Healthcare Associated Infection Prevention and Control Program: Campaign to Reduce Hospital Acquired Infections Goal 3: Mandatory Reporting

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Healthcare Associated Infection Prevention and
Control ProgramCampaign to Reduce Hospital
Acquired InfectionsGoal 3 Mandatory Reporting
Oversight

• Massachusetts Department of Public Health
• Betsy Lehman Center for Patient Safety and
  Medical Error Reduction

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GOAL 3Mandatory Reporting

• Regulations will require hospitals to report
  selected outcome and process measures to the
  National Healthcare Safety Network (NHSN).
• Reporting hospitals will provide three levels of
  access to the data
• DPH will have access to data that it will prepare
  for public reporting
• The Betsy Lehman Center will have access to data
  that are not quite ready for public reporting
• Individual hospitals will see their own data and
  aggregate data from other hospitals

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Mandatory Reporting (Continued)

• Publicly Reported Elements
• SSI for Hip and Knee Replacement
• BSI central venous catheters in ICUs (pathogens)
• Health care worker immunization rates influenza
  vaccine (pending)
• Betsy Lehman Elements
• - BSI for central venous catheter in ICUs
  (skin contaminants)
• - SSI for CABG
• - VAP head elevation MRSA point prevalence
• Elements for use in Internal QA only
• - BSI central venous catheter outside ICUs
  (pathogens
• skin contaminants
• - VAP rates

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GOAL 3Oversight

• Incorporate expert panel best practices into
  current regulations
• Add to current regulations provisions for
  educating patients about their role in preventing
  infections
• Task newly hired surveyors with helping hospitals
  implement recommended measures with role
  transitioning to
• Enforcement of new regulatory requirements