REPORT TO THE 26TH LEGISLATURE STATE OF HAWAII 2012

Size: px
Start display at page:

Download "REPORT TO THE 26TH LEGISLATURE STATE OF HAWAII 2012"

Transcription

1 REPORT TO THE 26TH LEGISLATURE STATE OF HAWAII 2012 PURSUANT TO ACT 177(11), SESSION LAWS OF HAWAII, 2011, RELATING TO HEALTHCARE ASSOCIATED INFECTIONS REPORTING Prepared by: State of Hawaii Department of Health December 2011

2 BACKGROUND Hawaii Statute Requirements for Healthcare-Associated Infections In July 2011, Governor Abercrombie signed Act 177 into law, allowing the Hawaii Department of Health (DOH) access to data submitted to the National Healthcare Safety Network (NHSN) for facilities under the Centers for Medicare and Medicaid Services (CMS) regulations and providing protection from disclosure for healthcare-associated infection (HAI) data provided to DOH under these reporting requirements. This will allow DOH to develop statewide surveillance for selected HAI. Specifically, DOH will be able to utilize nationally accepted standards to establish baseline HAI rates for facilities, monitor trends in HAI rates over time, and compare Hawaii HAI rates with national data. Subject to continuing funding from CDC, DOH may also use NHSN data to evaluate HAI reduction/elimination efforts and assist facilities in identifying related issues requiring additional attention. Beginning in June 2013, DOH will prepare a public report using methodology established by NHSN to report HAI rates for facilities in Hawaii. Pursuant to Section 3 of Act 177, this report provides an update regarding the progress toward HAI reporting in Hawaii. National Reporting of Healthcare-Associated Infections HAIs are infections that patients acquire during the course of receiving healthcare treatment for other conditions. These infections can be devastating and even deadly. Although these infections are largely preventable, they create a considerable burden in terms of impact on human life as well as financial costs to the healthcare system. They are among the top 10 leading causes of death in the United States and accounted for an estimated 1.7 million infections and 99,000 associated deaths in The Centers for Disease Control and Prevention (CDC) also estimates that HAIs result in more than $17 billion toward healthcare costs each year. 2 According to estimates from CDC, approximately 1 out of every 20 hospitalized patients will contract an HAI. CDC has developed NHSN, a web-based reporting system for data relating to HAI infections and best practices in HAI prevention. NHSN is now recognized as the gold standard for HAI surveillance. NHSN provides facilities across the country access to standardized HAI surveillance methodology and a system for monitoring compliance with evidence-based practices in infection control. To standardize national HAI reporting, CMS adopted NHSN as the surveillance system for HAI prevention and control for facilities participating in the CMS HAI Inpatient Prospective Payment System (IPPS) Hospital Inpatient Quality Reporting Program, formerly known as Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU). More than 4,900 healthcare facilities currently use NHSN as the foundation of their HAI elimination strategies. CMS will 1 Klevens RM, Edwards J, Richards C, Horan T, Gaynes R, Pollock D, Cardo D. Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, Public Health Reports 2007; 122: Bhutta A, Gilliam C, Honeycutt M, et al. Reduction of bloodstream infections associated with catheters in paediatric intensive care unit: stepwise approach. BMJ : Page 2 of 8

3 continue to develop reporting requirements for other facility types in the future (e.g. long-term care facilities, out-patient surgery, and out-patient cancer treatment faculties). Current CMS Reporting Requirements CMS has established reporting requirements through These rules apply to hospitals participating in the Hospital Inpatient Quality Reporting Program and the End Stage Renal Disease (ESRD) Quality Incentive Program. As agreement on technical details is reached among experts in HAI surveillance, additional reporting requirements will be added. The current HAI reporting schedule is listed below: In 2011, acute care hospitals began reporting central line-associated bloodstream infection (CLABSI) data from adult, pediatric, and neonatal intensive care units to NHSN and shared these with CMS. In January 2012, acute care hospitals will begin submitting catheter-associated urinary tract infection (CAUTI) data from adult and pediatric intensive care units and surgical site infection (SSI) data from inpatient colon and abdominal hysterectomy procedures to NHSN. In January 2012, outpatient dialysis facilities will begin reporting data on use of intravenous antimicrobial agents, positive blood cultures, and signs of infections at vascular access. In October 2012, long term acute care hospitals will begin reporting CLABSI and CAUTI. In October 2012, inpatient rehabilitation facilities will begin reporting CAUTI. In January 2013, acute care hospitals will begin reporting Clostridium difficile and methicillin-resistant Staphylococcus aureus (MRSA). These conditions were selected because they have evidence-based prevention strategies that have documented guidelines for prevention and control. Other conditions will be added in the future as national consensus is reached on the best practice guidelines and on the reliability of NHSN for calculating HAI measures. Recommendations for CLABSI can be found at the CDC website: Recommendations for prevention and control of CAUTI can be found at Recommendations for prevention and control of SSI can be found at Page 3 of 8

4 HAWAII PROGRESS ON NHSN REPORTING Seventeen acute care hospitals are currently enrolled and submitting data to NHSN. Not all of these facilities are reporting under the CMS regulations; some use NHSN voluntarily for HAI surveillance and monitoring prevention practices. Hawaii Facilities Enrolled in NHSN as of November 7, 2011 Castle Medical Center Hilo Medical Center Hawaii Medical Center West Hawaii Medical Center East Kaiser Permanente Medical Center Kapiolani Medical Center for Women and Children Kona Community Hospital Kuakini Medical Center Maui Memorial Medical Center North Hawaii Community Hospital Pali Momi Medical Center Shriners Hospitals for Children Straub Clinic & Hospital The Queens Medical Center Tripler Army Medical Center Wahiawa General Hospital Wilcox Memorial Hospital Location Kailua Hilo Ewa Beach Kealakekua Wailuku Kamuela Aiea Wahiawa Lihue Page 4 of 8

