Title 23
Health and Safety

Chapter 17.17
Health Care Quality Program

§ 23-17.17-6. Health care quality steering committee.

(a) The director shall establish and serve as chairperson of a health care quality steering committee of no more than nineteen (19) members to advise in the following matters:

(1) Determination of the comparable performance measures to be reported on;

(2) Assessment of factors, including, but not limited to, factors related to incidents and events reported to the department pursuant to § 23-17-40, contributing to the provision of quality health care and patient safety;

(3) Selection of the patient satisfaction survey measures and instrument;

(4) Methods and format for data collection;

(5) Program expansion and quality improvement initiatives;

(6) Format for the public quality performance measurement report;

(7) Consideration of nursing-sensitive performance measures to be reported on;

(8) Consideration of the relationship between human resources and quality, beginning with measurement and reporting for nursing staff;

(9) Consideration of measures associated with hospital-acquired infections with consultation of infections control experts and with the hospital-acquired infections and prevention advisory committee as established herein:

(i) Hospital-acquired infections and prevention advisory committee:

(A) The director of the department of health as the chairperson of the steering committee shall appoint a permanent subcommittee called the hospital-acquired infections and prevention advisory committee. Membership shall include representatives from public and private hospitals, infection control professionals, director care nursing staff, physicians, epidemiologists with expertise in hospital-acquired infections, academic researchers, consumer organizations, health insurers, health maintenance organizations, organized labor, and purchasers of health insurance, such as employers. The advisory committee shall have a majority of members representing the infection control community.

(B) The director of the department of health shall conduct a national and state specific public reporting format scan of hospital acquired infection public reporting to be completed and transmitted to the steering committee and referred to the advisory committee by October 1, 2008.

(C) The advisory committee shall assist and advise the steering committee and the department in the development of all aspects of the department’s methodology for collecting, analyzing, and disclosing the information collected under this act, including collection methods, formatting, and methods and means for release and dissemination.

(D) In developing the methodology for collecting and analyzing the hospital infection data, the department, steering committee and advisory committee shall consider existing methodologies and systems for data collection, such as the centers for disease control’s national healthcare safety network, or its successor; provided, however, the department’s discretion to adopt a methodology shall not be limited or restricted to any existing methodology or system. The data collection and analysis methodology shall be disclosed with the public report at the time of release.

(E) The department, steering committee and the advisory committee shall evaluate, on a regular basis, the quality and accuracy of hospital information reported under this act and the data collection, analysis, and dissemination methodologies.

(ii) Hospital reports:

(A) Individual hospitals shall collect data on hospital-acquired infections for the specific clinical procedures determined by the department by regulation, which may include the following general categories as further defined by the advisory committee:

(I) Surgical site infections;

(II) Ventilator-associated pneumonia;

(III) Central line-related bloodstream infections;

(IV) Urinary tract infections;

(V) Process of care measures, such as compliance with the surgical infection prevention/surgical care improvement program (SIP/SCIP) parameters, prevention bundles for central line-associated bloodstream infections, prevention bundles for catheter-associated urinary tract infections, hand hygiene compliance, compliance with isolation precautions; and

(VI) Other categories as recommended by the advisory committee.

(B) Beginning on or before April 1, 2009, hospitals shall submit quarterly reports on their hospital-acquired infection rates to the department. Quarterly reports shall be submitted, in a format set forth in regulations adopted by the department. Data in quarterly reports must cover a period ending not earlier than one month prior to submission of the report. Annual reports shall be made available to the public at each hospital and through the department. The first annual report shall be due no later than October 2010.

(C) The advisory committee shall recommend standardized criteria for reporting surgical site infection outcome data for quality improvement recommendations. This will include standards for post discharge surveillance. The information shall be included in hospital’s quality improvement and safety plan to reduce surgical site infection. The advisory committee shall recommend written guidelines to be given to every individual before and if necessary during their hospitalization for the purpose of preventing hospital-acquired infections. In emergency hospitalizations, written guidelines shall be given within a reasonable period of time.

(D) If the hospital is a division or subsidiary of another entity that owns or operates other hospitals or related organizations, the quarterly report shall be for the specific division or subsidiary and not the other entity.

(iii) Department reports:

(A) The department shall annually submit to the legislature a report summarizing the hospital quarterly reports and shall publish the annual report on its website. The first annual report shall be submitted and published no later than December 2010. Following the initial report, the department shall update the public information on a yearly basis after it has been reviewed by the steering committee with advice from the hospital-acquired infections and prevention advisory committee.

(B) All reports of outcome measures issued by the department may be risk-adjusted using NHSN methodology or other nationally accepted methodology, to adjust for the differences among hospitals as reviewed and recommended by the hospital-acquired infections and prevention advisory committee.

(C) The annual report shall compare hospital-acquired infection data as recommended by the advisory committee, collected under subsection (9)(B), for each individual hospital in the state. The department, in consultation with the advisory committee, shall make this comparison as easy to comprehend as possible. The report shall also include an executive summary, written in plain language that shall include, but not be limited to, a discussion of findings, conclusions, and trends concerning the overall state of hospital-acquired infections in the state, including a comparison to prior years. The report may include policy recommendations, as appropriate.

(D) The department shall publicize the report and its availability as widely as practical to interested parties, including, but not limited to, hospitals, providers, media organizations, health insurers, health maintenance organizations, purchasers of health insurance, organized labor, consumer or patient advocacy groups, and individual consumers. The annual report shall be made available to any person upon request.

(E) No hospital report of department disclosure may contain information identifying a patient, employee, or licensed healthcare professional in connection with a specific infection incident.

(10) Consideration of pressure ulcer occurrence; and

(11) Other related issues as requested by the director.

(b) The members of the health care quality performance steering committee shall include one member of the house of representatives, to be appointed by the speaker; one member of the senate, to be appointed by the president of the senate; the director or director’s designee of the department of human services; the director or the director’s designee of the department of behavioral healthcare, developmental disabilities and hospitals; the director or the director’s designee of the office of healthy aging; and thirteen (13) members to be appointed by the director of the department of health to include persons representing Rhode Island licensed hospitals and other licensed facilities/providers, the medical and nursing professions, the business community, organized labor, consumers, and health insurers and health plans and other parties committed to healthcare quality.