PETITION OF:

SECTION 1. Subsection (h) of Section 16L of Chapter 6A of the General Laws is hereby amended by inserting the following paragraph:—

(__). The council shall establish a state-wide database of all hospital acquired infection information, reported to the council pursuant to section 205A of Chapter 111, 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. 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 council’s web site. The council may 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.

Section 2. Subsection (h) of section 16L of Chapter 6A of the General Laws is hereby amended by inserting after the word “appropriate”, in the second sentence, the following words:- “, including, but not limited to, hospital acquired infection information”.

SECTION 3. Chapter 111 of the general laws, is hereby amended by inserting after section 205, the following new section:

Section 205A. Hospital acquired infection reporting.

Section 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 to the same setting.

Section 2. (a) Each 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. 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.

(b) No later than October 1, 2007, the department of public health shall promulgate regulations, 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 consult with the Health Care Quality and Cost Council prior to such promulgation, and may solicit and consider public comment.

(c) 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.

(d) Subsequent to the initial requirements identified in paragraph (c) of this subdivision the department shall, in consultation with the Health Care Quality and Cost Council, annually review and make a determination whether to require the tracking and reporting of other types of hospital acquired infections (for example, ventilator - associated pneumonias) that occur in hospitals and may also require the reporting of other standard quality measures and outcomes.

Section 3. Each hospital shall regularly report to the department, the Health Care Quality and Cost Council, and the Betsy Lehman Center for Patient Safety and Medical Error Reduction, in accordance with the guidelines established in section (b) above, the hospital infection data it has collected. The department 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 six months, and reports shall be submitted not more than sixty days after the close of the reporting period.

Section 4. (a) Subject to paragraph (c) of this subsection, on or before May first of each year the commissioner shall submit a report to the governor, the joint committee on health care financing, and the House and Senate committees on ways and means, and the Health Care Quality and Cost Council, which shall simultaneously be published in its entirety on the council'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 the Health Care Quality and Cost Council, and may consult with any 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 January 1, 2008, 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 July 1, 2008.

(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 the 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.

Information and records which are necessary to comply with the “pilot phase” of the statewide hospital acquired infection reporting system established pursuant to this section and which are necessary to the work product of medical peer review committees and agents of the department, including incident reports required to be furnished to the Board of Registration in Medicine or any information collected or compiled for the purpose of providing information for the development of the statewide hospital acquired infection reporting system shall be deemed to be proceedings, reports or records of a medical peer review committee for purposes of section two hundred and four of this chapter and may be so designated by the patient care assessment coordinator; provided, however, that such information and records so designated by the patient care assessment coordinator may be inspected, maintained and utilized by the Board of Registration in Medicine, including but not limited to its data repository and disciplinary unit. Such information and records inspected, maintained or utilized by the board of registration in medicine shall remain confidential, and not subject to subpoena, discovery or introduction into evidence, consistent with section two hundred and four; however, such records may not remain confidential if disclosed in an adjudicatory proceeding of the Board of Registration in Medicine, but the information and records shall be otherwise subject to the protections afforded by section two hundred and four. In no event, however, shall records of treatment maintained pursuant to section seventy of this chapter, or incident reports or records or information which are not necessary to comply with the development of the statewide hospital acquired infection reporting system pursuant to this section be deemed to be proceedings, reports or records of a medical peer review committee under this section; nor shall any person be prevented by the provisions of this section from testifying as to matters known by such person independent of the development of the statewide hospital acquired infection reporting system pursuant to this section.

(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 also issue a report to the governor, the joint committee on health care financing, and the House and Senate committees on ways and means, 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.

Section 5. 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.

Section 6. 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 therefore.

Section 7. Individual patient identifying information reported to the department under this section shall be subject to the provisions of section 70 of chapter 111. 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.

Section 8. Any licensed hospital in the Commonwealth, which does not comply with this section and the rules and regulation set forth by the department may have its license revoked or suspended by said department, be fined up to $1,000 per day per violation, or both.

SECTION 4. This act shall take effect upon its passage.