Hospital Performance Data Reporting/Ohio Hospital Compare ( HB 197)

1. Hospital Performance Data Reporting/Ohio Hospital Compare (HB 197) Ohio Department of Health Mandatory Reporting Requirements for HAIs 3/3/2010

2. What is Required of Hospitals for HAI Reporting • April 1st and October 1st of each year • Twelve-months of data • Currently collecting Quarter 3 2008 – Quarter 2 2009 data • Use the specifications created by the entity that developed or endorsed the measure • CDC – NHSN Manuals http://www.cdc.gov/nhsn/library.html • CMS – Specifications http://www.qualitynet.org/dcs/ContentServer?cid=1141662756099&pagename=QnetPublic% • All data Reported is presented to the public on Ohio Hospital Compare http://ohiohospitalcompare.ohio.gov/

3. CMS Infection Measures Surgical Care Improvement Project (SCIP) • All hospitals are required to report to ODH regardless of reporting to CMS • Hospitals must follow the specifications created by CMS for each reporting time period • SCIP procedural measures are intended to improve the safety of surgical care through the reduction of postoperative complications

4. CMS Infection Measures Surgical Care Improvement Project (SCIP) – cont. • Appropriateness of care measure ( SCIP‐Inf 1a, 2a, 3a) • SCIP‐Inf 1a‐ h: Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision • SCIP‐Inf‐2a‐ h: Prophylactic Antibiotic Selection for Surgical Patients • SCIP‐Inf‐3a‐ h: Prophylactic Antibiotics Discontinued within 24 Hours after Surgery End Time • These measures are stratified into 8 surgical categories • Overall Rate, CABG, Other Cardiac Surgery, Hip and knee Arthroplasty, Colon Surgery, Hysterectomy, Vascular Surgery

5. CMS Infection Measures Surgical Care Improvement Project (SCIP) – cont. • SCIP‐Card‐2: Surgery Patients on Beta Blocker Therapy Prior to Admission who Received a Beta Blocker during the • SCIP‐VTE‐1: Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered • SCIP‐VTE‐2: Surgery Patients who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours after Surgery

6. CDC Infection Measures Surgical Site Infections • Setting: surgical patients in any inpatient setting • Coronary artery bypass graft (CABG) • For CABG surgeries report: Deep incisional and organ space sternal site infections • Denominator should include both chest incision only and chest incision/graft site surgeries • Infections should only be counted for chest incisions • C‐Section (CSEC) • Knee Prosthesis (KPRO) • For Knee surgeries report: Deep incisional and organ space (knee joint) infections

7. CDC Infection Measures C. diff, MRSA and MSSA • Follow the NHSN Multidrug-resistant Organism (MDRO) and Clostridium difficile-Associated Disease (CDAD) Module Protocol • Laboratory Identified events • Hospital-Acquired Clostridium difficile (C. Diff.) • Hospital-Acquired Methicillin Resistant and Methicillin Susceptible Staphylococcus aureus Bacteremia (MRSA/MSSA Bacteremia) (SAB) • Healthcare facility onset • On or after day 4 with the day of admission indicated as day 1 • Lab confirmed positives • Not duplicate positives • Do not include readmission prior to 8 weeks

8. ODH Infection Measures • Health Care Provider Influenza Vaccination • First collection: Sept 1, 2009 - Mar 31, 2010 • First reporting: October 1, 2010 • Only Seasonal flu • Count only paid employees as of March 31st each year

9. ODH Infection Measures Hand-washing Program • Does your hospital have a program to improve hand hygiene practices? • Yes , No, Under development • 2. Does your hospital teach principles of hand hygiene and proper use of gloves to all clinical staff upon hire? • Yes , No • 3. Does your hospital monitor and provide feedback to clinical staff regarding their hand hygiene practices? • Yes, both, Partial (monitor only), No • 4. In your hospital’s clinical settings, are alcohol-based hand-rubs available for use at the point of care? • Yes , No • 5. In your hospital’s clinical settings, are gloves available for use at the point of care? • Yes , No • 6. Does your hospital prohibit the wearing of artificial nails by direct-care providers? • Yes , No

10. ODH Infection Measures Infection Control Staffing • 1. Does your hospital employ a qualified Infection Control Professional (ICP)? • Yes, No • 2. Does your hospital employ an Infection Control Professional (ICP) who is board certified in infection control (CIC)? • Yes, No • 3. Does your hospital have a board-certified Infectious Disease Physician either on staff or available for consult? • Yes, No

11. Process for Reporting Currently use an ODH electronic data entry system Must coordinate internally with you quality assurance staff Refer to the “Hospital Perforamnce Measures Instruction Manual for guidance - http://www.odh.ohio.gov/healthStats/hlthserv/hospitaldata/hospperf.aspx

12. NHSN – Purpose Provide facilities with risk-adjusted data that can be used for inter-facility comparisons and local quality improvement activities. Assist facilities in developing surveillance and analysis methods that permit timely recognition of patient and healthcare personnel safety problems and prompt intervention with appropriate measures. NHSN participants will not have to do duplicative entry into the ODH Hospital Reporting collection system

13. What offers the best transition to hospitals Use data that is already being collected Use a standardized data collection system Provide reporting to meet the statute’s requirement Provide reports that are easily understood by healthcare professionals Provide reports that are easily understood by the general public

14. Please contact Kaliyah Shaheen at 614-995-4982 or kaliyah.shaheen@odh.ohio.gov with questions