United States Government Accountability Office

GAO Testimony 

Before the Committee on Oversight and 

Government Reform, House of 

Representatives

HEALTH-CAREASSOCIATED INFECTIONS 

IN HOSPITALS 

Leadership Needed from 

HHS to Prioritize 

Prevention Practices and 

Improve Data on These 

Infections 

Statement of Cynthia A. Bascetta 

Director, Health Care 

For Release on Delivery

Expected at 11:00 a.m. EDT 

Wednesday, April 16, 2008

 

GAO-08-673T 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

April 16, 2008

HEALTH-CARE-ASSOCIATED INFECTIONS IN 

HOSPITALS 

Leadership Needed from HHS to Prioritize Prevention 

Practices and Improve Data on These Infections Highlights of GAO-08-673T, a testimony 

before the Committee on Oversight and 

Government Reform, House of 

Representatives 

According to the Centers for 

Disease Control and Prevention 

(CDC), health-care-associated 

infections (HAI)—infections that 

patients acquire while receiving

treatment for other conditions—

are estimated to be 1 of the top 10

causes of death in the nation. This

statement summarizes a report 

issued in March and released today,

Health-Care-Associated Infections 

in Hospitals: Leadership Needed 

from HHS to Prioritize Prevention 

Practices and Improve Data on 

These Infections (GAO-08-283). In

this report, GAO examined 

(1) CDC’s guidelines for hospitals 

to reduce or prevent HAIs and what

HHS does to promote their

implementation, (2) Centers for

Medicare & Medicaid Services’ 

(CMS) and hospital accrediting 

organizations’ required standards 

for hospitals to reduce or prevent 

HAIs, and (3) HHS programs that 

collect data related to HAIs and 

integration of the data across HHS.

To conduct the work, GAO

reviewed documents and 

interviewed HHS agency and 

accrediting organization officials. 

What GAO Recommends

In its report, GAO recommended

that the Secretary of HHS identify

priorities among the recommended 

practices in CDC’s guidelines and

establish greater consistency and

compatibility of the data collected

across HHS on HAIs. HHS generally 

agreed with GAO’s 

recommendations. GAO also

incorporated comments from the 

accrediting organizations as

appropriate. 

In its March report, which is summarized in this statement, GAO found the 

following: 

• CDC has 13 guidelines for hospitals on infection control and prevention, 

which contain almost 1,200 recommended practices, but activities across

HHS to promote implementation of these practices are not guided by a

prioritization of the practices. Although most of the practices have been 

sorted into categories primarily on the basis of the strength of the 

scientific evidence for the practice, other factors to consider in 

prioritizing, such as costs or organizational obstacles, have not been taken 

into account. 

• While CDC’s guidelines describe specific clinical practices recommended 

to reduce HAIs, the infection control standards that CMS and the 

accrediting organizations require of hospitals describe the fundamental 

components of a hospital’s infection control program. The standards are 

far fewer in number than CDC’s recommended practices and generally do 

not require that hospitals implement all recommended practices in CDC’s 

guidelines. 

• Multiple HHS programs have databases that collect data on HAIs, but 

limitations in the scope of information collected and a lack of integration 

across the databases constrain the utility of the data. 

GAO concluded that the lack of department-level prioritization of CDC’s large 

number of recommended practices has hindered efforts to promote their 

implementation. GAO noted that a few of CDC’s strongly recommended 

practices were required by CMS or the accrediting organizations but that it 

was not reasonable to expect CMS or the accrediting organizations to require 

additional practices without prioritization. GAO also concluded that HHS has 

not effectively used the HAI-related data it has collected through multiple 

databases across the department to provide a complete picture of the extent 

of the problem. 

To view the full product, including the scope 

and methodology, click on GAO-08-673T. 

For more information, contact Cynthia A. 