5 Hawaii Hospitals Currently Reporting CLABSI Data to NHSN Fifteen acute care hospitals are currently enrolled and submitting CLABSI data to NHSN. Two hospitals are not subject to the rule at this time. Shriners Hospital does not have intensive care units (ICUs), and Tripler, a U.S. Department of Defense facility, is not subject to CMS rules. Hawaii Facilities Currently Submitting CLABSI 3 data Castle Medical Center Hilo Medical Center Hawaii Medical Center East Hawaii Medical Center West Kaiser Permanente Medical Center Kapiolani Medical Center for Women and Children Kona Community Hospital Kuakini Medical Center Maui Memorial Medical Center North Hawaii Community Hospital Pali Momi Medical Center Shriners Hospitals for Children Straub Clinic & Hospital The Queens Medical Center Tripler Army Medical Center Wahiawa General Hospital Wilcox Memorial Hospital Submitting CLABSI Data 3 CMS rule relates to data on central line-associated bloodstream infections (CLABSI) from adult, pediatric, and neonatal ICUs. Page 5 of 8

6 Hawaii Hospitals Preparing to Report CAUTI Data to NHSN Fifteen acute care hospitals are preparing to submit CAUTI data to NHSN in Two hospitals are not subject to the rule at this time. Shriners Hospital does not have ICUs, and Tripler is not subject to CMS rules. Hawaii Facilities Prepared to Submit CAUTI 4 Data, Effective January 2012 Castle Medical Center Hilo Medical Center Hawaii Medical Center East Hawaii Medical Center West Kaiser Permanente Medical Center Kapiolani Medical Center for Women and Children Kona Community Hospital Kuakini Medical Center Maui Memorial Medical Center North Hawaii Community Hospital Pali Momi Medical Center Shriners Hospitals for Children Straub Clinic & Hospital The Queens Medical Center Tripler Army Medical Center Wahiawa General Hospital Wilcox Memorial Hospital Prepared to Submit Data 4 CMS rule relates to data on catheter-associated urinary tract infections (CAUTI) from adult and pediatric ICUs. Page 6 of 8

7 Hawaii Hospitals Preparing to Report SSI Data to NHSN Fifteen acute care hospitals are preparing to submit SSI data to NHSN in Two hospitals are not subject to the rule at this time. Shriners Hospital does not perform colon surgeries or abdominal hysterectomies. Tripler is not subject to CMS rules. Hawaii Facilities Prepared to Submit SSI 5 Data, Effective January 2012 Castle Medical Center Hilo Medical Center Hawaii Medical Center East Hawaii Medical Center West Kaiser Permanente Medical Center Kapiolani Medical Center for Women and Children Kona Community Hospital Kuakini Medical Center Maui Memorial Medical Center North Hawaii Community Hospital Pali Momi Medical Center Shriners Hospitals for Children Straub Clinic & Hospital The Queens Medical Center Tripler Army Medical Center Wahiawa General Hospital Wilcox Memorial Hospital Prepared to Submit Data 5 CMS rule relates to data on surgical site infections (SSI) for colon surgeries and abdominal hysterectomies. Page 7 of 8

8 Hawaii Out-Patient Dialysis Centers Preparing to Report Data to NHSN All out-patient dialysis centers in Hawaii are managed by one of two companies, Liberty Dialysis Hawaii, LLC or Fresenius Medical Care. Both organizations are preparing to submit data to NHSN in Out-patient dialysis centers will report data on positive blood cultures, use of antimicrobial agents, and signs of infections at vascular access. Hawaii Facilities Prepared to Submit Outpatient Dialysis Data, Effective January 2012 Liberty Dialysis Hawaii LLC Fresenius Medical Care Preparing to Submit Data Page 8 of 8

State HAI Template Utah. 1. Develop or Enhance HAI program infrastructure

State HAI Template Utah. 1. Develop or Enhance HAI program infrastructure State HAI Template Utah 1. Develop or Enhance HAI program infrastructure Successful HAI prevention requires close integration and collaboration with state and local infection prevention activities and

More information

Healthcare-associated Infection Flow

Healthcare-associated Infection Flow submitted to the HAI to the Infection present or incubating on admission (DE225) (Q1) Q1 = b or c DE225= A1035 or UNK Infection control person (DE231) (Q3) Q1 = a DE225 = A1032 page 2 Description of infection

More information

New Jersey State Department of Health and Senior Services Healthcare-Associated Infections Plan 2010

New Jersey State Department of Health and Senior Services Healthcare-Associated Infections Plan 2010 New Jersey State Department of Health and Senior Services Healthcare-Associated Infections Plan Introduction The State of New Jersey has been proactive in creating programs to address the growing public

More information

Principal Source of Payment

Principal Source of Payment Principal Source of Payment Principal Source of Payment Length: 2 Expected principal source of payment for this hospital admission. 01 = Medicare (Fee For Service Plans Only) 02 = Medicaid/QUEST Expanded

More information

National Action Plan to Prevent Health Care-Associated Infections: ROAD MAP TO ELIMINATION

National Action Plan to Prevent Health Care-Associated Infections: ROAD MAP TO ELIMINATION National Action Plan to Prevent Health Care-Associated Infections: ROAD MAP TO ELIMINATION 2013 National Action Plan to Prevent Health Care-Associated Infections: Road Map to Elimination April 2013 http://www.hhs.gov/ash/initiatives/hai/index.html

More information

TECHNICAL REPORT FOR HEALTHCARE-ASSOCIATED INFECTIONS. New Jersey Department of Health Health Care Quality Assessment

TECHNICAL REPORT FOR HEALTHCARE-ASSOCIATED INFECTIONS. New Jersey Department of Health Health Care Quality Assessment TECHNICAL REPORT FOR HEALTHCARE-ASSOCIATED INFECTIONS A SUPPLEMENT TO THE NEW JERSEY 2012 HOSPITAL PERFORMANCE REPORT New Jersey Department of Health Health Care Quality Assessment June 2013 Tables of

More information

Healthcare-associated Infections in Utah

Healthcare-associated Infections in Utah 2013 Healthcare-associated Infections in Utah Utah Department of Health Division of Disease Control and Prevention Published October 2014 2013 Annual Report Prepared by Rebecca L. Ward Division of Disease

