For about 20 years, the Centers for Disease Control and Prevention (CDC) has operated a knowledge collection 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 sign up for the network. It didn’t go well, but things have moved on since then. Lastly, 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 this 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 Health Care Safety Network, and NHSN is the acronym for it. It’s a data gathering tool to track health care acquired infections. And it’s been typically used more for hospitals. But when the pandemic hit, CMS made it mandatory for nursing homes to report to NHSN. And they had to report all types of COVID data. So, they had to report suspected COVID cases, total COVID deaths, PPE, hand hygiene, ventilator capacity, all types of information about COVID now had to be gathered. And this was in May of 2020 when this requirement went into place. And I know your listeners will remember that was the absolute heat of the pandemic. I mean, this was a real crisis moment. And so, this previously voluntary reporting for nursing homes now became mandatory. And CDC had a massive challenge on its hand. How do you enroll thousands of nursing homes in a matter of weeks to accurately gather and report this really crucial information?
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Tom Temin Well, frankly, it turns out to be a primitive system, because online registration for programs has become a component of American life and it’s widespread. And there are sites where, you know, another 10,000 people sign up within an hour and create an account. What was the difficulty?
Marshall Allen Yeah, I could see why you’d say that, but it’s actually a pretty complicated system. And then also, don’t underestimate the stress that the nursing homes were under at this time. Nursing homes are notoriously short staffed and trying to juggle a lot of different things at the moment. And don’t forget, COVID was really unknown at this time. So, you have these nursing homes where they have very high turnover, not a lot of trained staff having to create a login for this system. And I know it should seem really simple, but process was a little convoluted. Like specifically at one point in the process they had to upgrade their security access and they actually had to send in some actual like hard copy documentation to verify their identities because they didn’t have a quick access kind of immediate identity kind of thing built into the system. So, it was something that had to happen really fast under a huge amount of stress with the nursing homes not being well trained or well-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 is a small technical problem that the CDC needed to perfect.
Marshall Allen Yes, definitely. And so, they sent out a lot of guidance and they held a lot of webinars. But remember, this all happened in a matter of weeks. And so, they had to add to the system too. They had to create in the new system the capacity to gather all this data about COVID that had not previously been gathered before. And so, they did webinars. They did everything they could to get people enrolled, but they had about 12,000 nursing homes enrolled. Like really all at once. And so there were a lot of challenges with the enrollment. Getting people logged in was a challenge to help. Having people understand the guidance was a challenge. And one of the biggest challenges was that the helpdesk I mean, you can imagine the helpdesk for NHSN had never seen anything like this before, and suddenly they have thousands of nursing homes needing assistance. And the way the helpdesk was created, it did not have any phone assistance or live chat ability. It was all email. And so, you know, you have nuanced questions about the nursing home might have needed to know, what do I need to report? How do I need to report it? How do I get logged in? I forgot my password. I mean, you can imagine all these calls to the helpdesk, thousands of them at once. And so, it created a massive backlog because they didn’t have live support. It just made it really difficult to get these things answered over email.
Tom Temin: And this record was done in time to inform understanding of COVID in nursing homes?
Marshall Allen That’s right. And I mean, it’s pretty remarkable. You know, 12,000 nursing homes were temporarily registered. I mean, there were delays, there were problems, there were frustrations. But they signed up. They reported the knowledge. The only other thing we found, and this fed into our recommendations, was all the knowledge reported to the NHS and that was self-reported knowledge. And quality controls of knowledge are carried out. But we asked nursing homes how confident they were in themselves. We surveyed around two hundred care homes, and we also conducted interviews with care homes, asking them about their trust and the completeness and accuracy of the knowledge they reported in NHSN. And about 1 in four people said they did not consider the completeness and accuracy of the knowledge to be true. So one of our recommendations to the CDC was to step up their quality assurance checks, you know, provide more guidance and more documentation on the front end and then also verify knowledge on the back end. You know, establishing a quality assurance procedure so that you can actually determine that the knowledge that you’re collecting is actually 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 Yeah, NHSN has changed a lot. And we even asked the nursing homes whether things had improved since the height of the pandemic. And they had improved, but they still had challenges even when we were doing our data gathering. This was, two years after the height of the pandemic, when we were talking to them. They still had challenges with the reporting, with the different, different aspects of the system. And the reporting has been reduced. Now they’re still gathering vaccine data from the nursing homes. But the other thing CDC is talking about doing is expanding the use of NHSN. And so, as they look forward to expanding the use of it as they continue to gather this vaccine data, it’s important that they take these steps. You know, we recommended. Another thing we recommended is that they give some live support, whether it’s chat or telephone support, on their help desk, just so that the users don’t get frustrated when they’re trying to get that guidance.
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Tom Temin: And what is the population of informants in the network?
Marshall Allen, I think it’s about 15,000 nursing homes. I don’t know how many hospitals were out of reach of what we looked at. I know they added 12,000, and I think there were about 3,000 who 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.
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 it will be. But knowledge about the vaccine still relates to COVID 19. Knowledge about the vaccine still wishes 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 the CDC’s reaction been 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.