What Hospitals Must Report to the Department of Health

Adverse Events

Acute care hospitals and psychiatric hospitals must report to the department within 48 hours certain serious adverse events categories as adopted by the National Quality Forum.

Unprofessional Conduct

A medical facility (hospital, ambulatory surgery center, etc.) must report to the department when the hospital restricts the privileges of a practitioner based on professional misconduct, substandard practice or because of a mental or physical condition.

Reportable Operational or Maintenance Events

Acute care hospitals must report to the department within 48 hours certain serious events affecting the operation and maintenance of the facility.

Notifiable Conditions

Certain communicable diseases or conditions of public health importance, once discovered at a facility, must be reported to the department.

Healthcare Associated Infections

Acute care hospitals must report monthly to the department certain data about healthcare associated infections (HAI) and on those at-risk for infection, using CDC's National Healthcare Safety Network (NHSN) protocols.

Other Administrative Matters to Report

Accreditation Decision

Acute care hospitals must report any accreditation decision or any changes in accreditation status to the department within 30 calendar days.

Accreditation Survey

Acute care hospitals must report that an accreditation survey has been completed within two business days following the completion of the survey.

Changes to Certain Policies

Acute care hospitals must submit to the department certain policies and report any changes or additions to these policies. They include policies regarding admission, nondiscrimination, reproductive health, end of life and charity care.