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Massachusetts Department of Public Health Betsy Lehman Center for Patient Safety and Medical Error Reduction

Healthcare Associated Infection Prevention and Control Program: Campaign to Reduce Hospital Acquired Infections Goal 3: Mandatory Reporting & Oversight. Massachusetts Department of Public Health Betsy Lehman Center for Patient Safety and Medical Error Reduction. GOAL 3 Mandatory Reporting.

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Massachusetts Department of Public Health Betsy Lehman Center for Patient Safety and Medical Error Reduction

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  1. Healthcare Associated Infection Prevention and Control Program:Campaign to Reduce Hospital Acquired InfectionsGoal 3: Mandatory Reporting & Oversight Massachusetts Department of Public Health Betsy Lehman Center for Patient Safety and Medical Error Reduction

  2. GOAL 3Mandatory Reporting • Regulations will require hospitals to report selected outcome and process measures to the National Healthcare Safety Network (NHSN). • Reporting hospitals will provide three levels of access to the data: • DPH will have access to data that it will prepare for public reporting • The Betsy Lehman Center will have access to data that are not quite ready for public reporting • Individual hospitals will see their own data and aggregate data from other hospitals

  3. Mandatory Reporting (Continued) • Publicly Reported Elements • SSI for Hip and Knee Replacement • BSI central venous catheters in ICUs (pathogens) • Health care worker immunization rates: influenza vaccine (pending) • Betsy Lehman Elements - BSI for central venous catheter in ICUs (skin contaminants) - SSI for CABG - VAP head elevation; MRSA point prevalence • Elements for use in Internal QA only - BSI central venous catheter outside ICUs (pathogens & skin contaminants - VAP rates

  4. GOAL 3Oversight • Incorporate expert panel best practices into current regulations • Add to current regulations provisions for educating patients about their role in preventing infections • Task newly hired surveyors with helping hospitals implement recommended measures; with role transitioning to: • Enforcement of new regulatory requirements

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