Bascetta at (202) 512-7114 or 

bascettac@gao.gov. 
Mr. Chairman and Members of the Committee: 

I am pleased to be here today to discuss our work on federal government 

efforts to address the problem of health-care-associated infections (HAI)1

in hospitals and to provide a summary of our report, which you are 

releasing today, entitled Health-Care-Associated Infections in Hospitals:

Leadership Needed from HHS to Prioritize Prevention Practices and 

Improve Data on These Infections.

2

 According to the Centers for Disease 

Control and Prevention (CDC), HAIs are infections that patients acquire 

while receiving treatment for other conditions3

 and are estimated to be 1 

of the top 10 causes of death in the United States. For example, a patient 

may acquire an infection from bacteria on a device used to treat them, 

such as a needle or tube to deliver medicine, fluids, or blood. According to

CDC, the most common HAIs are urinary tract infections, surgical site 

infections, pneumonia, and bloodstream infections. 

HAIs can be expensive. In 2005 the average payment for a hospitalization 

in Pennsylvania was over six times higher for patients who contracted a 

hospital-acquired infection than for patients who did not acquire 

infections, according to a report by the Pennsylvania Health Care Cost 

Containment Council.4

 A 2007 study of 1.69 million patients who were 

discharged from 77 hospitals found that the additional cost of treating a 

patient with an HAI averaged $8,832.5

 The costs of HAIs are borne not only 

by the patients who suffer infections, but also by those who pay for care, 

such as the Centers for Medicare & Medicaid Services (CMS). According to 

 1

See app. I for a list of abbreviations used in this statement. 

2

GAO, Health-Care-Associated Infections in Hospitals: Leadership Needed from HHS to 

Prioritize Prevention Practices and Improve Data on These Infections, GAO-08-283 

(Washington, D.C.: March 31, 2008). 

3

In general, HAIs are distinct from community-acquired infections, that is, infections that 

patients may have acquired before entering the hospital. 

4

See Pennsylvania Health Care Cost Containment Council, Hospital-Acquired Infections in

Pennsylvania (Harrisburg, Pa.: November 2006). 

5

See D. Murphy et al., Dispelling the Myths: The True Cost of Healthcare-Associated

Infections (Washington, D.C.: Association for Professionals in Infection Control and 

Epidemiology, February 2007).

Page 1 GAO-08-673T
the American Hospital Association, Medicare paid for over one-third of all 

hospital costs in 2005.

6

Although not all HAIs are preventable, public and private organizations 

have established standards and other activities aimed at controlling and 

preventing them. CMS has established health and safety standards—

known as conditions of participation (COP)—with which hospitals must 

comply in order to be eligible for payment by Medicare and Medicaid and 

which include the COP for infection control.7

 Hospitals may choose one of

two ways to show that they have met these or equivalent standards: they 

may be certified by a state agency under agreement with CMS to survey 

the hospital’s compliance with the COPs or they may be accredited by one 

of two private organizations—the Joint Commission or the Healthcare 

Facilities Accreditation Program of the American Osteopathic Association 

(AOA).8

 Most hospitals are accredited by the Joint Commission.9 Other 

activities within the Department of Health and Human Services (HHS) 

aimed at addressing the problem of HAIs in hospitals include the 

development of guidelines by CDC, which contain recommended practices 

that hospitals may adopt, and the management of several databases in 

different parts of HHS that contain information about HAIs in hospitals. 

According to the Institute of Medicine, prevention of HAIs through 

implementation of evidence-based guidelines can lead to improvements in 

quality of care.10 Furthermore, the collection of national data on these 

infections can provide a benchmark for individual hospitals to gauge their 

performance and design targeted interventions. 

 6

Medicare is a federal health insurance program that serves over 42 million elderly and 

certain disabled beneficiaries and pays for health care needs, such as inpatient hospital 

stays and physician visits. 

7

See 42 C.F.R. § 482.1 (2007). 

