For about 20 years, the Centers for Disease Control and Prevention (CDC) has operated a knowledge-gathering site, called the National Healthcare Safety Network. In 2020, the CDC made it mandatory for nursing homes to report COVID cases. As a result, thousands of nursing homes had to enroll in the network. It didn’t go well, but things have moved forward since then. Last time, Federal Drive with Tom Temin spoke with Regional Deputy Inspector General for Health and Human Services Marshall Allen.
Interview Transcript:
Tom Temin: And tell us about that network and what happened when they made it mandatory for nursing homes to report fitness data?
Marshall Allen Well, the CDC has what’s called the National Healthcare Safety Network, and NHSN is the acronym for that. This is a knowledge collection tool for monitoring nosocomial infections. And sometimes it is used more in hospitals. But when the pandemic hit, CMS made it mandatory for nursing homes to report to NHSN. And they had to report all kinds of knowledge about COVID. So they had to report suspected COVID cases, overall COVID deaths, PPE, hand hygiene, ventilator capacity, and now all kinds of COVID data had to be collected. And that was in May 2020, when this requirement went into effect. And I know your listeners won’t forget that it was the absolute heat of the pandemic. I mean, it was a real moment of crisis. Thus, the former voluntary declaration for nursing homes is now mandatory. And the CDC had a huge challenge ahead. How can thousands of nursing homes be enrolled in a matter of weeks so that they, as they should, collect and report this really important data?
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Tom Temin Well, it sounds like it must be, frankly, a primitive system, because online enrollment for applications now is a part of American life, pretty widespread. And there are sites that, you know, 10,000 people sign up an hour and get an account. What was the difficulty?
Marshall Allen: yes, I understand why you say that, but it’s really quite a confusing system. And don’t underestimate the strain nursing homes were enduring at the time, either. Nursing homes are notoriously understaffed and lately are trying to juggle a lot of other things. And remember, COVID was literally unknown at the time. There are nursing homes where the turnover rate is very high and there are few qualified staff who have to create an identifier for this system. It may seem very simple, but the procedure was a bit confusing. Specifically, at some point in the procedure, they had to access their security access and they actually had to send actual documents, such as a hard copy, to determine their identity, why not not have a quick access prompt identity type built into the system. So all of this had to happen very quickly, under enormous strain, as the nursing homes were not well trained or adequately staffed.
Tom Temin: That’s right. So, part of this is a systemic challenge with the way nursing homes are organized and the type of staff they have. But it also turns out that there’s a small glitch that the CDC needed to perfect.
Marshall Allen Yes, definitely. So they sent out a lot of advice and did a lot of webinars. But remember, this all happened in a matter of weeks. And that’s why they also had to enrich the formula. They had to build into the new formula the ability to combine all this knowledge about COVID that hadn’t been collected before. And so, they did webinars. They did their best to sign up other people, but they had about 12,000 nursing homes signed up. Actually, all at once. So there were a lot of problems with the records. Connecting other people was a challenge for attendance. Getting other people to understand the advice was a challenge. And one of the most demanding situations was that the help desk, I mean, can you believe that the NHSN help desk had never noticed anything like this before, and as a result, they have thousands of retirement homes that want assistance. And the way the help desk was set up, it didn’t have phone support or live chat capabilities. It was only by email. And so, you know, you have nuanced questions about the nursing home, you may have wanted to know, what’s worth reporting? How do I deserve to report it? How can I log in? I forgot my password. I mean, can you believe all the calls to the help desk, thousands of them at a time. And that created a massive delay because they had no live help. It was very difficult to get an answer to those questions via email.
Tom Temin: And this record was done in time to inform understanding of COVID in nursing homes?
Marshall Allen It did. And I mean, that’s pretty remarkable. You know, 12,000 nursing homes got enrolled rapidly. I mean, there were backlogs, there were hassles, there were frustrations. But they did get enrolled. They did report the data. The one other thing that we found, and this went into our recommendations, was all the data reported to NHS and is self-reported data. And there are some QA checks done on the data. But we asked nursing homes what their confidence was. We did a survey of about 200 nursing homes, and we also did interviews with nursing homes, and we asked them what their confidence was about, the completeness and the accuracy of the data that they were reporting to NHSN. And about 1 in 4 said they did not have confidence in the completeness and accuracy of the data. And so, one of our recommendations to CDC was to bump up their QA checks, you know, give better guidance and documentation on the front end, and then also check the data on the back end. You know, have a QA process in place so that you can really verify the data that you’re gathering is really accurate.
