Reporting of Healthcare-Associated Infections (HAI) by CAHs (FMT Policy Brief #39)


Healthcare-Associated Infections (HAIs) in hospitals have garnered considerable attention in recent years and are the focus of multiple national and state reporting requirements and prevention initiatives. The purpose of this policy brief is to describe state HAI reporting requirements and the extent to which they apply to CAHs, and analyze data reported by CAHs on publicly-reported HAI measures in Hospital Compare. Key Findings:

  • A review of state statutes and regulations indicates that 34 of the 45 Flex states require hospitals to report data to the state and/or the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) on one or more Healthcare Associated Infections (HAIs).
  • In 12 of these 34 states, the HAI reporting requirement only applies to Prospective Payment System (PPS) hospitals or to hospitals with Intensive Care Units (ICUs); specifically excludes Critical Access Hospitals (CAHs) or low-volume hospitals; or includes a waiver or exemption process.
  • Among the six HAIs reported to Hospital Compare via NHSN, CAHs were most likely to report data on CDI (283 CAHs, 21.2%) and MRSA (227 CAHs, 17%), followed by SSI for colon surgery (189 CAHs, 14.1%), SSI for hysterectomy (153 CAHs, 11.4%), and CLABSI and CAUTI (147 CAHs, 11% each).
  • Although many CAHs do not have the minimum number of cases to calculate facility-level risk-standardized infection ratios, analysis of pooled data from groups of similar facilities can help track infection trends and identify potential targets for HAI prevention and quality improvement initiatives at the state level or among groups of CAHs providing similar services.

Another FMT policy brief describes evidence-based programs and strategies for reducing HAIs in CAHs.


Hospital Compare MBQIP Quality