But it is too early to assess the cost-effectiveness of benchmarking strategy, and it is not easy to carry out a full assessment.

References

Sources of Information

Tableau de bord des infections nosocomials:

www.sante.gouv.fr/icalin/accueil.htm

Pilot quality indicator project -Projet COMPAQH

http://ifr69.vjf.inserm.fr/compaqh/indic/indic06.html

Indicator ICALIN:

http://cclin-sudest.chu-lyon.fr/CLIN/CahierdesCharges_2005_2.pdf

Legistlation:

www.snof.org/chirurgie/endophtalmie_5.html

Author/s and/or contributors to this survey

OR, Zeynep

Suggested citation for this online article

OR, Zeynep. "Benchmarking quality to fight hospital infections". Health Policy Monitor, April 2006. Available at http://www.hpm.org/survey/fr/a7/2