More information

The Vermont Healthcare Associated Infection Prevention Plan

The Vermont Healthcare Associated Infection Prevention Plan The Vermont Healthcare Associated Infection Prevention Plan Submitted to the Centers for Disease Control and Prevention on January 1, 2010 This plan was developed through a collaborative effort of the

More information

MN HAI Prevention Plan 1

MN HAI Prevention Plan 1 Healthcare Associated Infections Plan Minnesota Department of Health Healthcare Associated Infections Program Introduction In response to the increasing concerns about the public health impact of healthcare-associated

More information

Value Based Purchasing (VBP) Awareness Brief. FY 2018 Value Based Purchasing Program Domain Weighting

Value Based Purchasing (VBP) Awareness Brief. FY 2018 Value Based Purchasing Program Domain Weighting Value Based Purchasing (VBP) Awareness Brief This Awareness Brief provides a high level summary understanding of value based purchasing. The Hospital Value Based Purchasing (VBP) Program adjusts hospitals

More information

HAI LEADERSHIP PARTNERING FOR ACCOUNTABLE CARE

HAI LEADERSHIP PARTNERING FOR ACCOUNTABLE CARE HAI LEADERSHIP PARTNERING FOR ACCOUNTABLE CARE Cepheid s Government Affairs Department Advocating for Patient Access to Molecular Diagnostics in the Era of Healthcare Reform A TEAM APPROACH Legislative

More information

National Healthcare Safety Network (NHSN) Introduction & Enrollment

National Healthcare Safety Network (NHSN) Introduction & Enrollment National Healthcare Safety Network (NHSN) Introduction & Enrollment Surveillance for Healthcare-Associated & Resistant Pathogens (SHARP) Unit 1 Introduction to NHSN Secure, internet-based surveillance

More information

National Provider Call: Hospital Value-Based Purchasing (VBP) Program

National Provider Call: Hospital Value-Based Purchasing (VBP) Program National Provider Call: Hospital Value-Based Purchasing (VBP) Program Fiscal Year 2016 Overview for Beneficiaries, Providers and Stakeholders Cindy Tourison, MSHI Lead, Hospital Inpatient Quality Reporting

More information

Hospital Inpatient Quality Reporting (IQR) Program

Hospital Inpatient Quality Reporting (IQR) Program Clinical Process Measures Program Changes for Fiscal Year 2014 Beginning with January 1, 2012 discharges; hospitals will begin data collection and submission for 4 new measures. Hospitals will not be required

More information

June 10, 2015. Dear Mr. Slavitt:

June 10, 2015. Dear Mr. Slavitt: 1275 K Street, NW, Suite 1000 Washington, DC 20005-4006 Phone: 202/789-1890 Fax: 202/789-1899 apicinfo@apic.org www.apic.org June 10, 2015 Andrew M. Slavitt Acting Administrator Centers for Medicare &

More information

1. Log into CDC NHSN and enter the Patient Safety Component.

1. Log into CDC NHSN and enter the Patient Safety Component. Instructions for Joining the Kansas Healthcare Collaborative Hospital Engagement Network NHSN Group For technical assistance, please contact Rob Rutherford: RRutherford@khconline.org or 785-235-0763 ext.1326

More information

DEPARTMENT OF HEALTH AND HUMAN SERVICES & 42 CFR 412 45 CFR

DEPARTMENT OF HEALTH AND HUMAN SERVICES & 42 CFR 412 45 CFR 1 DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Part 412 Office of the Secretary 45 CFR Part 170[CMS-1632-P] RIN-0938-AS41 Medicare Program; Hospital Inpatient

More information

REPORT TO THE GENERAL ASSEMBLY AN ACT CREATING A PROGRAM FOR QUALITY IN HEALTH CARE JUNE 30, 2015. Jewel Mullen, MD, MPH, MPA, Commissioner

REPORT TO THE GENERAL ASSEMBLY AN ACT CREATING A PROGRAM FOR QUALITY IN HEALTH CARE JUNE 30, 2015. Jewel Mullen, MD, MPH, MPA, Commissioner REPORT TO THE GENERAL ASSEMBLY AN ACT CREATING A PROGRAM FOR QUALITY IN HEALTH CARE JUNE 30, 2015 Jewel Mullen, MD, MPH, MPA, Commissioner State of Connecticut Department of Public Health 410 Capitol Avenue

More information

Template for State Healthcare Associated Infections Plans

Template for State Healthcare Associated Infections Plans Template for State Healthcare Associated Infections Plans In response to the increasing concerns about the public health impact of healthcare-associated infections (HAIs), the US Department of Health and

More information

Iowa Healthcare Collaborative (IHC) Iowa Report. CY2012 Healthcare-associated Infection (HAI) Data Collection and Reporting Guide

Iowa Healthcare Collaborative (IHC) Iowa Report. CY2012 Healthcare-associated Infection (HAI) Data Collection and Reporting Guide Iowa Healthcare Collaborative () Iowa Report Healthcare-associated Infection (HAI) Data Collection and Reporting Guide Revision Date: January 17, 2013 This document is intended to be a HAI data collection

More information

Healthcare-Associated Infection Public Reporting Program

Healthcare-Associated Infection Public Reporting Program West Virginia Health Care Authority Healthcare-Associated Infection Public Reporting Program 214 Annual Report Earl Ray Tomblin Governor James L. Pitrolo, Board Chair West Virginia Health Care Authority

More information

Overview of the Hospital Value-Based Purchasing (VBP) Fiscal Year (FY) 2017

Overview of the Hospital Value-Based Purchasing (VBP) Fiscal Year (FY) 2017 Overview of the Hospital Value-Based Purchasing (VBP) Fiscal Year (FY) 2017 Bethany Wheeler Hospital VBP Program Support Contract Lead HSAG February 17, 2015 2 p.m. ET Purpose This event will provide an

More information

Arizona Department of Health Services State Healthcare-Associated Infection Plan

Arizona Department of Health Services State Healthcare-Associated Infection Plan Executive Summary Healthcare-associated infections (HAI) are an emerging public health issue and have received increasing public attention. Arizona healthcare facilities and infection preventionists at

