2010 New York Code
PBH - Public Health
Article 28 - (2800 - 2822) HOSPITALS
2819 - Hospital acquired infection reporting.

§  2819. Hospital acquired infection reporting. 1. For the purposes of
  this section, "hospital acquired infection" shall mean any localized  or
  systemic patient condition that:
    (a)  resulted  from  the presence of an infectious agent or agents, or
  its toxin  or  toxins  as  determined  by  clinical  examination  or  by
  laboratory testing; and
    (b) was not found to be present or incubating at the time of admission
  unless the infection was related to a previous admission.
    2.  (a)  Each  general  hospital  shall  maintain a program capable of
  identifying and tracking hospital acquired infections for the purpose of
  public reporting under this section and quality improvement.
    (b) Such programs shall have the capacity to  identify  the  following
  elements:  the  specific  infectious  agents  or toxins and site of each
  infection; the clinical department or unit within the facility where the
  patient first became infected;  and  the  patient's  diagnoses  and  any
  relevant  specific  surgical,  medical or diagnostic procedure performed
  during the current admission.
    (c) The department shall establish guidelines, definitions,  criteria,
  standards and coding for hospital identification, tracking and reporting
  of  hospital  acquired  infections  which  shall  be consistent with the
  recommendations of recognized centers of expertise in the identification
  and prevention  of  hospital  acquired  infections  including,  but  not
  limited  to  the  National Health Care Safety Network of the Centers for
  Disease Control and Prevention or its successor.  The  department  shall
  solicit and consider public comment prior to such establishment.
    (d)  Hospitals  shall  be  initially  required  to identify, track and
  report hospital acquired infections that occur in critical care units to
  include surgical wound infections and central line  related  bloodstream
  infections.
    (e) For hospital acquired infections for which the department requires
  tracking  and reporting as permitted in this section, hospitals shall be
  required to report a suspected or confirmed hospital-acquired  infection
  associated   with   another   hospital   to  the  originating  hospital.
  Documentation of reporting should be maintained for  a  minimum  of  six
  years.
    (f) Subsequent to the initial requirements identified in paragraph (d)
  of  this  subdivision the department may, from time to time, require the
  tracking and reporting of other types of  hospital  acquired  infections
  (for   example,  ventilator  -  associated  pneumonias)  that  occur  in
  hospitals in consultation with technical advisors who are regionally  or
  nationally-recognized  experts  in  the  prevention,  identification and
  control of hospital acquired  infection  and  the  public  reporting  of
  performance data.
    3. Each hospital shall regularly report to the department the hospital
  infection  data  it  has  collected. The department shall establish data
  collection and analytical methodologies that meet accepted standards for
  validity and reliability. The frequency of reporting shall  be  monthly,
  and  reports shall be submitted not more than sixty days after the close
  of the reporting period.
    4. The commissioner shall  establish  a  state-wide  database  of  all
  reported  hospital  acquired  infection  information  for the purpose of
  supporting quality  improvement  and  infection  control  activities  in
  hospitals. The database shall be organized so that consumers, hospitals,
  healthcare  professionals,  purchasers and payers may compare individual
  hospital experience with that of other individual hospitals as  well  as
  regional and state-wide averages and, where available, national data.
    5.  (a)  Subject  to  paragraph  (c) of this subdivision, on or before
  September first of each year the commissioner shall submit a  report  to

the   governor  and  the  legislature,  which  shall  simultaneously  be
  published in its entirety on the department's web site,  that  includes,
  but  is  not  limited to, hospital acquired infection rates adjusted for
  the  potential  differences in risk factors for each reporting hospital,
  an analysis of trends in the prevention and control of hospital acquired
  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 hospital acquired infection and infectious disease  in  order
  to  develop  the adjustment for potential differences in risk factors to
  be used for public reporting.
    (c)(i) No later than July first,  two  thousand  six,  the  department
  shall  establish  a hospital acquired infection reporting system capable
  of  receiving  electronically  transmitted   reports   from   hospitals.
  Hospitals  shall  begin  to  submit  such  reports  as  directed  by the
  commissioner but in no case  later  than  January  first,  two  thousand
  seven.
    (ii)  The  first  year  of data submission under this section shall be
  considered  the  "pilot  phase"  of  the  statewide  hospital   acquired
  infection reporting system. The purpose of the pilot phase is to ensure,
  by various means, including any audit process referred to in subdivision
  seven  of  this  section,  the  completeness  and  accuracy  of hospital
  acquired infection reporting by hospitals. For data reported during  the
  pilot  phase,  hospital identifiers shall be encrypted by the department
  in any and all  public  databases  and  reports.  The  department  shall
  provide  each  hospital with an encryption key for that hospital only to
  permit  access  to  its  own  performance  data  for  internal   quality
  improvement purposes.
    (iii)  No  later  than one hundred eighty days after the conclusion of
  the pilot phase, the  department  shall  issue  a  report  to  hospitals
  assessing  the overall accuracy of the data submitted in the pilot phase
  and provide guidance for improving the  accuracy  of  hospital  acquired
  infection reporting. The department shall issue a report to the governor
  and  the  legislature assessing the overall completeness and accuracy of
  the data  submitted  by  hospitals  during  the  pilot  phase  and  make
  recommendations for the improvement or modification of hospital acquired
  infection  data  reporting  based  on  the  pilot phase as well as share
  lessons learned  in  prevention  of  hospital  acquired  infections.  No
  hospital  identifiable data shall be included in the pilot phase report,
  but aggregate or otherwise de-identified data may be included.
    (iv) After the pilot phase is completed, all data submitted under this
  section and  compiled  in  the  statewide  hospital  acquired  infection
  database  established  herein  and  all public reports derived therefrom
  shall include hospital identifiers.
    6. Subject to subdivision five of this section, a summary table, in  a
  format  designed to be easily understood by lay consumers, that includes
  individual facility  hospital  acquired  infection  rates  adjusted  for
  potential  differences  in  risk  factors  and comparisons with regional
  and/or state averages shall be developed and posted on the  department's
  web  site.  The  commissioner  shall  consult  with consumer and patient
  advocates and representatives of reporting facilities for the purpose of
  ensuring that such summary table report format is easily  understandable
  by  the public, and clearly and accurately portrays comparative hospital

performance  in  the  prevention  and  control  of   hospital   acquired
  infections.
    7.  To  assure  the  accuracy  of  the self-reported hospital acquired
  infection data and to assure that public reporting fairly reflects  what
  actually is occurring in each hospital, the department shall develop and
  implement an audit process.
    8.  For  the  purpose  of  ensuring  that hospitals have the resources
  needed for ongoing staff education and  training  in  hospital  acquired
  infection prevention and control, the department may make such grants to
  hospitals within amounts appropriated therefor.
    9.   Individual   patient  identifying  information  reported  to  the
  department under this section shall  be  subject  to  paragraph  (j)  of
  subdivision  one of section two hundred six of this chapter. Regulations
  under this section shall include standards to assure the  protection  of
  patient  privacy  in  data collected and released under this section and
  standards for the publication and release of data  reported  under  this
  section.