Annual Performance Plan and Report

Topics on this page: Goal 1. Objective B | Table of Related Performance Measures | Analysis of Results | Plans for the Future | Objective Progress Update Summary

Goal 1. Objective B: Improve healthcare quality and patient safety

HHS is committed to improving health care quality and patient safety by ensuring safe and effective medical products, promoting professional practices focused on improving quality of client care, and reducing healthcare-associated infections (HAI).

Several HHS components focus on achieving goals that improve health care quality. FDA protects the Nation’s health by ensuring the safety, effectiveness, and security of human and veterinary drugs, vaccines, and other biological products and medical devices. HHS also ensures quality of care and patient safety through HAI surveillance and prevention activities at AHRQ and CDC. CDC’s HAI program protects patients receiving care in U.S. healthcare settings through outbreak detection and control, identifying emerging threats, establishing prevention guidelines and supporting staffing to improve healthcare practitioner and hospital system practice. AHRQ develops strategies to strengthen quality and promotes improved practices through Patient Safety Organizations. The IHS Improving Patient Care (IPC) initiative is implementing the patient centered medical home model to help transition IHS to more continuous quality improvement and a greater focus on improvement through the use of measures and other results.

CMS is transforming into an agency that positively promotes and incentivizes the quality of care for its beneficiaries through payment policy. Examples include continued development of physician, hospital, and post-acute care provider quality reporting systems that will link payments to the quality and efficiency of care, while also reducing healthcare-associated infections. In addition, CMS is promoting state efforts to report on quality metrics related to care in Medicaid and the Children’s Health Insurance Program (CHIP). ACL, AHRQ, CDC, CMS, FDA, HRSA, IHS, NIH, OASH, OCR, ONC, and SAMHSA are working together to improve healthcare quality and patient safety for all Americans. Below are some key performance measures demonstrating HHS progress. The Office of the Secretary led this Objective’s assessment as a part of the Strategic Review.

Objective 1.B Table of Related Performance Measures

Reduce the central line-associated bloodstream infection (CLABSI) standardized infection ratio (SIR) (Lead Agency - CDC; Measure ID - 3.3.3)

Increase the number of hospitals and other selected health care settings that report into the National Healthcare Safety Network (NHSN) (Lead Agency - CDC; Measure ID - 3.3.4)

Percentage of health centers with at least one site recognized as a patient centered medical home (Lead Agency - HRSA; Measure ID - 1.I.A.3)

Reduce by 10 percent hospital-acquired catheter-associated urinary tract infections (CAUTI) by the end of FY 2015. (Lead Agency - CMS; Measure ID - MCR28.2)⁷

Decrease the prevalence of pressure ulcers in nursing homes (Lead Agency - CMS; Measure ID - MSC1)

Decrease the Percentage of Long-Stay Nursing Home Residents Receiving an Antipsychotic Medication (Lead Agency - CMS; Measure ID - MSC5)

Improve Children's Health Care Quality Across Medicaid and the Children's Health Insurance Program (Lead Agency - CMS; Measure ID - MCD6)

Improve Adult Health Care Quality Across Medicaid (Lead Agency - CMS; Measure ID - MCD8)

Actions taken on abbreviated new drug applications (Lead Agency - FDA; Measure ID - 223205)

Review and act on original Abbreviated New Drug Application (ANDA) submissions within the established time frame. (Lead Agency - FDA; Measure ID - 223215)

100 percent of hospitals and outpatient clinics operated by the Indian Health Service are accredited (excluding tribal and urban facilities). (Lead Agency - IHS; Measure ID - 20)

Increase the number of users of research using AHRQ-supported research tools to improve patient safety culture (Lead Agency - AHRQ; Measure ID - 1.3.38)

Analysis of Results

Healthcare-associated infections (HAIs) are a significant cause of death in the United States. Of these, central line-associated bloodstream infections (CLABSI) have a strong potential to cause serious illness or death and catheter-associated urinary tract infections (CAUTI) are among the most common. The HHS National Action Plan to Prevent Healthcare-Associated Infections identified CLABSIs as a priority for prevention with national 5-year prevention targets and metrics proposed. Likewise, new Healthy People 2020 objectives have been proposed to address the substantial human suffering and financial burden attributable to healthcare-associated infections, one of which is to reduce CLABSIs. CDC’s National Healthcare Safety Network (NHSN) is a surveillance system used for tracking and prevention of HAIs across healthcare settings, including hospitals in all 50 states, and non-hospital settings (e.g. hemodialysis and long-term acute care facilities). Exceeding its goal for FY 2013, CDC extended tracking capacity to more than 12,400 facilities. In FY 2013, CLABSIs decreased to 0.54 Standardized Infection Ratio (SIR) nationally in U.S. hospitals. This represents an improvement over the prior year but misses the target.