More information

ALABAMA Healthcare-Associated Infections Prevention Plan

ALABAMA Healthcare-Associated Infections Prevention Plan ALABAMA Healthcare-Associated Infections Prevention Plan 1. Develop or Enhance HAI program infrastructure Table 1: State infrastructure planning for HAI surveillance, prevention and control. Planning for

More information

The Centers for Medicare & Medicaid Services (CMS) Acute Care Hospital Fiscal Year (FY) 2018 Quality Improvement Program Measures

The Centers for Medicare & Medicaid Services (CMS) Acute Care Hospital Fiscal Year (FY) 2018 Quality Improvement Program Measures ID Me asure Name NQF # - (HRRP) ID Me asure Name NQF # - (HRRP) ID Me asure Name NQF # - (HRRP) CMS Measures Fiscal Year 2018 The Centers for Medicare & Medicaid Services (CMS) Acute Care Fiscal Year (FY)

More information

NURSE DRIVEN FOLEY CATHETER PROTOCOL

NURSE DRIVEN FOLEY CATHETER PROTOCOL NURSE DRIVEN FOLEY CATHETER PROTOCOL BACKGROUND There are over 1.7 million hospital-acquired infections in US hospitals annually, 40% of which are urinary tract infections. 80% of hospital-acquired UTIs

More information

March 2011 Association of State and Territorial Health Officials 2231 Crystal Drive, Suite 450, Arlington, VA 22202 202-371-9090 www.astho.

March 2011 Association of State and Territorial Health Officials 2231 Crystal Drive, Suite 450, Arlington, VA 22202 202-371-9090 www.astho. Table of Contents EXECUTIVE SUMMARY... 3 I. INTRODUCTION: The Case for Elimination... 5 Moving toward Elimination... 6 States Have a Critical Role to Play in HAI Prevention... 6 The Role of Policy in HAI

More information

associated Urinary Tract Infection Case Definitions

associated Urinary Tract Infection Case Definitions CDC/NHSN Cather-associated associated Urinary Tract Infection Case Definitions Chaz M. Rhone, MPH Regional HAI Epidemiologist Florida Department of Health *all information is directly from the NHSN site

More information

Review of Healthcare-Associated Infection (HAI) and Multidrug-Resistant Organism (MDRO) Reporting Requirements in the United States PRESENTED BY:

Review of Healthcare-Associated Infection (HAI) and Multidrug-Resistant Organism (MDRO) Reporting Requirements in the United States PRESENTED BY: Review of Healthcare-Associated Infection (HAI) and Multidrug-Resistant Organism (MDRO) Reporting Requirements in the United States PRESENTED BY: BYRAN DAI MASTERS OF HEALTH SCIENCE CANDIDATE 14 JHSPH

More information

Building and Sustaining New Jersey s Program to Prevent Healthcare-Associated Infections

Building and Sustaining New Jersey s Program to Prevent Healthcare-Associated Infections Building and Sustaining New Jersey s Program to Prevent Healthcare-Associated Infections I. Background and Need Healthcare-associated infections (HAI) are a significant public health problem in the United

More information

State and Federal Regulatory Requirements. Basics of Infection Prevention 2-Day Mini-Course 2013

State and Federal Regulatory Requirements. Basics of Infection Prevention 2-Day Mini-Course 2013 State and Federal Regulatory Requirements Basics of Infection Prevention 2-Day Mini-Course 2013 2 Objectives List national, state and local regulatory bodies that oversee infection prevention Describe

More information

Business Case for National Healthcare Safety Network (NHSN) Infection Surveillance Database

Business Case for National Healthcare Safety Network (NHSN) Infection Surveillance Database Business Case for National Healthcare Safety Network (NHSN) Infection Surveillance Database Executive Summary All hospitals understand the value of preventing healthcare-associated infections (HAIs) and

More information

Copyright, The Joint Commission National Patient Safety Goals

Copyright, The Joint Commission National Patient Safety Goals 2015 National Patient Safety Goals Background The National Patient Safety Goals (NPSGs) were established in 2002 to help accredited organizations address specific areas of concern in regards to patient

More information

AHRQ Patient Safety Tools and Resources

AHRQ Patient Safety Tools and Resources AHRQ Patient Safety Tools and Resources The Agency for Healthcare Research and Quality (AHRQ) offers practical, research-based tools and resources to help a variety of health care organizations, providers,

More information

This proposed rule clarifies and makes updates to details regarding this program that were finalized in

This proposed rule clarifies and makes updates to details regarding this program that were finalized in 2014 Ambulatory Surgery Center (ASC) and Outpatient Prospective Payment System (OPPS) A Summary of the Quality Provisions of the Proposed Rule Overview On July 8, 2013, the Centers for Medicare and Medicaid

More information

Preventable Hospital Acquired-Conditions (HACs), Including Infections

Preventable Hospital Acquired-Conditions (HACs), Including Infections June 25, 2012 Ms. Marilyn Tavenner Acting Administrator Centers for Medicare & Medicaid Services Department of Health and Human Services Room 445-G Hubert H. Humphrey Building 200 Independence Avenue,

More information

Welcome and Instructions

Welcome and Instructions Welcome and Instructions For audio, join by telephone at 877-594-8353, participant code: 56350822 Your line is OPEN. Please do not use the hold feature on your phone but do mute your line by dialing *6.

