§ 23-17.17-6 - Health care quality steering committee.
SECTION 23-17.17-6
§ 23-17.17-6 Health care quality steeringcommittee. – (a) The director shall establish and serve as chairperson of a health carequality steering committee of no more than nineteen (19) members to advise inthe following matters:
(1) Determination of the comparable performance measures tobe reported on;
(2) Assessment of factors, including, but not limited to,factors related to incidents and events reported to the department pursuant to§ 23-17-40, contributing to the provision of quality health care andpatient safety;
(3) Selection of the patient satisfaction survey measures andinstrument;
(4) Methods and format for data collection;
(5) Program expansion and quality improvement initiatives;
(6) Format for the public quality performance measurementreport;
(7) Consideration of nursing-sensitive performance measuresto be reported on;
(8) Consideration of the relationship between human resourcesand quality, beginning with measurement and reporting for nursing staff;
(9) Consideration of measures associated withhospital-acquired infections with consultation of infections control expertsand with the hospital-acquired infections and prevention advisory committee asestablished herein:
(i) Hospital-acquired infections and prevention advisorycommittee:
(a) The director of the department of health as thechairperson of the steering committee shall appoint a permanent subcommitteecalled the hospital-acquired infections and prevention advisory committee.Membership shall include representatives from public and private hospitals,infection control professionals, director care nursing staff, physicians,epidemiologists with expertise in hospital-acquired infections, academicresearchers, consumer organizations, health insurers, health maintenanceorganizations, organized labor, and purchasers of health insurance, such asemployers. The advisory committee shall have a majority of members representingthe infection control community.
(b) The director of the department of health shall conduct anational and state specific public reporting format scan of hospital acquiredinfection public reporting to be completed and transmitted to the steeringcommittee and referred to the advisory committee by October 1, 2008.
(c) The advisory committee shall assist and advise thesteering committee and the department in the development of all aspects of thedepartment's methodology for collecting, analyzing, and disclosing theinformation collected under this act, including collection methods, formatting,and methods and means for release and dissemination.
(d) In developing the methodology for collecting andanalyzing the hospital infection data, the department, steering committee andadvisory committee shall consider existing methodologies and systems for datacollection, such as the centers for disease control's national healthcaresafety network, or its successor; provided, however, the department'sdiscretion to adopt a methodology shall not be limited or restricted to anyexisting methodology or system. The data collection and analysis methodologyshall be disclosed with the public report at the time of release.
(e) The department, steering committee and the advisorycommittee shall evaluate, on a regular basis, the quality and accuracy ofhospital information reported under this act and the data collection, analysis,and dissemination methodologies.
(ii) Hospital reports:
(a) Individual hospitals shall collect data onhospital-acquired infections for the specific clinical procedures determined bythe department by regulation, which may include the following generalcategories as further defined by the advisory committee:
(I) Surgical site infections;
(II) Ventilator-associated pneumonia;
(III) Central line-related bloodstream infections;
(IV) Urinary tract infections;
(V) Process of care measures, such as compliance with thesurgical infection prevention/surgical care improvement program (SIP/SCIP)parameters, prevention bundles for central line-associated bloodstreaminfections, prevention bundles for catheter-associated urinary tractinfections, hand hygiene compliance, compliance with isolation precautions; and
(VI) Other categories as recommended by the advisorycommittee.
(b) Beginning on or before April 1, 2009, hospitals shallsubmit quarterly reports on their hospital-acquired infection rates to thedepartment. Quarterly reports shall be submitted, in a format set forth inregulations adopted by the department. Data in quarterly reports must cover aperiod ending not earlier than one month prior to submission of the report.Annual reports shall be made available to the public at each hospital andthrough the department. The first annual report shall be due no later thanOctober 2010.
(c) The advisory committee shall recommend standardizedcriteria for reporting surgical site infection outcome data for qualityimprovement recommendations. This will include standards for post dischargesurveillance. The information shall be included in hospital's qualityimprovement and safety plan to reduce surgical site infection.
(d) If the hospital is a division or subsidiary of anotherentity that owns or operates other hospitals or related organizations, thequarterly report shall be for the specific division or subsidiary and not theother entity.
(iii) Department reports:
(a) The department shall annually submit to the legislature areport summarizing the hospital quarterly reports and shall publish the annualreport on its website. The first annual report shall be submitted and publishedno later than December 2010. Following the initial report, the department shallupdate the public information on a yearly basis after it has been reviewed bythe steering committee with advice from the hospital-acquired infections andprevention advisory committee.
(b) All reports of outcome measures issued by the departmentmay be risk-adjusted using NHSN methodology or other nationally acceptedmethodology, to adjust for the differences among hospitals as reviewed andrecommended by the hospital-acquired infections and prevention advisorycommittee.
(c) The annual report shall compare hospital-acquiredinfection data as recommended by the advisory committee, collected undersubsection (9)(b), for each individual hospital in the state. The department,in consultation with the advisory committee, shall make this comparison as easyto comprehend as possible. The report shall also include an executive summary,written in plain language that shall include, but not be limited to, adiscussion of findings, conclusions, and trends concerning the overall state ofhospital-acquired infections in the state, including a comparison to prioryears. The report may include policy recommendations, as appropriate.
(d) The department shall publicize the report and itsavailability as widely as practical to interested parties, including, but notlimited to, hospitals, providers, media organizations, health insurers, healthmaintenance organizations, purchasers of health insurance, organized labor,consumer or patient advocacy groups, and individual consumers. The annualreport shall be made available to any person upon request.
(e) No hospital report of department disclosure may containinformation identifying a patient, employee, or licensed health careprofessional in connection with a specific infection incident.
(10) Consideration of pressure ulcer occurrence; and
(11) Other related issues as requested by the director.
(b) The members of the health care quality performancesteering committee shall include one member of the house of representatives, tobe appointed by the speaker; one member of the senate, to be appointed by thepresident of the senate; the director or director's designee of the departmentof human services; the director or the director's designee of the department ofmental health, retardation, and hospitals; the director or the director'sdesignee of the department of elderly affairs; and thirteen (13) members to beappointed by the director of the department of health to include personsrepresenting Rhode Island licensed hospitals and other licensedfacilities/providers, the medical and nursing professions, the businesscommunity, organized labor, consumers, and health insurers and health plans andother parties committed to health care quality.