The FY 2013 CAUTI SIR was 1.03, which reflects a 12 percent increase over its 2010 baseline, but an improvement over the previous year’s result. There are a number of reasons for the increase, including the addition of new hospitals reporting into the National Healthcare Safety Network as part of CMS’s Hospital Inpatient Quality Reporting Program. These new reporters were shown to have a consistently higher SIR than previous facilities. Also, better quality of reported data as a result of CDC outreach and education regarding reporting requirements in the Hospital Inpatient Quality Reporting program may have resulted in an increase in the number of CAUTIs reported, raising the SIR among this group of hospitals. In addition, ICUs have a higher prevalence of CAUTI and ICU reporting of CAUTI is incentivized by CMS' Hospital Inpatient Quality Reporting (HIQR) program, which is not the case for non-ICU reporting.

A Patient Centered Medical Home (PCMH) is a delivery model designed to improve the quality of care through enhanced access, planning, management and monitoring of patient care. In FY 2010 about 1 percent of HRSA-funded health centers had at least one site recognized as a PCMH. Through a series of quality improvement efforts, by the end of FY 2014, 58 percent of HRSA health centers had at least one site recognized as a patient centered medical home, exceeding the target of 40 percent.

Pressure ulcers or "bed sores" can cause damage to a patient's tissues and other serious complications like infection. Since 2007 there has been a steady decrease in the reported prevalence in pressure ulcers. A decrease of even 0.1 percent represents more than 1,000 fewer nursing home residents with pressure ulcers, not only reducing the cost of care but also improving nursing home residents’ quality of life. The FY 2013 result is 6.1 percent, which exceeds the target of 6.9 percent.

The National Partnership to Improve Dementia Care in Nursing Homes is committed to improving the quality of care for individuals with dementia living in nursing homes. The Partnership has a mission to deliver health care that is person-centered, comprehensive and interdisciplinary with a specific focus on protecting residents from being prescribed antipsychotic medications unless there is a valid, clinical indication and a systematic process to evaluate each individual’s need. CMS supports this effort and reports the percentage of long-stay nursing home residents that received an antipsychotic medication with a quality measure (QM) derived from the Minimum Data Set (MDS). CMS is currently reporting historical results and has set performance targets beginning in FY 2014. The FY 2013 result was 20.3 percent, which represented a slight increase over the previous year.

CMS continues to work closely with states to improve children’s health care quality across Medicaid and CHIP, as required by the CHIP Reauthorization Act of 2009 (CHIPRA). In collaboration with states, CMS developed and published the Child Core Set of quality measures. CMS is encouraging all states to use and report on the Child Core Set to collect data that will lead to improved health outcomes and to enhance the accuracy and applicability of the pediatric quality measures program specific to the Medicaid and CHIP programs. In FY 2013, 88 percent of states reported on at least seven quality measures in the Child Core Set, exceeding the target. In addition, the Affordable Care Act requires that HHS develop a core set of adult quality performance measures for voluntary use by states to assess the care received by adults in the Medicaid program. By encouraging states to report the core measures in a standardized manner, CMS is creating a foundation for a national system of quality measurement, reporting and improvement for adults in Medicaid. With 59 percent of states reporting on at least three quality measures in FY 2013, CMS just missed its target of 60 percent.

Generics play an important and increasing role in providing safe, effective, and affordable drugs to the American public and thereby in controlling health care expenditures. FDA’s Center for Drug Evaluation and Research has launched initiatives to streamline and modernize the generic review program. The growing capacity of the program is measured in total actions taken on generic drug applications. In FY 2014, the actual number of actions taken on applications was 1521, exceeding the FY 2014 target. FDA will be replacing this measure in FY 2015 with a new measure (223215) that better reflects the changes in methodology for counting the total actions required in the recent Generic Drug User Fee Act legislation.