More information

Lessons from the Pioneers Reporting Healthcare-Associated Infections

Lessons from the Pioneers Reporting Healthcare-Associated Infections Lessons from the Pioneers Reporting Healthcare-Associated Infections Lessons from the Pioneers Re p o rt i n g He a lt h c a r e-associated In f e c t i o n s By Anna Spencer Deborah Sward James Ward William

More information

HOSPITAL EPIDEMIOLOGY AND INFECTION CONTROL MANDATORY INFECTION CONTROL EDUCATION

HOSPITAL EPIDEMIOLOGY AND INFECTION CONTROL MANDATORY INFECTION CONTROL EDUCATION Office of Origin: Department of Hospital Epidemiology and Infection Control (HEIC) I. PURPOSE The purpose of this policy is to: A. Ensure compliance with California Health and Safety Code, section 1288.95

More information

HOSPITAL-ACQUIRED INFECTIONS. New York State 2013. New York State

HOSPITAL-ACQUIRED INFECTIONS. New York State 2013. New York State HOSPITAL-ACQUIRED INFECTIONS New York State 2013 New York State New York State Department of Health, Albany, NY September 2014 Table of Contents Executive Summary... 3 Background... 23 Hospital Acquired

More information

A Review of the Hospital Performance Data Expansion Policy and Outpatient Measures Data Requirements

A Review of the Hospital Performance Data Expansion Policy and Outpatient Measures Data Requirements A Review of the Hospital Performance Data Expansion Policy and Outpatient Measures Data Requirements Theressa Lee, Director, Center for Quality Measurement and Reporting Presented to the HSCRC Performance

More information

SCORING METHODOLOGY Fall 2015

SCORING METHODOLOGY Fall 2015 SCORING METHODOLOGY Fall 2015 HOSPITAL SAFETY SCORE Contents What is the Hospital Safety Score?... 4 Eligible and Excluded Hospitals... 4 Scoring Methodology... 5 Measures... 5 How Measures are Scored...

More information

Portland State Office Building, Room 1B 1:00 pm to 3:00 pm 800 NE Oregon Street Portland, OR 97232

Portland State Office Building, Room 1B 1:00 pm to 3:00 pm 800 NE Oregon Street Portland, OR 97232 HEALTHCARE-ASSOCIATED INFECTIONS ADVISORY COMMITTEE June 25, 2014 Portland State Office Building, Room 1B 1:00 pm to 3:00 pm 800 NE Oregon Street Portland, OR 97232 MEMBERS PRESENT: MEMBERS EXCUSED: Paul

More information

Ohio Healthcare-Associated Infection Prevention Plan December 2009

Ohio Healthcare-Associated Infection Prevention Plan December 2009 Ohio Healthcare-Associated Infection Prevention Plan December 2009 Background In response to the increasing concerns about the public health impact of healthcare-associated infections (HAIs), the US Department

More information

Arizona Department of Health Services Healthcare-Associated Infection Plan Progress Report June 2010

Arizona Department of Health Services Healthcare-Associated Infection Plan Progress Report June 2010 On December 31 st, 2010, the Arizona Department of Health Services (ADHS) submitted the state healthcare-associated infection (HAI) plan to the United States Department of Health and Human Services. The

More information

2. Is the data entered: Manually (i.e. by user) Automatically (i.e. by the ST product) Both

2. Is the data entered: Manually (i.e. by user) Automatically (i.e. by the ST product) Both Starter Questions for Assessing Capabilities of Surveillance Technology (ST) & Their Vendors These are questions which might be asked of each ST vendor. This preliminary information may help compare products

More information

June 2, 2014. RE: File Code CMS-1608-P. Dear Ms. Tavenner:

June 2, 2014. RE: File Code CMS-1608-P. Dear Ms. Tavenner: . June 2, 2014 Marilyn Tavenner Centers for Medicare & Medicaid Services Room 445-G, Hubert H. Humphrey Building 200 Independence Avenue SW Washington, DC RE: File Code CMS-1608-P Dear Ms. Tavenner: The

More information

How to Verify Your NHSN Data is Being Reported to CMS for IPPS Reporting

How to Verify Your NHSN Data is Being Reported to CMS for IPPS Reporting How to Verify Your NHSN Data is Being Reported to CMS for IPPS Reporting To comply with the Inpatient Prospective Payment System (IPPS) CMS Reporting Requirements, National Health and Safety Network (NHSN)

More information

OPERATIONAL DIRECTIVE

OPERATIONAL DIRECTIVE OPERATIONAL DIRECTIVE Enquiries to: Healthcare Associated Infection Unit OD number: OD0527/14 Phone number: 08 9388 4868 Date: 26 May 2014 Supersedes: OD 0197/09 (12/06/2009) File No: F-AA-28007 Subject:

More information

End secrecy, save lives Public transparency Our issues:

End secrecy, save lives Public transparency Our issues: End secrecy, save lives Public transparency Our issues: Health care acquired infections medical errors improved oversight and information about physician care medical device safety Medical Harm: Response

More information

Central Line-Associated Bloodstream Infection (CLABSI) Prevention. Basics of Infection Prevention 2-Day Mini-Course 2013

Central Line-Associated Bloodstream Infection (CLABSI) Prevention. Basics of Infection Prevention 2-Day Mini-Course 2013 Central Line-Associated Bloodstream Infection (CLABSI) Prevention Basics of Infection Prevention 2-Day Mini-Course 2013 2 Objectives Describe the etiology and epidemiology of central line associated bloodstream

More information

Hospital Information. Facility Name: Primary HEN Contact: Quality Lead: Infection Preventionist: HEN 2.0 Survey Questions

Hospital Information. Facility Name: Primary HEN Contact: Quality Lead: Infection Preventionist: HEN 2.0 Survey Questions Hospital Information Facility : Quality Lead: Infection Preventionist: Email Email Email HEN 2.0 Survey Questions Patient and Family Engagement 1) Prior to scheduled admission, hospital staff provides

More information

Catheter-Associated Urinary Tract Infection (CAUTI) Prevention. Basics of Infection Prevention 2 Day Mini-Course 2013

Catheter-Associated Urinary Tract Infection (CAUTI) Prevention. Basics of Infection Prevention 2 Day Mini-Course 2013 Catheter-Associated Urinary Tract Infection (CAUTI) Prevention Basics of Infection Prevention 2 Day Mini-Course 2013 2 Objectives Define the scope of healthcare-associated urinary tract infections (UTI)

More information

Constance D. Jones, RN, CIC Coordinator, North Carolina Healthcare-Associated Infection Prevention Program

Constance D. Jones, RN, CIC Coordinator, North Carolina Healthcare-Associated Infection Prevention Program Constance D. Jones, RN, CIC Coordinator, North Carolina Healthcare-Associated Infection Prevention Program Which category does North Carolina fall into? Marathon (Established) is defined as a long distance

