Healthcare Associated Infections
In 2006, the General Assembly amended the MHCC’s statute to give it authority to collect and report information on healthcare-associated infections in hospitals. HG 19-134(e)(6)
The Commission convened an HAI Technical Advisory Committee (TAC) composed of hospital infection preventionists, hospital epidemiologists, public health professionals, and patients/health care consumers. In December 2007 the TAC released a report, Developing a System for Collecting and Publicly Reporting Data on Healthcare-Associated Infections in Maryland.
In 2010, the Commission developed the Maryland Healthcare-Associated Infections (HAI) Prevention Plan in consultation with the Department of Health and Mental Hygiene (DHMH), Infectious Disease and Environmental Health Administration’s (IDEHA) Office of Infectious Disease, Epidemiology and Outbreak Response, and with the Maryland Health Quality and Cost Council. The Commission’s HAI Advisory Committee guided the development of this initial plan and continues to provide on-going guidance.
2016 Revised Maryland Healthcare Associated Infections Prevention Plan: In 2016, DHMH updated the plan to address strategies for tracking, reporting, evaluating, and preventing healthcare-associated infections in the state.
Timeline for mandatory HAI reporting by Maryland hospitals
• Hospital enrollment in the CDC National Healthcare Safety Net (NHSN) system
• CLABSI in ICUs (Adult/Pediatrics, NICU)
• Active Surveillance Testing for MRSA in ICUs using MHCC survey. The requirement ended in 2012 following sustained hospital performance over 90%.
• Healthcare Worker Influenza Vaccination Rates using MHCC survey
• SSI reporting for hip, knee, and CABG procedures
• Clostridium difficile LabID facility-wide inpatient locations (July 1st)
• Expanded data collection requirements to align with CMS (effective January 1, 2014)
• Maryland aligns with CMS reporting requirements
• CAUTI in adult/pediatric ICUs
• MRSA bacteremia LabID facility-wide inpatient locations
• SSI for abdominal hysterectomy and colon
• NHSN Healthcare Personnel Influenza Vaccination module, reporting expanded to all outpatient healthcare personnel
• Both CLABSI and CAUTI reporting expanded to include adult/pediatric medical, surgical, and medical/surgical wards
MHCC Data Schedule: This schedule includes dates for initial data pulls, preview reports, and public reporting of HAI hospital data on the Quality Reports website.
Healthcare Associated Infections (HAI) Advisory Committee Roster: The roster of HAI Advisory Committee members is available.
HAI Advisory Committee Meeting Dates: This is the schedule for the 2017 Healthcare Associated Infections Advisory Committee. They meet on a quarterly basis at the MHCC offices, with other meetings as needed.
Summaries of past HAI Advisory Committee meetings: Past summaries and agendas are available on the MHCC website.
Auditing the HAI data reported by the hospitals is a key component of the MHCC public reporting initiative. MHCC has been reviewing and auditing HAI data since 2009 soon after public reporting began.
Current SSI and CAUTI Audit: This document describes the 2015/2016 audit of SSI and CAUTI data. Findings will be shared in a webinar in the near future.
Healthcare-Associated Infections (HAI) Data Quality Review Findings SFY 2015 (November 18, 2015)
Quality of Surgical Site Infection Reporting by Maryland Hospitals (May 6, 2014)
Healthcare-Associated Infections (HAI) Data Quality Review and Chart Audit SFY 2012 and SFY 2013 (May 22, 2013)
Healthcare-Associated Infections (HAI) Data Quality Review and Chart Audit (May 23, 2012)
Maryland Central Line-Associated Blood Stream Infections: Data Quality Review and Chart Audit (June 2010) Report
Maryland Central Line-Associated Blood Stream Infections: Data Quality Review and Chart Audit (June 2010) Presentation
Upcoming Webinars (Learn More)
• DHMH CAAUSE
• VHQC Affinity Group
Health Services Cost Review Commission: The HAI data collected through the NHSN surveillance system is used in the HSCRC Quality Based Reimbursement (QBR) methodology.
Maryland Hospital Association
Maryland Patient Safety Center: The Clean Collaborative focuses on proper cleaning and disinfection of facility-wide, high-touch areas to reduce HAIs.
VHQC Maryland & Virginia Quality Innovation Network: Maryland and Virginia hospitals are participating in a collaborative focusing on reducing CLABSI, CAUTI, CDI, and VAE.
Antibiotic Resistance Patient Safety Atlas: This online tool provides data about healthcare-associated infections (HAIs) caused by antibiotic resistant bacteria reported through NHSN. More information is available online.
CMS HAI Reporting Requirements: While Maryland has a Medicare waiver, Maryland has aligned with CMS reporting requirements as of January 1, 2014. The CMS healthcare facility HAI reporting requirements for different healthcare facilities via NHSN, are available online.
Maryland HAI Progress Report: Maryland’s 2015 HAI Progress Report is available online. Past Year Reports are also available online.
NHSN: HAI data reported on the website is pulled from the CDC's National Healthcare Safety Network (NHSN). Training materials for acute care hospitals are available online.