In this special issue, we have described results from the IMPAQ-RAND team’s formal longitudinal evaluation of HHS’s National Action Plan to Prevent Healthcare-associated Infections1 and have discussed efforts to address healthcare–associated infections (HAIs) at the state, regional, and local levels. In this final article, we take a step back to consider briefly the overall impact of the Action Plan and to describe some possible future directions for addressing HAIs. While HAIs are not new, the environment of the modern healthcare system provides some new challenges and opportunities for eliminating HAIs. In the context of extraordinary medical advances during recent decades, healthcare has become increasingly complex, and many common medical procedures and treatments can also be the source of HAIs. For example, widespread use of antibiotics to combat infection can also lead to increased antimicrobial resistance, whereas beneficial but invasive medical procedures, including surgery or the use of catheters, can compromise the body’s natural defenses. Further, as more and more patients survive life-threatening diseases, the treatments used to address many diseases weaken some patients’ immune responses, making them more vulnerable to HAIs. Today’s healthcare system makes use of a complex network of venues that provide differing levels and types of care; however, as patients move frequently across healthcare and home venues, they have the potential to carry with them strains of organisms that can transmit HAIs to others. There is widespread recognition of the personal and financial costs associated with HAIs, including the potential for loss of life or impaired functioning, billions of dollars spent annually to treat HAIs, and decreasing public trust in the healthcare system. Awareness of these issues led to the development of HHS’s National Action Plan to Prevent Healthcare-associated Infections, which we have discussed in this special issue of Medical Care. HHS’s Action Plan was the result of both a growing enthusiasm for using evidence-based strategies and guidelines to prevent and mitigate HAIs as well as frustration at the lack of a prioritized and coordinated approach for addressing HAIs, an adequate infrastructure for aligning interventions, and a robust system for measuring progress. The focus on evidence-based strategies and guidelines grew out of a major paradigm shift that occurred during the first decade of the 21st century, as data emerged showing that substantial numbers of hospital-based HAIs were preventable with use of evidence-based strategies.2 These include activities such as reducing the initial and ongoing use of antibiotics and limiting the use of devices known to compromise the body’s natural defenses (eg, catheters) to only those situations in which use is known to improve medical outcomes. Other evidence-based interventions include standardizing the use of hand-washing, and “bundling” evidence-based medical care practices to ensure that each individual procedure occurs as it should and when it should. Multiple public and private organizations have prompted healthcare organizations to implement evidence-based interventions to improve patient outcomes. The enthusiasm for developing and implementing evidence-based procedures also contributed to the expectation that effective prevention practices could be rapidly identified and implemented in healthcare facilities across the nation. This hope turned to frustration, as stakeholders-ranging from local healthcare practitioners to national policy leaders-recognized that too many guidelines were being recommended and that a prioritized and coordinated approach for addressing HAIs was lacking. This frustration was articulated in a 2008 report released by the Government Accountability Office (GAO), which criticized the federal effort to address HAIs, focusing on the multitude of clinical practices for preventing HAIs and related adverse events, the fragmentation of data across government agencies, and the lack of interoperability across databases.3 The GAO emphasized the need for improved coordination of HAI prevention efforts and 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.”3 The GAO report was followed by congressional hearings on HAIs. Prompted by Congress, HHS developed its Action Plan to enhance collaboration and coordination and to strengthen the impact of national efforts to address HAIs. WAS THE ACTION PLAN RESPONSIVE TO THE NEED FOR PRIORITIZATION OF HAI PREVENTION PRACTICES AND COORDINATION OF DATA SOURCES? A key overarching issue for the IMPAQ-RAND evaluation of HHS’s Action Plan was whether or not the Action Plan was responsive to the 2 major concerns that motivated its development: first, the need for prioritization of HAI prevention practices and, second, the need to coordinate disparate federal data sources for tracking HAIs. Overall, our evaluation found that the Action Plan addressed both these issues. Prioritization of HAI Prevention Practices First, the Action Plan made many efforts to prioritize HAI prevention practices. Evidence for the prioritization began with the Action Plan’s selection of 6 conditions and the development of targets and metrics for these conditions. The initial version of the Action Plan, released in 2009, prioritized HAI prevention practices associated with hospitalizations as compared with other venues. Over time, the Action Plan expanded its focus to include ambulatory surgical centers, dialysis centers, and long-term care venues. The Action Plan also initially focused on efforts to reduce HAIs among hospital patients, as was appropriate, as patients have been the main victims of HAIs. Subsequently, the focus shifted to include influenza vaccination for healthcare personnel as a strategy for interrupting the pattern of unvaccinated healthcare workers contributing to infection risk for vulnerable patients. The Action Plan prioritized HAI prevention practices through its research strategies and has established and applied well-developed criteria