More information

Quality Reporting: Implications for Value Based Purchasing

Quality Reporting: Implications for Value Based Purchasing Physician Leadership Network Clinical Discussions 2013 Webinar Series Quality Reporting: Implications for Value Based Purchasing Host: Dr. Adrienne Mims Facilitator: Dr. Kim Rask Faculty: Mary Cox Suzanne

More information

Better to Best. 2011 Quality Excellence Achievement Awards. Recognizing Illinois Hospitals Leading in Quality and Innovation COMPENDIUM

Better to Best. 2011 Quality Excellence Achievement Awards. Recognizing Illinois Hospitals Leading in Quality and Innovation COMPENDIUM Better to Best 2011 Quality Excellence Achievement Awards COMPENDIUM Recognizing Illinois Hospitals Leading in Quality and Innovation 2011 Quality Excellence Achievement Awards Overview IHA s Quality Care

More information

Medicare Long-Term Care Hospital Prospective Payment System

Medicare Long-Term Care Hospital Prospective Payment System Medicare Long-Term Care Hospital Prospective Payment System Payment Rule Brief PROPOSED RULE Program Year: FFY 2015 Overview, Resources, and Comment Submission On May 15, the Centers for Medicare and Medicaid

More information

Centers for Medicare & Medicaid Services 1

Centers for Medicare & Medicaid Services 1 Affordable Care Act Section 3004 Inpatient Rehabilitation Facility Quality Reporting Program Provider Training Caroline D. Gallaher, R.N., B.S.N, J.D. CMS, Office of Clinical Standards and Quality Division

More information

Welcome! Limited dial-in lines are available. Please send a chat message if needed. This event is being recorded.

Welcome! Limited dial-in lines are available. Please send a chat message if needed. This event is being recorded. Welcome! Audio for this event is available via ReadyTalk Internet Streaming. No telephone line is required. Computer speakers or headphones are necessary to listen to streaming audio. Limited dial-in lines

More information

In the postacute continuum space, long-term acute care hospitals (LTCH)

In the postacute continuum space, long-term acute care hospitals (LTCH) Postacute CDI: An Introduction to Long-Term Acute Care Hospitals WHITE PAPER Summary: This white paper provides an overview of long-term acute care hospitals and how they differ from short-term acute care

More information

Updates to NHSN for IRF Locations within Acute Care & Critical Access Facilities

Updates to NHSN for IRF Locations within Acute Care & Critical Access Facilities Updates to NHSN for IRF Locations within Acute Care & Critical Access Facilities NHSN version 6.6.1 allows users with inpatient rehabilitation units within acute care and critical access facilities to

More information

Catheter-Associated Urinary Tract Infection (CAUTI) Event

Catheter-Associated Urinary Tract Infection (CAUTI) Event Catheter-Associated Urinary Tract Infection () Event Introduction: Urinary tract infections (UTIs) are tied with pneumonia as the second most common type of healthcare-associated infection, second only

More information

HOSPITAL-ACQUIRED INFECTIONS. New York State 2008

HOSPITAL-ACQUIRED INFECTIONS. New York State 2008 HOSPITAL-ACQUIRED INFECTIONS New York State 2008 New York State Department of Health May 1, 2009 Version 2.0 1 Technical Advisory Workgroup Audrey Adams, RN, MPH, CIC Montefiore Medical Center Henry and

More information

Eliminating CLABSI A National Patient Safety Imperative

Eliminating CLABSI A National Patient Safety Imperative Eliminating CLABSI A National Patient Safety Imperative Second Progress Report on the National On the CUSP: Stop BSI Project A Project of: Health Research & Educational Trust Johns Hopkins University Quality

More information

U.S. Department of Health & Human Services May 7, 2014. New HHS Data Shows Major Strides Made in Patient Safety, Leading to Improved Care and Savings

U.S. Department of Health & Human Services May 7, 2014. New HHS Data Shows Major Strides Made in Patient Safety, Leading to Improved Care and Savings U.S. Department of Health & Human Services May 7, 2014 New HHS Data Shows Major Strides Made in Patient Safety, Leading to Improved Care and Savings The data in this report shows a substantial nine percent

More information

healthcare associated infection 1.2

healthcare associated infection 1.2 healthcare associated infection A C T I O N G U I D E 1.2 AUSTRALIAN SAFETY AND QUALITY GOALS FOR HEALTH CARE What are the goals? The Australian Safety and Quality Goals for Health Care set out some important

More information

Lives Lost, Lives Saved: A Comparative Analysis of Avoidable Deaths at Hospitals Graded by The Leapfrog Group

Lives Lost, Lives Saved: A Comparative Analysis of Avoidable Deaths at Hospitals Graded by The Leapfrog Group Lives Lost, Lives Saved: A Comparative Analysis of Avoidable Deaths at Hospitals Graded by The Leapfrog Group April 2016 by Matt Austin, Ph.D. Jordan Derk, M.P.H. Armstrong Institute for Patient Safety

More information

APIC Position Paper: The Use of Administrative (Coding/Billing) Data for Identification of Healthcare-Associated Infections (HAIs) in US Hospitals

APIC Position Paper: The Use of Administrative (Coding/Billing) Data for Identification of Healthcare-Associated Infections (HAIs) in US Hospitals 1275 K Street, NW, Suite 1000 Washington, DC 20005-4006 Phone: 202/789-1890 Fax: 202/789-1899 apicinfo@apic.org www.apic.org APIC Position Paper: The Use of Administrative (Coding/Billing) Data for Identification

More information

NHSN e-news. Inside this issue: Reminder! Data for CMS Quality Reporting Programs Due February 15: Volume 8, Issue 4 December 2013

NHSN e-news. Inside this issue: Reminder! Data for CMS Quality Reporting Programs Due February 15: Volume 8, Issue 4 December 2013 Volume 8, Issue 4 December 2013 Reminder! Data for CMS Quality Reporting Programs Due February 15: (NOTE: February 15 th is a Saturday. Regardless, data must be submitted by 11:59pm Central Time on February