8

Section 1865(b)(1) of the Social Security Act also provides that any other national 

accreditation body that meets certain requirements as determined by the Department of 

Health and Human Services may accredit hospitals. 

9

In calendar year 2007, about 81 percent of hospitals were accredited by the Joint 

Commission, state survey agencies certified approximately 16 percent of hospitals, and less 

than 2 percent were accredited by AOA. Less than 1 percent of hospitals were accredited 

by both the Joint Commission and AOA. The Joint Commission was formerly known as the 

Joint Commission on Accreditation of Healthcare Organizations or “JCAHO.” 

10See K. Adams et al., Priority Areas for National Action: Transforming Health Care 

Quality, Institute of Medicine of the National Academies (Washington, D.C.: The National 

Academies Press, 2003). 

Page 2 GAO-08-673T
Federal and state lawmakers are also concerned about HAIs and have 

taken action to reduce them. With the passage of the Deficit Reduction Act 

of 2005 (DRA),11 the Congress took steps to revise the way Medicare pays 

hospitals so that beginning on October 1, 2008, they would not receive

higher payments for patients that acquire certain preventable conditions 

(including any of three HAIs) during their hospital stays.12 The HAI-related 

preventable conditions that CMS identified in the final regulation 

implementing subsection 5001(c) of the DRA were urinary tract infections

caused by catheters, infections caused by vascular catheters, and 

mediastinitis following coronary artery bypass graft surgery.13 According 

to Consumers Union—a nonprofit organization that has a campaign to 

stop HAIs—23 state legislatures have enacted laws that require public 

reporting of hospital HAI rates or HAI-related information.14

My statement today is based on the report that you are releasing today.15 In 

that report, we examined (1) CDC’s guidelines for hospitals to reduce or

prevent HAIs, and what HHS does to promote their implementation; 

(2) CMS’s and the accrediting organizations’ required standards for 

hospitals to reduce or prevent HAIs, and how compliance is assessed; and 

 11Pub. L. No. 109-171, § 5001(c), 120 Stat. 4, 30. 

12Under Medicare, hospitals generally receive fixed payments for inpatient stays based on 

diagnosis-related groups (DRG), a system that classifies stays by patient diagnoses and

procedures. Some DRGs take account of certain comorbidities or complications associated 

with a diagnosis or procedure and pay at a higher rate than would otherwise be paid for the 

diagnosis or procedure. In a final regulation implementing section 5001(c) of the DRA, CMS 

identified certain preventable conditions it would not consider as a comorbidity or

complication that would lead to the higher payment. See 72 Fed. Reg. 47130, 47200-217 

(Aug. 22, 2007). The DRA also requires hospitals to indicate the diagnoses that were 

present in patients at the time of admission in order for CMS to determine if a preventable 

condition developed during a patient’s hospital stay. 

13Mediastinitis is inflammation of the area between the lungs (the heart, the large blood 

vessels, the trachea, the esophagus, the thymus gland, and connective tissues). Additional 

preventable conditions that will no longer result in higher payments to hospitals include 

hospital-acquired injuries, such as fractures, pressure ulcers, objects left in the body during 

surgery, air embolisms, and blood incompatibility. CMS plans to propose additional 

conditions in the fiscal year 2009 Hospital Inpatient Prospective Payment Systems

proposed rule. See 72 Fed. Reg. 47130 (Aug. 22, 2007). 

14See Consumers Union, “State Hospital Infection Disclosure Laws,” available at 

http://www.consumersunion.org/campaigns/stophospitalinfections/learn.html, accessed on

March 10, 2008. 

15GAO-08-283. 

Page 3 GAO-08-673T
(3) HHS programs that collect data related to HAIs in hospitals, and the 

extent to which the data are integrated across HHS. 

