CHAPTER 77
HB 1548-FN – FINAL VERSION
14Apr2010… 1243eba
2010 SESSION
01/09
HOUSE BILL 1548-FN
AN ACT relative to ambulatory surgical facilities under the law requiring reporting of hospital infections.
SPONSORS: Rep. Rosenwald, Hills 22; Rep. Batula, Hills 19; Rep. Wendelboe, Belk 1; Rep. Millham, Belk 5; Rep. Irwin, Hills 3; Sen. Sgambati, Dist 4; Sen. Fuller Clark, Dist 24
COMMITTEE: Health, Human Services and Elderly Affairs
This bill includes ambulatory surgical facilities in the law requiring hospitals to report infections.
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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Matter which is either (a) all new or (b) repealed and reenacted appears in regular type.
14Apr2010… 1243eba
10-2465
01/09
STATE OF NEW HAMPSHIRE
In the Year of Our Lord Two Thousand Ten
AN ACT relative to ambulatory surgical facilities under the law requiring reporting of hospital infections.
Be it Enacted by the Senate and House of Representatives in General Court convened:
77:1 Reporting of Infections; Ambulatory Surgical Facilities Added. Amend the subdivision heading preceding RSA 151:32 to read as follows:
Reporting of Hospital and Ambulatory Surgical Facility Infections
77:2 Reporting of Infections; Ambulatory Surgical Facilities Added. Amend the section heading of RSA 151:33 to read as follows:
151:33 Hospitals and Ambulatory Surgical Facilities Required to Report.
77:3 New Paragraph; Ambulatory Surgical Facilities Added. Amend RSA 151:33 by inserting after paragraph II the following new paragraph:
II-a. Any ambulatory surgical facility licensed pursuant to this chapter shall maintain a program capable of identifying and tracing infections for the purpose of reporting under this section. Such program shall have the capacity to identify the following elements:
(a) Surgical wound infections.
(b) Surgical antimicrobial prophylaxis.
(c) Coverage rates of influenza vaccination for health care personnel.
77:4 Reporting of Hospital Infections; Date Deleted; Ambulatory Surgical Facilities Added. Amend RSA 151:33, III-V to read as follows:
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 and ambulatory surgical facilities 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 commissioner of the department shall adopt rules, pursuant to RSA 541-A, for hospital and ambulatory surgical facility 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 and ambulatory surgical facility shall regularly report to the department hospital and ambulatory surgical facility acquired infections and the infection data it has collected. Such reporting shall be done in the manner directed by the department in accordance with rules adopted pursuant to RSA 541-A. 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.
77:5 Reporting of Hospital and Ambulatory Surgical Facility Infections; Database. Amend RSA 151:34 and RSA 151:35 to read as follows:
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 and ambulatory surgical facilities. The database shall be organized so that consumers, hospitals, ambulatory surgical facilities, health care professionals, purchasers, and payers may compare individual hospital and ambulatory surgical facility experience with that of other individual hospitals and ambulatory surgical facilities 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 and ambulatory surgical facility, an analysis of trends in the prevention and control of infection rates in hospitals and ambulatory surgical facilities across the state, regional and, if available, national comparisons for the purpose of comparing individual hospital and ambulatory surgical facility 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 and ambulatory surgical facilities. Whether or not the department has established such a reporting system, hospitals and ambulatory surgical facilities 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 and ambulatory surgical facility 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 and ambulatory surgical facility infection data and to assure that public reporting fairly reflects what actually is occurring in each hospital and ambulatory surgical facility, 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 and ambulatory surgical facility identifiers in the information released to the public.
151:35 Limitation. No hospitals or ambulatory surgical facilities 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.
77:6 Effective Date. This act shall take effect July 1, 2011.
Approved: May 19, 2010
Effective Date: July 1, 2011