for identifying those research methodologies and projects most likely to generate new knowledge to support evidence-based strategies and procedures for HAI prevention. Furthermore, the use of incentives to encourage healthcare practitioners and practices to systematically collect data to support Action Plan metrics and targets offers further evidence of prioritization of HAI prevention practices. Coordination of HAI Data Systems The Action Plan also improved coordination of HAI data systems across HHS agencies. This was a major goal in the Action Plan in 2009, with the establishment of national metrics with corresponding 5-year prevention targets. The Action Plan commitment to system-level metrics and targets illustrates an intent to make an observable difference, not just with processes but with outcomes. The public commitment to achieving the targets by 2013 focused a broad and diverse set of efforts on a uniform set of goals. The Action Plan selected data sources and baseline years for each metric. Stakeholders iteratively and rigorously pursued strategies for improving definitions of infections and for refining data collection tools to enable assessment of progress toward achieving target goals. To focus all of the national, regional, state, and local efforts on a transparent assessment of HAI rates over time requires substantial coordination and messaging. The Action Plan has led to reductions in HAI rates with progress made toward most targets for which associated data are available. HOW WELL DID THE ACTION PLAN ADDRESS THE CHALLENGE OF FINDING CONSISTENT AND SUSTAINABLE RESOURCES TO SUPPORT IMPLEMENTATION? Although the Action Plan can be considered successful in addressing the challenges of prioritization and coordination, the absence of predictable fiscal resources dedicated to curbing HAIs has been notable. During the early 21st century, the lack of predictable and sustainable resources has become a reality for large government programs, particularly those spanning multiple stakeholders. Action Plan leadership, through its Steering Committee, was able to draw from and build upon the long-standing and extensive support of its lead agencies, generating extraordinary clinical, intellectual, political, and leadership resources that convened to address one of the most devastating epidemics ever known to our nation. A strength of the Action Plan has been its effective and astute leveraging, on an ad hoc basis, of already existing resources. However, a predictable and steady flow of resources has not been readily available. In the absence of a sustained influx of resources, the pace of advancement may have been muted and enthusiasm for growth by key stakeholders somewhat slow. Although agency collaboration has been substantial, relationships among stakeholders and potential collaborators may have been strained as agencies and organizations competed for limited resources. If there is one counterfactual consideration relevant to the contexts in which the Action Plan and its goals were developed, it is how the Action Plan advances might have been different if explicit resource needs were estimated, tested, and shared with stakeholders and the public. This would have been consistent with the principle of transparency that the Action Plan supports and would have provided some boundaries for federal stakeholders to assess realistic goals within a specified time period. In addition, concerns of critics of the Action Plan, particularly external stakeholders and clinical practice settings that initially questioned the gap between ambitious Action Plan goals for expansion and the lack of financial support for their own local efforts, might have been mitigated if a shared understanding of available resources and costs had been more widely recognized. Despite this limitation, the Action Plan’s ability to leverage available infrastructure and resources has supported substantial and ongoing progress during a challenging economic period. FUTURE DIRECTIONS Moving forward, HHS leadership will need to decide how best to sustain the momentum achieved through the Action Plan to continue to reduce and, eventually, to eliminate HAIs. Particular attention will need to be focused on securing the resources—both financial and nonfinancial—that are necessary to sustain progress. A key decision point for healthcare policymakers is to determine the extent to which the campaign to eradicate HAIs should be aligned with—or in some cases embedded within—other healthcare efforts. The potential for alignment offers opportunities to leverage existing resources and capabilities within the healthcare system on an ongoing basis. We highlight 4 potential opportunities below. Managing HAIs Within the Broader Patient Safety Movement A key strength of the Action Plan was the creation of a dedicated federal home for coordination. This coordinating body identified gaps in HAI prevention infrastructure and helped ensure the ongoing engagement of key stakeholders in the Action Plan. Maintaining such a leadership body in the future would help keep the focus on HAIs. However, a key issue is to determine the relative allocation of federal funding specifically to support the HAI effort as compared with a broader investment in the patient safety movement—which includes HAIs as well as other preventable conditions. There may be advantages to making the HAI effort an important component of patient safety overall rather than a movement of its own. Substantial infrastructure investments for preventing HAIs will also be applicable to other major healthcare challenges that span venues and require multiple diverse inputs. With this regard, the Action Plan provides a model for the broader patient safety agenda which like HAIs spans beyond hospitals to other healthcare settings in which improvement infrastructure is typically less developed. Using Information Technology (IT) to Monitor and Address HAIs HAI data and monitoring pose an ongoing challenge because of the significant expense and effort required to support