The Commonwealth of Massachusetts

Executive Office of Health and Human Services
Department of Public Health
Bureau of Health Care Safety and Quality
99 Chauncy Street, 2nd Floor, Boston, MA 02111
617-753-8000 

DEVAL L. PATRICK
GOVERNOR
TIMOTHY P. MURRAY
LIEUTENANT GOVERNOR
JUDYANN BIGBY, MD
SECRETARY
JOHN AUERBACH
COMMISSIONER	

CIRCULAR LETTER: DHCQ 09-01-506

TO:             CEO, Massachusetts Public Health Hospitals
       
FROM:       Paul Dreyer, Ph.D., Director 

DATE:        January 26, 2009

SUBJECT:  Public Health Hospitals Reporting Requirements

The purpose of this letter is to inform Massachusetts Public Health Hospitals  of a requirement for the collection and reporting of selected healthcare-associated infection (HAI) data.  The Executive Office of Health and Human Services, has requested that the statewide Infection Prevention and Control Program initially implemented for acute care hospitals now be extended to other hospital types including Massachusetts Public Health Hospitals.  The requirement includes the following:

	1. No later than February 17, 2009 Public Health Hospitals shall register with the Center 	    for Disease Control and Prevention’s (CDC) National Health Safety Network (NHSN).
	2. No later than March 1, 2008, Public Health care hospitals shall nominate a facility 	  
               administrator and subsequently grant access rights on the NHSN system to DPH and 
               BLC.  These rights give DPH and BLC access to certain specific healthcare-   
               associated infection measures entered into NHSN and rights to hospital-specific 
               reports generated by NHSN.
	3. No later than April 1, 2009, each hospital must collect and submit the specified HAI  
               data elements to NHSN as outlined in the summary (see Attachment 1).

The Executive Office’s request continues to fulfill a mandate of the Healthcare Reform Act passed in 2006 that required DPH to create an Infection Prevention and Control Program, of which reporting is a key element. Public reporting is becoming increasingly important in assuring transparency and accountability.  The first priority was to implement the Program in acute care hospitals.

The data elements being requested are revised from the recommendations made by an Expert Panel for acute care hospitals.  BLC and DPH representatives met with Public Hospitals Infection Preventionists to develop an implementation strategy and to determine measures which are applicable to each of the four Public Health Hospitals.  See Appendix 1 for a list of the data elements.

If you have any questions, please contact 
Roberta Bernstein at roberta.bernstein@state.ma.us, 617-753-8062 
or Eileen McHale at eileen.mchale@state.ma.us, 617-624-5723.

Thank you for your cooperation.

ATTACHEMENT 1
DATA ELEMENTS

HOSPITAL	CVC-BSI true path
ICU	CVC-BSI skin cont
ICU	CVC-BSI
outside
ICU	VAP	C-difficile
Incidence	Influenza Vac
employees	
Lemuel Shattuck
	√	√	√		√	√	
Massachusetts Hospital
School					√	√	
Tewksbury			√		√	√	
Western Massachusetts			√		√	√