In carrying out this work for the report you are releasing today, we 

interviewed officials from CDC, CMS, the Agency for Healthcare Research 

and Quality (AHRQ), the Food and Drug Administration, the Joint 

Commission, and AOA. We also interviewed selected experts in the field of 

infection control. In addition, we reviewed and analyzed CDC’s infection

control and prevention guidelines issued from 1981 through 2007; minutes

of the Healthcare Infection Control Practices Advisory Committee; the 

World Health Organization’s guideline on hand hygiene;

16 CMS’s COPs for 

hospitals and interpretive guidelines,17 which describe the COPs and 

provide survey procedures used to determine compliance with them; the 

Joint Commission’s standards for hospitals and its hospital standards 

manual; and AOA’s standards for hospitals and its hospital standards 

manual. We refer to the guidance that CMS provides about its COPs in the 

interpretive guidelines, and that the Joint Commission and AOA provide 

about their standards in their respective manuals, as “standards 

interpretations.”18 We also reviewed manuals and other documents that 

explain the HHS programs that collect HAI-related data, and related 

publications and data analyses conducted by the agencies based on the 

data collected. We conducted the performance audit for the report you are 

releasing today from January 2007 to March 2008, in accordance with 

generally accepted government auditing standards. Those standards 

require that we plan and perform the audit to obtain sufficient, appropriate 

 16See World Health Organization, WHO Guidelines on Hand Hygiene in Healthcare 

(Advanced Draft): Global Patient Safety Challenge 2005-2006: Clean Care Is Safer Care 

(Geneva, Switzerland, 2006). 

17In addition to reviewing CMS’s interpretive guidelines that can be found in CMS’s State

Operations Manual, we reviewed CMS’s revised interpretive guidelines for the infection 

control COP, which were published in November 2007. Throughout this report, where we

refer to the interpretive guidelines for infection control we are referring to the November

2007 revision. 

18Standards interpretations are given by CMS primarily in its State Operations Manual,

which is arranged by COP (Appendix A of the State Operations Manual contains the COPs 

for hospitals); by the Joint Commission in its Comprehensive Accreditation Manual for 

Hospitals: The Official Handbook, which identifies rationales and performance 

expectations that are used to measure each standard and is organized into 11 chapters of 

safety and quality standards, such as “Medication Management” and “Leadership;” and by

AOA’s standards manual, Accreditation Requirements for Healthcare Facilities, which

provides explanations for surveyors and the scoring procedures along with its standards

and is organized into 32 chapters. 

Page 4 GAO-08-673T
evidence to provide a reasonable basis for our findings and conclusions 

based on our audit objectives. We believe that the evidence obtained 

provides a reasonable basis for our findings and conclusions based on our 

audit objectives. A detailed explanation of our methodology is included in

our report. 

In brief, we found that federal authorities and private organizations have 

undertaken a number of activities to address the problem of HAIs. CDC 

has 13 guidelines for hospitals on infection control and prevention, which 

contain almost 1,200 recommended practices. However, activities across 

HHS to promote implementation of these practices are not guided by a 

prioritization of the practices. Although most of the practices have been 

sorted into categories primarily on the basis of the strength of the 

scientific evidence for the practice, other factors to consider in

prioritizing, such as costs or organizational obstacles, have not been taken 

into account. We concluded that a lack of department-level prioritization 

of CDC’s large number of recommended practices has hindered efforts to 

promote their implementation. While CDC’s guidelines describe specific 

clinical practices recommended to reduce HAIs, the infection control 

standards that CMS and the accrediting organizations require of hospitals 

describe the fundamental components of a hospital’s infection control 

program. The standards are far fewer in number than CDC’s recommended 

practices and generally do not require that hospitals implement all 

recommended practices in CDC’s guidelines. We noted that a few of CDC’s 

strongly recommended practices were required by CMS or the accrediting 

organizations but that it was not reasonable to expect CMS or the 

accrediting organizations to require additional practices without 

prioritization. Other federal efforts include multiple HHS programs that 

collect data on HAIs, but limitations in the scope of information collected

and a lack of integration across the programs’ databases constrain the 

utility of the data. We concluded that HHS has not effectively used the 

HAI-related data it has collected through multiple databases across the 

department to provide a complete picture about the extent of the problem. 

