Or. Admin R. 333-018-0110 - HAI Reporting for Hospitals

Hospitals must participate in the Health Care Acquired Infection (HAI) reporting program.  Each hospital must collect data on HAI outcome and process measures for the program.  Each hospital must do the following:

• Report outcome measures to the National Healthcare Safety Network (NHSN) within 30 days of the end of the collection           month;
• Report process measures to the Hospital Inpatient Quality Reporting Program (formerly the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) program);
• Submit NICU outcome measures to NHSN;
• Quarterly report process measures to Oregon’s designated Quality Improvement Organization’s clinical warehouse;
• Comply with the processes and methods prescribed by the Center for Disease Control (CDC) for NHSN data submission;
• Authorize disclosure of NHSN data to the Office for Oregon Health Policy and Research;
• Comply with the reporting processes and methods prescribed by the Center for Medicare and Medicaid Services for the RHQDAPU program.

Each facility must designate an infection control professional, who must screen a variety of data for signs of HAI’s during a patient’s stay, including laboratory, pharmacy, radiology, imaging, pathology, admission, transfer, discharge and patient charts.  The infection control professional must follow-up to detect HAI’s by reviewing patient medical records, subsequent hospitalization records, or surgery clinical records and conducting surgeon, patient or other facility surveys.