IHS uses outside accrediting bodies, such as the Joint Commission, the Accreditation Association for Ambulatory Health Care, or the Centers for Medicare & Medicaid Services, to develop national standards of quality of care and manages IHS-operated hospitals and ambulatory health centers to meet these standards. IHS has consistently maintained 100 percent accreditation of IHS-operated hospitals and outpatient clinics since 2007 that  participate in accreditation visits. This is one of the most demanding measures to meet, given the growing clinical quality of care assessments that are required as well as issues related to health facilities maintenance and renovation that are critical to accreditation.

AHRQ developed the Hospital Survey on Patient Safety Culture so hospitals could determine how well they were doing in establishing a culture of safety in comparison to other similar hospitals. In FY 2014, 1,851 hospitals indicated in this survey that they use AHRQ-supported tools to improve patient safety, exceeding the target as the program has consistently for years. Interest in other AHRQ tools and resources has also remained strong, based on for example, on-going participation in webinars describing resources, electronic downloads, and orders placed for various products.

Plans for the Future

There have been significant investments in the expansion of the NHSN and HAI prevention by the CDC. CDC plans to increase the number of health care organizations reporting into the National Healthcare Safety Network to 19,000 facilities by FY 2016. That would be a more than four-fold increase from FY 2011 when only 5,000 hospitals were reporting. These investments should help facilitate the continued reduction of HAIs due to CLABSIs in FY 2014 and FY 2015 and, consequently, CDC's targets for FY 2014 and FY 2015 are 0.4 and 0.35, respectively.

HHS lowered its FY 2014 and 2015 targets to reflect significant challenges recently in CAUTI prevention. CMS projects a potential spike in the CAUTI SIR around January 2015 when hospitals begin reporting CAUTI data in non-ICUs as part of CMS' HIQR program. The need for continued widespread implementation of prevention strategies remains. Despite measurement-related factors that could be contributing to increasing SIRs, data from large prevention projects are showing that CAUTIs can be significantly decreased in US hospitals using the current interventions and metrics. For further information about plans to reduce CAUTI infection rates, please view this HHS Agency Priority Goal at performance.gov.

For HRSA’s Patient-Centered Medical Home initiative, HRSA will continue to provide PCMH transformation technical assistance to health centers through national- and state-based webinars and practice coaching.  Due to the success of this program, future targets show expectations of continued growth in the percentage of PCMHs.

CMS plans to continue its efforts to promote the reduction of pressure ulcers as an enhancement of the quality of healthcare throughout the nursing home community. The FY 2014, 2015, and 2016 target reflect an expectation of continued improvement in the incidence of ulcers.

CMS promotes a multidimensional approach to protecting residents from being prescribed antipsychotic medications unless there is a valid, clinical indication and a systematic process to evaluate each individual’s need that includes; research, partnerships and state-based coalitions, revised surveyor guidance, training for providers and surveyors and public reporting. CMS’s FY 2016 target for the percentage of long-stay nursing home residents that received an antipsychotic medication is 16.7 percent, which will reflect a reduction of 30 percent over the 2011 baseline.

CMS has goals to improve quality in both Medicaid and CHIP and has a phased in approach that allows states to take an iterative approach to quality improvement. CMS will continue to work closely with states to improve children’s health care quality across Medicaid and CHIP, as required by the CHIP Reauthorization Act of 2009 (CHIPRA). In collaboration with states, CMS developed and published a Child Core Set of quality measures. CMS is encouraging all states to use and report on the Child Core Set to collect data that will lead to improved health outcomes and to enhance the accuracy and applicability of the pediatric quality measures program specific to the Medicaid and CHIP programs. In FY 2016 CMS will focus technical assistance efforts to ensure that 90 percent of states report on at least ten quality measures in the Child Core Set. In addition, as required by Affordable Care Act, HHS will encourage states to report on a core set of adult quality performance measures for Medicaid. Although state reporting is voluntary, CMS will use state reporting to assess the care received by adults in the Medicaid program. By encouraging states to report the core measures in a standardized manner, CMS is creating a foundation for a national system of quality measurement, reporting, and improvement for adults in Medicaid. CMS will aim to have 70 percent of states report on at least nine adult quality measures by FY 2016.