In order to help reduce HAIs in hospitals, we recommended that the 

Secretary of HHS take the following two actions: (1) Identify priorities 

among CDC’s recommended practices and determine how to promote 

implementation of the prioritized practices, including whether to 

incorporate selected practices into CMS’s conditions of participation 

(COP) for hospitals. (2) Establish greater consistency and compatibility of 

the data collected across HHS on HAIs to increase information available 

about HAIs, including reliable national estimates of the major types of 

HAIs. In commenting on a draft of our report, HHS generally agreed with 

Page 5 GAO-08-673T
our recommendations. It indicated that CMS would consider whether to 

incorporate some of CDC’s recommended practices into CMS’s hospital 

COPs, and it identified some steps CMS would take to achieve greater 

consistency and compatibility of the data collected on HAIs. In response to 

comments from the Joint Commission, we clarified our discussion of Joint 

Commission activities; in addition, we incorporated technical comments 

from the Joint Commission and AOA. 

CDC has 13 guidelines for hospitals on infection control and prevention, 

and in these guidelines CDC recommends almost 1,200 practices for 

implementation to prevent HAIs and related adverse events. (See table 1.)

The guidelines cover such topics as prevention of catheter-associated 

urinary tract infections, prevention of surgical site infections, and hand

hygiene. An example of a recommended practice in the hand hygiene 

guideline is the recommendation that health care workers decontaminate 

their hands before having direct contact with patients. Most of the 

practices are sorted into five categories—from strongly recommended for 

implementation to not recommended—primarily on the basis of the 

strength of the scientific evidence for each practice. Over 500 practices are 

strongly recommended. CDC and AHRQ have conducted some activities to

promote implementation of recommended practices, such as 

disseminating the guidelines and providing research funds. However, these 

steps have not been guided by a prioritization of recommended practices. 

One factor to consider in prioritization is strength of evidence, as CDC has 

done. In addition to strength of evidence, an AHRQ study identified other 

factors to consider in prioritizing recommended practices, such as costs or

organizational obstacles. Furthermore, the efforts of the two agencies 

have not been coordinated. For example, we found that CDC and AHRQ 

independently examined various aspects of the evidence related to 

improving hand hygiene compliance, such as the selection of hand hygiene 

products and health care worker education. Although this could have been 

an opportunity for coordination, an official from the HHS Office of the 

Secretary told us that no one within the office is responsible for 

coordinating infection control activities across HHS. 

CDC Has 13 Infection 

Control and 

Prevention Guidelines 

Containing Almost 

1,200 Recommended 

Practices, but 

Activities across HHS 

to Promote 

Implementation Are 

Not Guided by 

Prioritization of 

Practices 

Page 6 GAO-08-673T
Table 1: CDC’s Infection Control and Prevention Guidelines, with Number of Recommended Practices, Issued between 1981 

and 2007 

Guideline (issue date) 

Total number of

recommended

practices

1 Guideline for Prevention of Catheter-associated Urinary Tract Infections (1981) 24

2 Guideline for Infection Control in Health Care Personnel (1998) 183

3 Guideline for Prevention of Surgical Site Infection (1999) 63

4 Guidelines for Preventing Opportunistic Infections among Hematopoietic Stem Cell Transplant 

Recipients (2000) 

a

5 Guidelines for the Prevention of Intravascular Catheter-Related Infections (2002) 111

6 Guideline for Hand Hygiene in Health-Care Settings (2002) 42

7 Recommendations for Using Smallpox Vaccine in a Pre-Event Vaccination Program (2003) b

8 Guidelines for Environmental Infection Control in Health-Care Facilities (2003) 329

9 Guidelines for Preventing Health-Care-Associated Pneumonia (2003) 208

10 Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Settings 

(2005) 

b

11 Influenza Vaccination of Health-Care Personnel (2006) 6

12 Management of Multidrug-Resistant Organisms in Healthcare Settings (2006) 80

13 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare 

Settings (2007)

152

Total 1,198

Source: GAO analysis of CDC guidelines. 

a

For the purpose of this table, we do not include a count of the recommended practices in this 

guideline because the guideline is targeted to a specific patient population that not all hospitals treat. 