Tom Temin: We’re talking to Marshall, Allen. Es the deputy regional inspector general for Health and Human Services. And now that we’re here in 2024, I did that work, that inspection of this formula at the end of 2023. Why now?
Marshall Allen: Yes, the NHSN has replaced a lot of things. And we even asked nursing homes if things had moved forward since the height of the pandemic. And they had stepped up, but they still had demanding situations even when we were gathering knowledge. Two years after the peak of the pandemic, when we were talking to them. They still had difficulties with reporting, with the other facets of the system. And reports have dropped. Today, they are still gathering knowledge about vaccines in nursing homes. But the other thing the CDC is talking about is expanding the use of the NHSN. It is vital that they take those steps. You know, we’re bringing them forward. Another thing we propose is that they provide live support, either via chat or phone, at their help desk, so that users don’t get frustrated when seeking that advice.
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Tom Temin And what is the current population of reporting entities now on the network?
Marshall Allen, I think it’s about 15,000 nursing homes. I don’t know how many hospitals were outside the scope of what we looked at. I know they added 12,000, and I think there were about 3,000 that were already voluntarily registered before. the pandemic.
Tom Temin: So it’s fair to assume that there are tens or even tens of thousands of hospitals that have already been publishing reports for some time now.
Marshall Allen Yeah, there are fewer hospitals in the nursing homes, so there probably aren’t that many. But yeah, hospitals have been reporting to NHSN for years and they report things like, you know, C-diff infections, MRSA infections, central line infections, all that type of data is really important. But another thing with the quality improvement, I mean, the hospitals were outside the scope of what we’re doing, but the hope is that if they can improve the QA checks for the nursing homes, that maybe that would also affect the QA checks for the hospital data, too.
Tom Temin: And maybe they just have hospitals that are smart about this, tasked with training new entities on the formula and how to use it.
Marshall Allen Certainement. I think one of the demanding situations for nursing homes is turnover rates. You know, staffing is at a critical point right now in nursing homes. And a lot of that is due to the undeniable turnover of staff. And that’s anything, we’ve found out with everyone we’ve talked to. You can designate a user to be the key user for NHSN reporting, but then that user can just leave and then you’ll have to designate someone new. It’s a real challenge to keep this formula up to date.
Tom Temin And you said in the report that COVID reports are about to expire, that requirement for nursing homes. And then he told me that there would be an increase in the number of reporting entities. So what’s next for the network?
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Marshall Allen: Well, we don’t know for sure what it will be. And CDC officials haven’t told us what that would be. But vaccine knowledge is still for COVID-19. Knowledge of the vaccine will still need to be reported to the NHSN through care homes. And then they talked about expanding it, but they didn’t specify what it would look like.
Tom Temin Because, while hospitals report some of those infections, that kind of thing happens all the time in nursing homes.
Marshall Allen: Definitely, I mean, there are a lot of tactics to use the NHSN. It’s a valuable tool.
Tom Temin: What recommendations have you received and what has been the reaction from the CDC so far?
Marshall Allen: Well, we had three pieces of advice. The first was to upload a live chat, a live help to the phone support service, to a user or someone in the live chat, so that express questions can be answered in real time. On that they were in part agreement. You know they have to agree or disagree on this. They agree in part. They said they had made a lot of comments and we responded to them. Although we still think you know you want to upload live help. And the other two were similar in terms of the quality of knowledge, one piece of advice was the guidance they provided. to other people when they signed up. The CDC agreed with that. And then the other goal that they signed up with was to improve the quality assurance procedure so that they can be sure that the data that is reported is complete and accurate.
Tom Temin is the host of Federal Drive and has been offering insight into federal generation and control issues for more than 30 years.