Section 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.
Source. 2006, 292:1, eff. July 1, 2007.