However, for the hospitals that do treat such patients, this guideline provides at least another 164 

recommended practices. 

b

The practices in these guidelines are not organized in a way that supports counting the total number 

of practices. 

Page 7 GAO-08-673T
While CDC’s infection control guidelines describe specific clinical 

practices recommended to reduce HAIs, the infection control standards 

that CMS and the accrediting organizations require as part of the hospital 

certification and accreditation processes describe the fundamental 

components of a hospital’s infection control program. These components 

include the active prevention, control, and investigation of infections. 

Examples of standards and corresponding standards interpretations that

hospitals must follow include educating hospital personnel about infection 

control and having infection control policies in place. The standards are 

far fewer in number than the recommended practices in CDC’s 

guidelines—for example, CMS’s infection control COP contains two 

standards. Furthermore, CMS and the accrediting organizations generally 

do not require that hospitals implement all recommended practices in 

CDC’s infection control and prevention guidelines. Only the Joint 

Commission and AOA have standards that require the implementation of 

certain practices recommended in CDC’s infection control guidelines. For 

example, the Joint Commission and AOA require hospitals to annually 

offer influenza vaccinations to health care workers, whereas CMS’s 

interpretive guidelines, or standards interpretations, are more general,

stating that hospitals should adopt policies and procedures based as much 

as possible on national guidelines that address hospital-staff-related 

issues, such as evaluating hospital staff immunization status for designated 

infectious diseases. CMS, the Joint Commission, and AOA assess 

compliance with their infection control standards through direct 

observation of hospital activities and review of hospital policy documents 

during on-site surveys. 

Multiple HHS programs collect data on HAIs, but limitations in the scope 

of information they collect and the lack of integration across the databases 

maintained by these separate programs constrain the utility of the data. 

Three agencies within HHS—CDC, CMS, and AHRQ—currently collect 

HAI-related data for a variety of purposes in databases maintained by four 

separate programs: CDC’s National Healthcare Safety Network (NHSN) 

program, CMS’s Medicare Patient Safety Monitoring System (MPSMS), 

CMS’s Annual Payment Update (APU) program, and AHRQ’s Healthcare 

Cost and Utilization Project (HCUP). Each of these databases presents 

only a partial view of the extent of the HAI problem because each focuses 

its data collection on selected types of HAIs and collects data from a 

different subset of hospital patients across the country. (See table 2.) 

Although officials from the various HHS agencies discuss HAI data 

collection with each other, we did not find that the agencies were taking 

steps to integrate any of the existing data by creating linkages across the 

CMS’s and 

Accrediting 

Organizations’ 

Required Hospital 

Standards Describe 

Components of 

Infection Control 

Programs, and 

Compliance with 

These Standards Is 

Assessed through OnSite Surveys 

Multiple HHS 

Programs Collect 

Data on HAIs, but 

Lack of Integration of 

Available Data and 

Other Problems Limit 

Utility of the Data 

Page 8 GAO-08-673T
databases, such as creating common patient identifiers. Creating linkages 

across the HAI-related databases could enhance the availability of 

information to better understand where and how HAIs occur. For 

example, data on surgical infection rates and data on surgical processes of 

care are collected for some of the same patients in two different databases 

that are not linked. As a consequence, the potential benefit of using the 

existing data to monitor the extent to which compliance with the 

recommended surgical care processes leads to actual improvements in 

surgical infection rates has not been realized. Although none of the 

databases collect data on the incidence of HAIs for a nationally 

representative sample of hospital patients, CDC officials have produced 

national estimates of HAIs. However, those estimates derive from 

assumptions and extrapolations that raise questions about the reliability of

those estimates. 

