§ 2819. Hospital acquired infection reporting. 1. For the purposes of this section, "hospital acquired infection" shall mean any localized or systemic patient condition that:(a) resulted from the presence of an infectious agent or agents, or its toxin or toxins as determined by clinical examination or by laboratory testing; and
(b) was not found to be present or incubating at the time of admission unless the infection was related to a previous admission. 2. (a) Each general hospital shall maintain a program capable of identifying and tracking hospital acquired infections for the purpose of public reporting under this section and quality improvement.
(b) Such programs shall have the capacity to identify the following elements: the specific infectious agents or toxins and site of each infection; the clinical department or unit within the facility where the patient first became infected; and the patient's diagnoses and any relevant specific surgical, medical or diagnostic procedure performed during the current admission.
(c) The department shall establish guidelines, definitions, criteria, standards and coding for hospital identification, tracking and reporting of hospital acquired infections which shall be consistent with the recommendations of recognized centers of expertise in the identification and prevention of hospital acquired infections including, but not limited to the National Health Care Safety Network of the Centers for Disease Control and Prevention or its successor. The department shall solicit and consider public comment prior to such establishment.
(d) Hospitals shall be initially required to identify, track and report hospital acquired infections that occur in critical care units to include surgical wound infections and central line related bloodstream infections.
(e) For hospital acquired infections for which the department requires tracking and reporting as permitted in this section, hospitals shall be required to report a suspected or confirmed hospital-acquired infection associated with another hospital to the originating hospital. Documentation of reporting should be maintained for a minimum of six years.
(f) Subsequent to the initial requirements identified in paragraph (d) of this subdivision the department may, from time to time, require the tracking and reporting of other types of hospital acquired infections (for example, ventilator - associated pneumonias) that occur in hospitals in consultation with technical advisors who are regionally or nationally-recognized experts in the prevention, identification and control of hospital acquired infection and the public reporting of performance data. 3. Each hospital shall regularly report to the department the hospital infection data it has collected. The department shall establish data collection and analytical methodologies that meet accepted standards for validity and reliability. The frequency of reporting shall be monthly, and reports shall be submitted not more than sixty days after the close of the reporting period. 4. The commissioner shall establish a state-wide database of all reported hospital acquired infection information for the purpose of supporting quality improvement and infection control activities in hospitals. The database shall be organized so that consumers, hospitals, healthcare professionals, purchasers and payers may compare individual hospital experience with that of other individual hospitals as well as regional and state-wide averages and, where available, national data. 5. (a) Subject to paragraph (c) of this subdivision, on or before September first of each year the commissioner shall submit a report to the governor and the legislature, which shall simultaneously be published in its entirety on the department's web site, that includes, but is not limited to, hospital acquired infection rates adjusted for the potential differences in risk factors for each reporting hospital, an analysis of trends in the prevention and control of hospital acquired infection rates in hospitals across the state, regional and, if available, national comparisons for the purpose of comparing individual hospital performance, and a narrative describing lessons for safety and quality improvement that can be learned from leadership hospitals and programs.
(b) The commissioner shall consult with technical advisors who have regionally or nationally acknowledged expertise in the prevention and control of hospital acquired infection and infectious disease in order to develop the adjustment for potential differences in risk factors to be used for public reporting.
(c)(i) No later than July first, two thousand six, the department shall establish a hospital acquired infection reporting system capable of receiving electronically transmitted reports from hospitals. Hospitals shall begin to submit such reports as directed by the commissioner but in no case later than January first, two thousand seven.
(ii) The first year of data submission under this section shall be considered the "pilot phase" of the statewide hospital acquired infection reporting system. The purpose of the pilot phase is to ensure, by various means, including any audit process referred to in subdivision seven of this section, the completeness and accuracy of hospital acquired infection reporting by hospitals. For data reported during the pilot phase, hospital identifiers shall be encrypted by the department in any and all public databases and reports. The department shall provide each hospital with an encryption key for that hospital only to permit access to its own performance data for internal quality improvement purposes.
(iii) No later than one hundred eighty days after the conclusion of the pilot phase, the department shall issue a report to hospitals assessing the overall accuracy of the data submitted in the pilot phase and provide guidance for improving the accuracy of hospital acquired infection reporting. The department shall issue a report to the governor and the legislature assessing the overall completeness and accuracy of the data submitted by hospitals during the pilot phase and make recommendations for the improvement or modification of hospital acquired infection data reporting based on the pilot phase as well as share lessons learned in prevention of hospital acquired infections. No hospital identifiable data shall be included in the pilot phase report, but aggregate or otherwise de-identified data may be included.
(iv) After the pilot phase is completed, all data submitted under this section and compiled in the statewide hospital acquired infection database established herein and all public reports derived therefrom shall include hospital identifiers. 6. Subject to subdivision five of this section, a summary table, in a format designed to be easily understood by lay consumers, that includes individual facility hospital acquired infection rates adjusted for potential differences in risk factors and comparisons with regional and/or state averages shall be developed and posted on the department's web site. The commissioner shall consult with consumer and patient advocates and representatives of reporting facilities for the purpose of ensuring that such summary table report format is easily understandable by the public, and clearly and accurately portrays comparative hospital performance in the prevention and control of hospital acquired infections. 7. To assure the accuracy of the self-reported hospital acquired infection data and to assure that public reporting fairly reflects what actually is occurring in each hospital, the department shall develop and implement an audit process. 8. For the purpose of ensuring that hospitals have the resources needed for ongoing staff education and training in hospital acquired infection prevention and control, the department may make such grants to hospitals within amounts appropriated therefor. 9. Individual patient identifying information reported to the department under this section shall be subject to paragraph (j) of subdivision one of section two hundred six of this chapter. Regulations under this section shall include standards to assure the protection of patient privacy in data collected and released under this section and standards for the publication and release of data reported under this section.