FDA will retire its current abbreviated new drug applications measure (ID 223205) in FY 2015 due to a provision in the recent Generic Drug User Fee Act legislation, which changes the methodology for counting the total actions. The measure will be replaced with a new measure (223215) that better reflects the new methodology. FDA expects targets to continue to improve in the future.

IHS has committed to maintaining 100 percent accreditation of IHS-operated hospitals and outpatient clinics, using the standards and practices recommended by the Joint Commission, the Accreditation Association of Ambulatory Health-Care (AAAHC) or CMS.  The Joint Commission, the AAAHC, and CMS continue to revise standards and have been increasing clinical quality of care assessments, which IHS plans to adapt to and continue to meet.  The FY 2015 and 2016 targets are to maintain 100 percent accreditation at IHS-operated hospitals and outpatient clinics (excluding tribally operated facilities).

AHRQ continues to produce patient safety culture assessment tools for hospitals, medical offices, nursing homes, and pharmacies. One of these tools is a comparative database that healthcare providers can use as a benchmark for comparison on patient safety approaches. Information for this database report comes from the four patient safety culture survey tools: Hospital Survey on Patient Safety Culture (HSOPS), Medical Office Survey on Patient Safety Culture, Nursing Home Survey on Patient Safety Culture, and Pharmacy Survey on Patient Safety Culture. AHRQ is taking steps to update portfolio research topic areas and plans to continue to expand the number of research users through FY 2016.

Objective Progress Update Summary

HHS demonstrated progress toward this objective as shown by the representative performance measures described in the HHS Annual Performance Plan and Report. Further evidence of progress is described below.

• CDC’s National Healthcare Safety Network (NHSN) is the nation’s most widely used healthcare-associated infection (HAI) tracking system, with more than 13,000 healthcare facilities participating across all 50 states. NHSN provides facilities, states, regions, and the nation with data needed to identify problem areas, measure progress of prevention efforts, and ultimately eliminate healthcare-associated infections. The use of NHSN allows facilities to monitor central line-associated bloodstream infections (CLABSI), surgical site infections (SSI), and Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia.
• The success of the efforts to reduce the prevalence of pressure ulcers in nursing homes can be attributed to greater collaboration between state survey agencies and Quality Improvement Organizations and the national Advancing Excellence in America’s Nursing Homes campaign. In FY 2013, the actual reported prevalence of Stage 2 and greater pressure ulcers among high risk residents was 6.1 percent, better than the target of 6.9 percent.
• In FY 2013, 88 percent of states¹² reported on at least seven Children's Health Insurance Program Reauthorization Act (CHIPRA) quality measures, exceeding the target to work with states to ensure that 85 percent of states report on at least seven quality measures in the children’s core set of measures. CMS has provided states with instructions for annual reporting to demonstrate how to submit data for this initiative and CMS will continue to evaluate options to improve state quality reporting as agency information systems are enhanced.
• In FY 2013, 59 percent of states¹³ reported on at least three adult health care quality measures, falling just short of our target to have 60 percent of states reporting on at least three quality measures in the Adult Core Set. Although state reporting is voluntary, by encouraging states to report the core measures in a standardized manner, CMS is using technical support to create a foundation for a national system of quality measurement, reporting, and improvement for adults in Medicaid.
• HRSA is implementing a Patient-Centered Medical Home (PCMH) initiative designed to improve the quality of care in health centers and support their efforts to achieve national PCMH recognition or accreditation. Data are collected on the percentage of health centers recognized as a patient centered medical home by national/state accrediting organizations. At the end of FY 2014, more than 55 percent of health centers had at least one site that was recognized as a PCMH.
• NIH-funded research is showing that tests for genes or other biological markers can help predict which treatments will work best for individuals. In one example, recent research has shown that genetics tests can be used to help identify which women with a high risk of developing breast cancer should take medicines to reduce their risk of developing cancer. On-going research will further assess and explore the promise of these findings.

The Department is continuing to support and execute the programs contributing to this objective, monitoring progress, performance, and program integrity while adjusting to any budgetary constraints or changes to programmatic demands.