CHAPTER 292
HB 1741-FN – FINAL VERSION
07Mar2006… 1043h
04/20/06 1793s
24May2006… 2330eba
2006 SESSION
01/09
HOUSE BILL 1741-FN
AN ACT relative to reporting requirements concerning infections in hospitals.
SPONSORS: Rep. Pepino, Hills 11; Rep. Lund, Rock 5; Rep. Powers, Rock 16; Rep. Hess, Merr 9; Rep. Rogers Johnson, Rock 13; Sen. Boyce, Dist 4; Sen. Gallus, Dist 1
COMMITTEE: Health, Human Services and Elderly Affairs
AMENDED ANALYSIS
This bill requires hospitals to report on infections to the department of health and human services. Under this bill, the commissioner of the department of health and human services is required to establish a statewide database for the purposes of public reporting.
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Explanation: Matter added to current law appears in bold italics.
Matter removed from current law appears [in brackets and struckthrough.]
Matter which is either (a) all new or (b) repealed and reenacted appears in regular type.
07Mar2006… 1043h
04/20/06 1793s
24May2006… 2330eba
06-2088
01/09
STATE OF NEW HAMPSHIRE
In the Year of Our Lord Two Thousand Six
AN ACT relative to reporting requirements concerning infections in hospitals.
Be it Enacted by the Senate and House of Representatives in General Court convened:
292:1 New Subdivision; Reporting of Hospital Infections. Amend RSA 151 by inserting after section 31 the following new subdivision:
Reporting of Hospital Infections
151:32 Definitions. In this subdivision:
I. “Commissioner” means the commissioner of the department of health and human services.
II. “Department” means the department of health and human services.
III. “Infection” means any localized or systemic patient condition that resulted from the presence of an infectious agent or agents, or its toxin or toxins as determined by clinical examination.
151:33 Hospitals Required to Report.
I. Any hospital licensed pursuant to this chapter shall maintain a program capable of identifying and tracking infections for the purpose of reporting under this section. Such program shall have the capacity to identify the following elements:
(a) The specific infectious agents or toxins and site of each infection;
(b) The clinical department or unit within the facility where the patient first became infected or was first diagnosed; and
(c) The patient’s diagnoses at time of admission and any relevant specific surgical, medical, or diagnostic procedure performed during the current admission.
II.(a) Hospitals shall initially identify, track, and report infections to include:
(1) Central line related bloodstream infections;
(2) Ventilator associated pneumonia; and
(3) Surgical wound infections.
(b) Hospitals shall also initially identify, track, and report process measures including:
(1) Adherence rates of central line insertion practices;
(2) Surgical antimicrobial prophylaxis; and
(3) Coverage rates of influenza vaccination for health care personnel and patients/residents.
III. Subsequent to the initial requirements identified in paragraph II, the department shall, from time to time, require the tracking and reporting of other types of infections, including urinary tract infections when reporting protocols are identified by the department, that occur in hospitals in consultation with technical advisors who are regionally or nationally-recognized experts in the prevention, identification, and control of hospital infections and the reporting of performance data. The department shall make progress reports every 6 months to the oversight committee on health and human services, established in RSA 126-A:13, concerning the development of reporting protocols for tracking of urinary tract infections and shall notify the oversight committee on health and human services when the tracking of urinary tract infections has commenced, which shall be on or before July 1, 2007.
IV. The department shall establish guidelines, definitions, criteria, standards, and coding for hospital identification, tracking, and reporting of infections which shall be consistent with the recommendations of recognized centers of expertise in the identification and prevention of infections including, but not limited to the National Health Care Safety Network and the Healthcare Infection Control Practices Advisory Committee of the Centers for Disease Control and Prevention or its successor, the Joint Commission on the Accreditation of Healthcare Organizations, the Centers for Medicare and Medicaid Services, the Hospital Quality Alliance, the National Quality Forum, and the New Hampshire health care quality assurance commission under RSA 151-G.
V. Each hospital shall regularly report to the department the hospital infection data it has collected. The commissioner shall establish data collection and analytical methodologies that meet accepted standards for validity and reliability. In no case shall the frequency of reporting be required to be more frequently than once every 3 months, and reports shall be submitted not more than 60 days after the close of the reporting period.
151:34 Statewide Database Required.
I. The department shall establish a statewide database of all reported infection information for the purpose of monitoring quality improvement and infection control activities in hospitals. The database shall be organized so that consumers, hospitals, health care professionals, purchasers, and payers may compare individual hospital experience with that of other individual hospitals as well as regional and statewide averages and, where available, national data.
II.(a) Subject to subparagraph (c), on or before June 1 of each year, provided that the data collection and analytical methodologies meet accepted standards for validity and reliability, the commissioner shall report on the department’s web site infection rates both exclusive and inclusive of adjustments for potential differences in risk factors for each reporting hospital, an analysis of trends in the prevention and control of 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 infections and infectious diseases in order to develop the adjustment for potential differences in risk factors to be used for public reporting.
(c)(1) Within 180 days of the effective date of this section, the department shall establish an infection reporting system capable of receiving electronically transmitted reports from hospitals. Whether or not the department has established such a reporting system, hospitals shall begin to submit reports as required by this section within 6 months of the effective date of this section.
(2) The first 6 months of data submission under this section shall be considered the “pilot phase” of the statewide infection reporting system. The purpose of the pilot phase is to ensure, by various means, the completeness and accuracy of infection reporting by hospitals.
(3) No later than 60 days after the conclusion of the pilot phase, the commissioner shall issue a report to hospitals and to the oversight committee on health and human services assessing the overall accuracy of the data submitted in the pilot phase and provide guidance for improving the accuracy of infection reporting.
(4) After the pilot phase is completed, all data submitted under this section and compiled in the statewide infection database established under this section and all public reports derived therefrom shall include hospital identifiers.
(5) The first public report required pursuant to subparagraph (4) shall be made not later than 7 months after the completion date of the pilot phase.
III. To assure the accuracy of the self-reported hospital infection data and to assure that public reporting fairly reflects what actually is occurring in each hospital, the department shall make a quarterly report to the oversight committee on health and human services on its infection rate data. If the commissioner is not satisfied with the overall accuracy of the data submitted, the commissioner shall validate the results and the methodology used to collect and analyze the data. The commissioner shall notify the oversight committee on health and human services relative to the validation of such data. After notification to the oversight committee, the commissioner may release such information to the public. If, however, the commissioner concludes that he or she is unable to adequately validate the data, the commissioner shall notify the oversight committee on health and human services of that fact and the reasons therefor and, in that case, the commissioner shall not be required to include hospital identifiers in the information released to the public.
151:35 Limitation. No hospitals shall provide, and the department shall not collect, any data that identifies an individual patient, including but not limited to name, street address, city or town, telephone number, and social security number.
292:2 New Subparagraph; New Hampshire Health Care Quality Commission; Member Added. Amend RSA 151-G:1, II by inserting after subparagraph (c) the following new subparagraph:
(d) The state epidemiologist, department of health and human services.
292:3 Effective Date. This act shall take effect July 1, 2007.
Approved: June 15, 2006
Effective: July 1, 2007