Page 9 GAO-08-673T
Table 2: Selected Characteristics of HHS Databases That Contain HAI-Related Information

Responsible agency and database HAI-related data collected Population for which data are collected 

CDC’s National Healthcare Safety 

Network (NHSN) 

Infection types

• central-line-associated BSI 

• catheter-associated UTI 

• VAP 

• postprocedure pneumonia 

• SSI 

• MDROa

• otherb

Most hospitals report on patients in selected 

critical care units and those undergoing 

selected procedures such as coronary 

bypass surgery and colon surgery. 

CMS’s Medicare Patient Safety

Monitoring System (MPSMS) 

Infection typesc

• central-line-associated BSI 

• catheter-associated UTI 

• postoperative pneumonia 

• antibiotic-associated C. difficile

• MRSA 

• VRE 

National sample of hospitalized Medicare 

patients. 

CMS’s Annual Payment Update (APU) 

database 

Practices to prevent or reduce SSIs 

• providing antibiotics within 1 hour of 

surgery 

• selecting appropriate antibiotics to prevent 

surgical infections 

• stopping the administration of the 

antibiotics within 24 hours of end of 

surgery 

National inpatient population for selected 

surgical procedures.d

AHRQ’s Healthcare Cost and Utilization 

Project (HCUP) database, Nationwide 

Inpatient Sample 

Infection types

• postoperative sepsise

• “infection due to medical care” (focused on 

intravenous and catheter infections) 

A sample of inpatients in hospitals in 37 

states. 

Source: GAO analysis of CDC, CMS, and AHRQ information.

Notes: BSI is bloodstream infection; C. difficile is Clostridium difficile; MDRO is multidrug-resistant

organism; MRSA is methicillin-resistant Staphylococcus aureus; SSI is surgical site infection; UTI is 

urinary tract infection; VAP is ventilator-associated pneumonia; and VRE is vancomycin-resistant 

enterococci. 

a

For patients whose infections are laboratory-confirmed, NHSN collects data on the pathogens 

identified, and for specified pathogens (including those responsible for MRSA and VRE), the result of 

any testing of their resistance to specific antibiotics. Participating hospitals have the option to report 

separately the number of times in a given month that they tested specimens of any of eight specified 

organisms for resistance to selected antibiotics, as well as the results of those tests. From these data,

NHSN produces rates of antimicrobial resistance relative to the number of nonduplicative specimens 

tested (i.e., excluding multiple tests for the same organism in the same patient). This part of NHSN 

does not distinguish between MDRO infections acquired in the hospital and community-acquired 

infections present at admission. 

Page 10 GAO-08-673T
b

Hospitals can choose to submit to NHSN data on other types of HAIs, such as skin and soft tissue 

infections, cardiovascular system infections, and gastrointestinal system infections. CDC does not 

provide data collection protocols for these types of infections, but they can be entered into NHSN as

“custom events” using definitions provided separately by CDC. 

c

In 2007, CMS added catheter-associated UTIs, VAP, MRSA, and VRE to MPSMS and dropped 

insertion-site infections associated with central vascular catheters, BSIs, and postoperativeassociated UTIs.

d

The three practice measures are assessed for certain categories of surgeries: coronary artery 

bypass graft; other cardiac surgery; colon surgery; hip arthroplasty; knee arthroplasty; abdominal 

hysterectomy; vaginal hysterectomy; and vascular surgery. 

e

The rate of postoperative sepsis is computed only for patients undergoing elective surgeries. 

HAIs in hospitals can cause needless suffering and death. Federal 

authorities and private organizations have undertaken a number of 

activities to address this serious problem; however, to date, these 

activities have not gained sufficient traction to be effective. 