HAI surveillance and reporting. The ongoing growth of health IT, including the use of electronic health records, provides a potential opportunity to improve HAI care both for individual patients and for population health as a whole. Health IT can be used to automate many of the steps involved in collecting data on HAIs: IT can be used to bring together all the information on a particular patient, and then data can be combined across patients to provide a better understanding of how a particular HAI affects population health. To enhance HAI data and monitoring, additional investment is needed to automate HAI surveillance and reporting. This will require collaboration and cooperation with health IT vendors and commitment to basing surveillance on entire episodes of care, which can span months for conditions such as surgical site infections (which optimally take into account a follow-up period), or for conditions such as Clostridium difficile (which can recur multiple times within the same patient). These advances should be paired with a more aggressive approach to data validation, that is, ensuring that data have been collected in a fair and unbiased way that uses best practices. Because data collection occurs at the state and local levels, it will be essential to engage major state-level and local-level and other private stakeholders with interests and expertise in HAI data validation in the identification of best practices and the development of feasible data validation strategies. The expansion of health IT, although complex, offers the promise of increasing collaboration and leveraging resources across both the public and private sectors and spanning the national to local levels. Connecting the Basic Science and Epidemiology of HAIs With Prevention Practice and Implementation Science Moving forward, knowledge development surrounding HAIs will be well supported with a balanced investment in a 4-pronged approach that includes: (1) basic science, (2) epidemiology, (3) development of prevention practices, and (4) implementation science—as well as linking findings across these disciplines. The Action Plan succeeded in endorsing a research agenda that highlights HAI-related gaps for each of these areas and shows how advances in each area are needed to move forward the other areas. Following the model of translational research, the discovery of the basic mechanisms of HAIs will inform a better understanding of the epidemiology of HAIs, and, subsequently, the development of prevention practices and new findings from implementation science, which feeds back into the overall scientific evidence base for HAIs. The Action Plan has already developed criteria for prioritizing HAI research that is likely to have a high impact in eliminating HAIs. Now, it is important for healthcare leaders to evaluate the research that has been carried out to determine where high-value research has occurred and to decide whether the prioritization criteria still hold. This type of feedback can enhance an understanding of which research is most helpful. It will also be critical to emphasize implementation science, that is, the development of learning laboratories in which research occurs in real-world clinical settings.4,5 One of the challenges that the Action Plan sought to address was the need for a multipronged approach to address HAIs—which come in many forms and are transmitted through multiple sources across diverse locations—but one that does not overburden the individuals, mostly at the local, regional, and state levels, who are responsible for implementation. This balance has not yet been fully achieved, and continuing efforts will be required to determine which approaches are providing the highest value. Taking Advantage of State-of-the-Art Implementation and Dissemination Tools The adoption of HAI prevention practices can be augmented by taking advantage of state-of-the-art implementation and dissemination tools. Aligning with the larger patient safety and implementation science movements will increase the likelihood that HAI research results will be effectively translated into improved human health. Implementation science has been developing new methods for assessing the effectiveness of healthcare interventions and approaches. These include meta-analysis, cost-effectiveness studies, and patient-centered outcomes research. AHRQ’s evidence-based practice centers have been developing reports on which HAI interventions improve outcomes in which settings.6 CONCLUSIONS Although the potential directions described above suggest ways in which the HAI movement can be aligned with other efforts to achieve economies of scale, it is important to emphasize that a specific focus on HAIs will continue to be necessary—whether or not HAI-related efforts are folded into the larger patient safety movement. In the future, continuing efforts will be required to track progress in addressing the most pervasive HAIs and to identify new infections and means of transmission and to find ways to address those HAIs. Although the Action Plan has improved the prioritization and coordination of efforts related to HAIs, attention to these processes must be ongoing. Regular evaluation of HAI-related efforts, including self-monitoring of key implementation goals, can support this need. A self-monitoring approach will allow Action Plan leaders to build upon the insights achieved through the external evaluation. Supplementing the development and utilization of longitudinal HAI rate trend reports with additional metrics about the implementation of HAI supportive infrastructures, engagement of stakeholders, outcomes of research funding, and adoption of evidence measures can serve as ongoing tools that the Action Plan can internalize as part of its own infrastructure. Careful monitoring of these metrics will inform how the context and goals of the Action Plan are translated into key decisions, processes, and outcomes. This type of self-monitoring is likely to improve the Action Plan’s effectiveness even further.