(a) Individual hospitals shall collect data on health-care associated infection rates related to specific clinical procedures as determined by the Advisory Committee and set forth in regulations promulgated by the Department. Examples may include the following categories:
(1) Surgical site infections such as total hip and knee arthroplasty;
(2) Central line-related bloodstream infections in an intensive care unit (ICU);
(3) Direct health-care provider's influenza vaccination rates; and
(4) Other categories as provided under subsection (c) of this section.
(b) (1) Infection control professionals, or a designee, of hospitals shall submit quarterly reports on their health-care associated infection rates to the Department using the accepted Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) definitions. Prevention and control data related to quality measures will be based on nationally recognized and recommended standards that may include those developed by the CDC, Centers for Medicare and Medicaid, and/or the Agency for Healthcare, Research and Quality, to name a few. Data in quarterly reports must cover a period ending not earlier than 45 days prior to submission of the report. Quarterly reports shall be made available to each hospital 45 days after submittal to the Department for review by the hospitals. The hospitals shall have 7 days to review the quarterly reports and report any changes to the Department. Following the 7-day review period, such quarterly reports shall be made available to the public at each hospital and through the Department (the “public report”).
(2) 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 for the other entity.
(c) After June 30, 2010, and upon consultation with the Advisory Committee and other experts in infection, prevention, identification and control, the Department may revise categories of infections set forth in subsection (a) of this section.