More information

Between the national baseline and 50% better than national baseline

Between the national baseline and 50% better than national baseline Hospital Ratings Our hospitals have turned into breeding grounds for dangerous even deadly infections. Consumer Reports has expanded its hospital Ratings and now includes information about two common and

More information

Darlene Rodgers, BSN, RN, CNN, CPHQ Executive Director, ESRD Networks 15/17

Darlene Rodgers, BSN, RN, CNN, CPHQ Executive Director, ESRD Networks 15/17 Darlene Rodgers, BSN, RN, CNN, CPHQ Executive Director, ESRD Networks 15/17 To build strategic partnerships with dialysis providers, ESRDS Network, renal associations, public health professionals, federal

More information

Relevant Quality Measures for Critical Access Hospitals

Relevant Quality Measures for Critical Access Hospitals Policy Brief #5 January 0 Relevant Quality Measures for Critical Access Hospitals Michelle Casey MS, Ira Moscovice PhD, Jill Klingner RN, PhD, Shailendra Prasad MD, MPH University of Minnesota Rural Health

More information

Raoult Ratard, MD, MS, MPH Louisiana State Epidemiologist. Debra Rushing, RN, MBA/HCM, CPE Executive Director eqhealth Solutions Louisiana

Raoult Ratard, MD, MS, MPH Louisiana State Epidemiologist. Debra Rushing, RN, MBA/HCM, CPE Executive Director eqhealth Solutions Louisiana Raoult Ratard, MD, MS, MPH Louisiana State Epidemiologist Debra Rushing, RN, MBA/HCM, CPE Executive Director eqhealth Solutions Louisiana Erica Washington, MPH Healthcare-Associated Infections Coordinator

More information

Inside this Issue: September 2015 Celebrating NHSN s 10th Anniversary! 2. Volume 10, Issue 3. Patient Safety Component

Inside this Issue: September 2015 Celebrating NHSN s 10th Anniversary! 2. Volume 10, Issue 3. Patient Safety Component T h e C e n t e r s f o r D i s e a s e C o n t r o l a n d P r e v e n t i o n ( C D C ) NHSN e-news Volume 10, Issue 3 Inside this Issue: September 2015 Celebrating NHSN s 10th Anniversary! 2 Patient

More information

Value-Based Purchasing An Opportunity for Clinical Nurse Leaders

Value-Based Purchasing An Opportunity for Clinical Nurse Leaders Value-Based Purchasing An Opportunity for Clinical Nurse Leaders Marjorie S. Wiggins, DNP, MBA, RN, FAAN, NEA-BC Senior Vice President, Patient Care Services/Chief Nursing Officer AACN-CNL Summit, Long

More information

Hospital Value-based Purchasing Specifications 2016 Updated August 2015

Hospital Value-based Purchasing Specifications 2016 Updated August 2015 Description Methodology Measurement Period Allowable Exclusions Total Performance Score Individual measures CMS incentive program for PPS hospitals. The purpose is to achieve value by tying payment to

More information

HEN 2.0 Kickoff. Jessica Rowden, Clinical Quality Improvement Manager August 19, 2015

HEN 2.0 Kickoff. Jessica Rowden, Clinical Quality Improvement Manager August 19, 2015 HEN 2.0 Kickoff Jessica Rowden, Clinical Quality Improvement Manager August 19, 2015 1 Agenda Current HEN 2.0 contract status Potential HEN 2.0 strategy Aligning MHA strategies Potential contract deliverables

More information

June 10, 2011. Dear Dr. Berwick:

June 10, 2011. Dear Dr. Berwick: Donald Berwick, M.D., M.P.P. Administrator Centers for Medicare & Medicaid Services Hubert H. Humphrey Building 200 Independence Avenue, S.W., Room 445-G Washington, DC 20201 RE: CMS-1518-P, Medicare Program;

More information

Maryland Healthcare-Associated Infections Prevention Plan. Submitted to the Office of the Secretary U.S. Department of Health and Human Services

Maryland Healthcare-Associated Infections Prevention Plan. Submitted to the Office of the Secretary U.S. Department of Health and Human Services Maryland Healthcare-Associated Infections Prevention Plan Submitted to the Office of the Secretary U.S. Department of Health and Human Services January 1, 2010 Table of Contents Summary of Maryland HAI

More information

Mandated Infection Prevention Staffing Ratios in N.J.

Mandated Infection Prevention Staffing Ratios in N.J. Mandated Infection Prevention Staffing Ratios in N.J. Kathy Horn, RN, CIC Director of Infection Prevention Services roye-horn.kathleen@hunterdonhealthcare.org (There are no financial disclosures.) 2 Objectives

More information

Summary of Infection Prevention and Control Program Assessment. Prepared for: The Delaware Health and Social Services Division of Public Health

Summary of Infection Prevention and Control Program Assessment. Prepared for: The Delaware Health and Social Services Division of Public Health AZ Saving Lives Reducing Risk Protecting Your Bottom Line Summary of Infection Prevention and Control Program Assessment Introduction/Background Prepared for: The Delaware Health and Social Services Division

More information

The Leapfrog Hospital Survey Scoring Algorithms. Scoring Details for Sections 2 9 of the 2016 Leapfrog Hospital Survey

The Leapfrog Hospital Survey Scoring Algorithms. Scoring Details for Sections 2 9 of the 2016 Leapfrog Hospital Survey The Leapfrog Hospital Survey Scoring Algorithms Scoring Details for Sections 2 9 of the 2016 Leapfrog Hospital Survey Table of Contents 2016 Leapfrog Hospital Survey Scoring Algorithms... 3 Section 2:

More information

June 25, 2012. Dear Acting Administrator Tavenner,

June 25, 2012. Dear Acting Administrator Tavenner, June 25, 2012 Marilyn B. Tavenner, RN, Acting Administrator Centers for Medicare and Medicaid Services Department of Health and Human Services Attention: CMS-1588-P P.O. Box 8011 Baltimore, MD 21244-1850

