§§1-7 -

C.26:2H-12.39 to


§8 –


§9 - Note to §§1-8


P.L. 2007, CHAPTER 196, approved October 31, 2007

Senate Committee Substitute for

Senate, Nos. 147 and 919



An Act concerning general hospitals, and supplementing Title 26 of the Revised Statutes and P.L.2004, c.9 (C.26:2H-12.23 et seq.).


     Be It Enacted by the Senate and General Assembly of the State of New Jersey:


     1.    Sections 1 through 7 of this act shall be known and may be cited as the “Health Care Facility-Associated Infection Reporting and Prevention Act.”


     2.    The Legislature finds and declares:

     a.     Health care facility-associated infections constitute a major public health problem in this country, affecting from 5% to 10% of hospitalized patients annually, resulting in an estimated two million infections, and 90,000 deaths, and adding an estimated $4.5 to $5.7 billion in health care costs;

     b.    Many health care facility-associated infections can be prevented, and a goal of zero health care facility-associated infections is desirable.  There are many simple and effective practices in hospitals that can dramatically reduce the incidence of health care facility-associated infections, such as hand washing, using gloves and properly sterilized equipment, and following the same established best practices, every time, for procedures such as the insertion of an intravenous tube to deliver fluids and medication;

     c.     The uniform reporting of health care facility-associated infections to the State, and the review and analysis of this data by the Department of Health and Senior Services, will provide a measurable means to assist hospitals in improving patient outcomes;

     d.    The federal Centers for Disease Control and Prevention recommends that states establishing public reporting systems for health care facility-associated infections focus on major site categories to report rates of health care facility-associated infections related to procedures and conditions including, but not limited to, urinary tract infections, surgical site infections, ventilator-associated pneumonia, and central line-related bloodstream infections.  A focus on major site categories helps ensure that data collection is concentrated in populations where health care facility-associated infections are more prevalent, and that the infection rates reported are most useful for targeting prevention practices and making comparisons among hospitals and within hospitals, over time;

     e.     The Department of Health and Senior Services currently provides comparative hospital performance data in its annual New Jersey Hospital Performance Report, and including information about hospital infection rates will further enhance the value of the report to the public and health care providers;  and

     f.     Therefore, it is a matter of public health and fiscal policy that patients in New Jersey’s hospitals receive health care that incorporates best practices in infection control, not only to protect their health and lives, but also to ensure the economic viability of New Jersey’s hospitals.


     3.    A general hospital licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) shall be required to report quarterly to the Department of Health and Senior Services, in a form and manner prescribed by the Commissioner of Health and Senior Services:

     a.     process quality indicators of hospital infection control that have been identified by the federal Centers for Medicare and Medicaid Services, as selected by the commissioner in consultation with the Quality Improvement Advisory Committee within the department; and 

     b.    beginning 30 days after the adoption of regulations pursuant to this act, data on infection rates for the major site categories that define health care facility-associated infection locations, multiple infections, and device-related and non-device related infections, identified by the federal Centers for Disease Control and Prevention, as selected by the commissioner in consultation with the Quality Improvement Advisory Committee within the department. 

     The information shall be transmitted in such a manner as to not include identifying information about patients.


     4.    The commissioner shall promptly advise a hospital in the event the commissioner determines that based on information reported by the facility, a change in facility practices or policy is necessary to improve performance in the prevention of health care facility-associated infection and quality of care provided at the facility.


     5.    The commissioner shall make available to members of the public, on the official Internet website of the Department of Health and Senior Services, the information reported pursuant to this act, in such a format as the commissioner deems appropriate to enable comparison among hospitals, with respect to the information, and shall include information in the New Jersey Hospital Performance Report annually issued by the commissioner that measures the performance of general hospitals in the State with respect to process quality indicators and health care facility-associated infection among patients.


     6.    The commissioner may, by regulation, expand the health care facility-associated infection reporting requirements in this act to other types of health care facilities, as the commissioner determines appropriate.


     7.    The Commissioner of Health and Senior Services, in consultation with the Quality Improvement Advisory Committee in the department, pursuant to the “Administrative Procedure Act,” P.L.1968, c.410 (C.52:14B-1 et seq.), shall adopt rules and regulations to effectuate the purposes of this act.

     The regulations shall: establish standard methods for identifying and reporting health care facility-associated infections; identify the major site categories for which infections shall be reported, taking into account the categories most likely to improve the delivery and outcome of health care in the State; and specify the methodology for presenting the data to the public, including procedures to adjust for differences in case mix and severity of infections among hospitals.


     8.    The Commissioner of Health and Senior Services and the Commissioner of Human Services shall compile their findings and recommendations for operational changes related to patient safety in health care facilities, based on information reported to the commissioners pursuant to the “Patient Safety Act,” P.L.2004, c.9 (C.26:2H-12.23 et seq.).

     The commissioners shall jointly issue an annual report of their findings and recommendations to the Governor, and to the Legislature pursuant to section 2 of P.L.1991, c.164 (C.52:14-19.1), to be made available on the official Internet website of the Department of Health and Senior Services.


     9.    This act shall take effect on the 90th day after enactment, except that the Commissioner of Health and Senior Services may take such anticipatory administrative action in advance as shall be necessary for the implementation of the act.




     Requires hospitals to report certain information concerning infection rates to DHSS and requires DHSS to make information public.