Concluding 

Observations 

We identified two possible reasons for the lack of effective actions to 

control HAIs. First, although CDC’s guidelines are an important source for 

its recommended practices on how to reduce HAIs, the large number of 

recommended practices and lack of department-level prioritization have 

hindered efforts to promote their implementation. The guidelines we 

reviewed contain almost 1,200 recommended practices for hospitals, 

including over 500 that are strongly recommended—a large number for a 

hospital trying to implement them. A few of these are required by CMS’s or 

accrediting organizations’ standards or their standards interpretations, but 

it is not reasonable to expect CMS or accrediting organizations to require 

additional practices without prioritization. Although CDC has categorized 

the practices on the basis of the strength of the scientific evidence, there

are other factors to consider in developing priorities. For example, work 

by AHRQ suggests factors such as costs or organizational obstacles that 

could be considered. The lack of coordinated prioritization may have 

resulted in duplication of effort by CDC and AHRQ in their reviews of 

scientific evidence on HAI-related practices. 

Second, HHS has not effectively used the HAI-related data it has collected 

through multiple databases across the department to provide a complete 

picture of the extent of the problem. Limitations in the databases, such as 

nonrepresentative samples, hinder HHS’s ability to produce reliable 

national estimates on the frequency of different types of HAIs. In addition,

currently collected data on HAIs are not being combined to maximize their 

utility. HHS has made efforts to use the currently collected data to 

understand the extent of the problem of HAIs, but the lack of linkages 

Page 11 GAO-08-673T
across the various databases results in a lost opportunity to gain a better 

grasp of the problem of HAIs. 

HHS has multiple methods to influence hospitals to take more aggressive 

action to control or prevent HAIs, including issuing guidelines with 

recommended practices, requiring hospitals to comply with certain 

standards, releasing data to expand information about the nature of the 

problem, and soon, using hospital payment methods to encourage the 

reduction of HAIs. Prioritization of CDC’s many recommended practices 

can help guide their implementation, and better use of currently collected 

data on HAIs could help HHS—and hospitals themselves—monitor efforts 

to reduce HAIs. We concluded that leadership from the Secretary of HHS 

is currently lacking to do this. Without such leadership, the department is 

unlikely to be able to effectively leverage its various methods to have a 

significant effect on the suffering and death caused by HAIs. 

Mr. Chairman, this completes my prepared remarks. I would be happy to 

respond to any questions you or other members of the committee may 

have at this time. 

For further information about this statement, please contact 

Cynthia A. Bascetta at (202) 512-7114 or bascettac@gao.gov. Contact 

points for our Offices of Congressional Relations and Public Affairs may 

be found on the last page of this statement. Key contributors to this 

statement were Linda T. Kohn, Assistant Director; Shaunessye Curry; 

Shannon Slawter Legeer; Eric Peterson; and Roseanne Price.

Contact and 

Acknowledgments 

Page 12 GAO-08-673T
Page 13 GAO-08-673T

Appendix I: Abbreviations 

AHRQ Agency for Healthcare Research and Quality 

AOA Healthcare Facilities Accreditation Program of the 

 American Osteopathic Association 

APU Annual Payment Update 

BSI bloodstream infection 

CDC Centers for Disease Control and Prevention 

CMS Centers for Medicare & Medicaid Services 

COP condition of participation 

DRA Deficit Reduction Act of 2005 

DRG diagnosis-related group 

FDA Food and Drug Administration 

HAI health-care-associated infection 

HCUP Healthcare Cost and Utilization Project 

HHS Department of Health and Human Services 

MDRO multidrug-resistant organism 

MPSMS Medicare Patient Safety Monitoring System 

MRSA methicillin-resistant Staphylococcus aureus 

NHSN National Healthcare Safety Network 

SSI surgical site infection 

UTI urinary tract infection 

VAP ventilator-associated pneumonia 

VRE vancomycin-resistant enterococci 

(290704) 
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