More information

Answers to Frequently Asked Questions on Reporting in NHSN

Answers to Frequently Asked Questions on Reporting in NHSN Answers to Frequently Asked Questions on Reporting in NHSN 1. With multiple infection sites, if you are unsure of the primary site of the infection, what should you do? If more than one NHSN operative

More information

Analyzing Data in NHSN

Analyzing Data in NHSN Analyzing Data in NHSN Lindsey Weiner, MPH Epidemiologist Alabama Hospital Quality Initiative Webinar September 16, 2015 National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare

More information

APIC Position Paper: The Importance of Surveillance Technologies in the Prevention of Healthcare-Associated Infections (HAIs)

APIC Position Paper: The Importance of Surveillance Technologies in the Prevention of Healthcare-Associated Infections (HAIs) 1275 K Street, NW, Suite 1000 Washington, DC 20005-4006 Phone: 202/789-1890 Fax: 202/789-1899 apicinfo@apic.org www.apic.org APIC Position Paper: The Importance of Surveillance Technologies in the Prevention

More information

Prevention of CAUTI is discussed in the CDC/HICPAC document, Guideline for Prevention of Catheter-associated Urinary Tract Infection 4.

Prevention of CAUTI is discussed in the CDC/HICPAC document, Guideline for Prevention of Catheter-associated Urinary Tract Infection 4. Urinary Tract Infection (Catheter-Associated Urinary Tract Infection [] and Non-Catheter-Associated Urinary Tract Infection [UTI]) and Other Urinary System Infection [USI]) Events Introduction: Urinary

More information

Value Based Purchasing and You

Value Based Purchasing and You Value Based Purchasing and You David Gourley, RRT, MHA, FAARC Director of Clinical Services and Risk Management Millennium Respiratory Services Whippany, New Jersey Value Based Purchasing and You Overview

More information

Medicare Inpatient Rehabilitation Facility Prospective Payment System

Medicare Inpatient Rehabilitation Facility Prospective Payment System Medicare Inpatient Rehabilitation Facility Prospective Payment System Payment Rule Brief PROPOSED RULE Program Year: FFY 2015 Overview, Resources, and Comment Submission On May 7, 2014, the Centers for

More information

IMPACT OF ELECTRONIC HAND HYGIENE MONITORING SYSTEMS: A REVIEW OF CASE STUDIES

IMPACT OF ELECTRONIC HAND HYGIENE MONITORING SYSTEMS: A REVIEW OF CASE STUDIES IMPACT OF ELECTRONIC HAND HYGIENE MONITORING SYSTEMS: A REVIEW OF CASE STUDIES BY SUDHANSHU GAKHAR & JASON BURNHAM INTRODUCTION Hospital-acquired infections (HAIs) burden patients, complicate treatments,

More information

Improving Hospital Performance

Improving Hospital Performance Improving Hospital Performance Background AHA View Putting patients first ensuring their care is centered on the individual, rooted in best practices and utilizes the latest evidence-based medicine is

More information

Hawaii Health Care Forums: Building Bridges to Better Health

Hawaii Health Care Forums: Building Bridges to Better Health Castle Medical Center A full-service medical center located in Kailua. Castle offers a wide range of inpatient, outpatient, and home-based services. Castle is the primary health care facility for the Windward

More information

Medicare Inpatient Rehabilitation Facility Prospective Payment System

Medicare Inpatient Rehabilitation Facility Prospective Payment System Medicare Inpatient Rehabilitation Facility Prospective Payment System Payment Rule Brief FINAL RULE Program Year: FFY 2015 Overview and Resources On August 6, 2014, the Centers for Medicare and Medicaid

More information

How We Rate Hospitals

How We Rate Hospitals How We Rate Hospitals June 2014 1. Overview....................................................................... 2 2. Patient Outcomes 2.1 Avoiding infections.......................................................

More information

United States Government Accountability Office March 2008 GAO-08-283

United States Government Accountability Office   March 2008 GAO-08-283 GAO United States Government Accountability Office Report to the Chairman, Committee on Oversight and Government Reform, House of Representatives March 2008 HEALTH-CARE- ASSOCIATED INFECTIONS IN HOSPITALS

More information

Medicare Inpatient Rehabilitation Facility Prospective Payment System Fiscal Year 2017

Medicare Inpatient Rehabilitation Facility Prospective Payment System Fiscal Year 2017 Proposed Rule Summary Medicare Inpatient Rehabilitation Facility Prospective Payment System Fiscal Year 2017 May 2016 1 P a g e Table of Contents Overview and Resources... 2 Inpatient Rehabilitation Facility

More information

2011 NATIONAL PATIENT SAFETY GOALS. Created by UMC s Clinical Education & Research Department

2011 NATIONAL PATIENT SAFETY GOALS. Created by UMC s Clinical Education & Research Department 2011 NATIONAL PATIENT SAFETY GOALS Created by UMC s Clinical Education & Research Department Background The National Patient Safety Goals (NPSG) were established in 2002 to help accredited organizations

More information

Prevention of CAUTI is discussed in the CDC/HICPAC document, Guideline for Prevention of Catheter-associated Urinary Tract Infection 4.

Prevention of CAUTI is discussed in the CDC/HICPAC document, Guideline for Prevention of Catheter-associated Urinary Tract Infection 4. Urinary Tract Infection (Catheter-Associated Urinary Tract Infection [CA] and Non-Catheter-Associated Urinary Tract Infection []) and Other Urinary System Infection [USI]) Events Introduction: Urinary

More information

Medicare Long-Term Care Hospital Prospective Payment System

Medicare Long-Term Care Hospital Prospective Payment System Medicare Long-Term Care Hospital Prospective Payment System May 5, 2015 Payment Rule Brief PROPOSED RULE Program Year: FFY 2016 Overview, Resources, and Comment Submission On May 17, the Centers for Medicare

More information

Sepsis Surveillance Definition Work Update

Sepsis Surveillance Definition Work Update Sepsis Surveillance Definition Work Update Anthony Fiore, MD, MPH Chief, Epidemiology Research and Innovations Branch Division of Healthcare Quality Promotion Centers for Disease Control and Prevention

More information