Date of Award

Spring 5-22-2026

Document Type

Doctor of Nursing Practice Final Manuscript

Degree Name

Doctor of Nursing Practice

Department

Nursing

First Advisor

Autumn Roque, DNP, APRN, PMHNP- BC

Abstract

Abstract

This policy paper advocates for a comprehensive redesign of the Centers for Medicare & Medicaid Services’ (CMS) Hospital‑Acquired Condition Reduction Program (HACRP). HACRP links hospital payment to patient safety outcomes by imposing financial penalties on hospitals in the lowest‑performing quartile for selected infection measures. A substantial body of evidence demonstrates that HACRP rely on self-reported infection data vulnerable to measurement bias, and show mixed or negative associations with improvements in healthcare‑associated infection (HAI) outcomes and disproportionately penalizes safety‑net and teaching hospitals, which are medical center that provides care for vulnerable populations—such as the uninsured, low-income individuals, and Medicaid recipients—regardless of their ability to pay or immigration status. These institutions typically operate on thin financial margins. Collectively, these limitations indicate that HACRP conflates hospital performance with patient social risk, effectively penalizing hospitals for factors beyond their direct operational control and raising fundamental concerns regarding equity, fairness, and measurement validity within value‑based payment. This research identifies a critical policy gap: HACRP lacks structured, evidence‑based implementation support to help hospitals reduce HAIs, particularly in settings with high clinical complexity and social risk. To address this gap, the research proposes a composite reform package that integrates robust risk adjustment for clinical severity and social determinants of health (SDH); balanced incentives that reward validated improvement; mandatory external data validation through risk‑based audits and multi‑source data triangulation; enhanced transparency via public dashboards, audit summaries, and methodology change logs; and required participation in federally supported infection prevention initiatives aligned with the Centers for Disease Control and Prevention’s (CDC) Targeted Assessment for Prevention (TAP) strategy and Agency for Healthcare Research and Quality (AHRQ) Safety Programs. Aligning HACRP with CDC TAP reframes the program from a predominantly punitive payment mechanism into a prevention‑oriented model that links accountability to the support hospitals’ need to achieve equitable and sustained reductions in HAIs. This approach is feasible because it relies on existing infrastructure (NHSN surveillance, TAP targeting tools, and AHRQ implementation support) and scales by standardizing core expectations while allowing hospitals to tailor local workflows. Using Bardach and Patashnik’s Eightfold Path as the primary policy analysis framework—complemented by Donabedian’s structure–process–outcome model, Kingdon’s Policy Streams, and an SDH equity lens—this research systematically evaluates HACRP’s design limitations and constructs. It compares reform alternatives and projects clinical, equity, and economic outcomes. Economic modeling demonstrates that prevention-driven infection reduction, coupled with improvement-based incentives, can generate net cost savings while mitigating the inequitable penalty burden. Collectively, this analysis advances an actionable, equity‑forward redesign of HACRP that aligns federal payment policy with prevention science, implementation capacity, and ethical imperatives to improve patient safety across U.S. hospitals.

Keywords: HACRP; value‑based purchasing; health equity; risk adjustment; social determinants of health; infection prevention; CDC TAP; AHRQ Safety Programs; external validation; implementation science; Eightfold Path.

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Available for download on Thursday, May 18, 2028

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