Healthcare Associated Infection Prevention and Control Program: Campaign to Reduce Hospital Acquired Infections Goal 3: Mandatory Reporting & Oversight Massachusetts Department of Public Health Betsy Lehman Center for Patient Safety and Medical Error Reduction

GOAL 3 Mandatory 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

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

GOAL 3 Oversight 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