Chapter 168
2010 -- S 2994
Enacted 06/25/10
A N A C T
RELATING TO
HEALTH AND SAFETY -- HEALTH CARE QUALITY PROGRAM
Introduced By: Senators Gallo, Perry, Miller, Pichardo, and DeVall
Date Introduced: June 08, 2010
It is enacted by the General
Assembly as follows:
SECTION 1. Sections 23-17.17-2 and 23-17.17-6 of the General
Laws in Chapter 23-
17.17 entitled "Health
Care Quality Program" are hereby amended to read as follows:
23-17.17-2.
Definitions. -- (a) "Clinical outcomes"
means information about the results
of patient care and treatment.
(b)
"Director" means the director of the department of health or his or
her duly
authorized agent.
(c) "Health care
facility" has the same meaning as contained in the regulations
promulgated by the director of health pursuant to chapter 17 of
this title.
(d) "Health care
provider" means any physician, or other licensed practitioners with
responsibility for the care, treatment, and services rendered to a
patient.
(e)
"Hospital-acquired infection" means a localized or systemic
condition: (1) that results
from adverse reaction to the presence of an infectious
agent(s) or its toxin(s); and (2) may include
infections not present or exhibiting signs and symptoms at the
time of admission to the hospital as
determined by the department with recommendations from the
health care quality steering
committee with advice from the hospital acquired infections and
prevention advisory committee.
(f) "Insurer"
means any entity subject to the insurance laws and regulations of this state,
that contracts or offers to contract to provide, deliver,
arrange for, pay for, or reimburse any of the
costs of health care services, including, without
limitation, an insurance company offering
accident and sickness insurance, a health maintenance
organization, as defined by section 27-41-
1, a nonprofit hospital or medical service
corporation, as defined by chapters 27-19 and 27-20, or
any other entity providing a plan of health insurance or
health benefits.
(g) "Patient
satisfaction" means the degree to which the facility or provider meets or
exceeds the patients' expectations as perceived by the
patient by focusing on those aspects of care
that the patient can judge.
(h) "Performance
measure" means a quantitative tool that provides an indication of an
organization's performance in relation to a specified process or
outcome.
(i)
"Quality of care" means the result or outcome of health care efforts.
(j) "Reporting
program" means an objective feedback mechanism regarding individual or
facility performance that can be used internally to support
performance improvement activities
and externally to demonstrate accountability to the
public and other purchasers, payers, and
stakeholders.
(k)
"Risk-adjusted" means the use of statistically valid techniques to
account for patient
variables that may include, but need not to be limited to, age,
chronic disease history, and
physiologic data.
(l) "Consumer
information" means, but is not limited to, providing written
recommendations to every individual before and during their
hospitalization for the purpose of
preventing hospital acquired infections. In emergency
hospitalizations, written guidelines shall be
given within a reasonable period of time.
23-17.17-6.
Health care quality steering committee. -- (a) The director shall establish
and serve as chairperson of a health care quality
steering committee of no more than nineteen (19)
members to advise in the following matters:
(1) Determination of
the comparable performance measures to be reported on;
(2) Assessment of
factors, including, but not limited to, factors related to incidents and
events reported to the department pursuant to section
23-17-40, contributing to the provision of
quality health care and patient safety;
(3) Selection of the
patient satisfaction survey measures and instrument;
(4) Methods and format
for data collection;
(5) Program expansion
and quality improvement initiatives;
(6) Format for the
public quality performance measurement report;
(7) Consideration of
nursing-sensitive performance measures to be reported on;
(8) Consideration of the
relationship between human resources and quality, beginning
with measurement and reporting for nursing staff;
(9) Consideration of
measures associated with hospital-acquired infections with
consultation of infections control experts and with the hospital-acquired
infections and prevention
advisory committee as established herein:
(i)
Hospital-acquired infections and prevention advisory committee:
(a) The director of the
department of health as the chairperson of the steering committee
shall appoint a permanent subcommittee called the
hospital-acquired infections and prevention
advisory committee. Membership shall include representatives
from public and private hospitals,
infection control professionals, director care nursing staff, physicians,
epidemiologists with
expertise in hospital-acquired infections, academic
researchers, consumer organizations, health
insurers, health maintenance organizations, organized labor,
and purchasers of health insurance,
such as employers. The advisory committee shall have a
majority of members representing the
infection control community.
(b) The director of the
department of health shall conduct a national and state specific
public reporting format scan of hospital acquired infection
public reporting to be completed and
transmitted to the steering committee and referred to the
advisory committee by October 1, 2008.
(c) The advisory
committee shall assist and advise the steering committee and the
department in the development of all aspects of the department's
methodology for collecting,
analyzing, and disclosing the information collected under this
act, including collection methods,
formatting, and methods and means for release and dissemination.
(d) In developing the methodology
for collecting and analyzing the hospital infection
data, the department, steering committee and advisory
committee shall consider existing
methodologies and systems for data collection, such as the centers
for disease control's national
healthcare safety network, or its successor; provided, however,
the department's discretion to
adopt a methodology shall not be limited or restricted to
any existing methodology or system. The
data collection and analysis methodology shall be
disclosed with the public report at the time of
release.
(e) The department,
steering committee and the advisory committee shall evaluate, on a
regular basis, the quality and accuracy of hospital
information reported under this act and the data
collection, analysis, and dissemination methodologies.
(ii) Hospital reports:
(a) Individual
hospitals shall collect data on hospital-acquired infections for the specific
clinical procedures determined by the department by
regulation, which may include the following
general categories as further defined by the advisory
committee:
(I) Surgical site
infections;
(II)
Ventilator-associated pneumonia;
(III) Central
line-related bloodstream infections;
(IV) Urinary tract
infections;
(V) Process of care
measures, such as compliance with the surgical infection
prevention/surgical care improvement program (SIP/SCIP)
parameters, prevention bundles for
central line-associated bloodstream infections, prevention
bundles for catheter-associated urinary
tract infections, hand hygiene compliance, compliance with
isolation precautions; and
(VI) Other categories
as recommended by the advisory committee.
(b) Beginning on or
before April 1, 2009, hospitals shall submit quarterly reports on their
hospital-acquired infection rates to the department. Quarterly reports
shall be submitted, in a
format set forth in regulations adopted by the department.
Data in quarterly reports must cover a
period ending not earlier than one month prior to submission
of the report. Annual reports shall
be made available to the public at each hospital and
through the department. The first annual
report shall be due no later than October 2010.
(c) The advisory committee
shall recommend standardized criteria for reporting surgical
site infection outcome data for quality improvement
recommendations. This will include
standards for post discharge surveillance. The information
shall be included in hospital's quality
improvement and safety plan to reduce surgical site infection. The
advisory committee shall
recommend written guidelines to be given to every individual
before and if necessary during their
hospitalization for the purpose of preventing hospital-acquired
infections. In emergency
hospitalizations, written guidelines shall be given within a
reasonable period of time.
(d) 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 the other entity.
(iii) Department
reports:
(a) The department
shall annually submit to the legislature a report summarizing the
hospital quarterly reports and shall publish the annual report
on its website. The first annual
report shall be submitted and published no later than
December 2010. Following the initial report,
the department shall update the public information on a
yearly basis after it has been reviewed by
the steering committee with advice from the
hospital-acquired infections and prevention advisory
committee.
(b) All reports of
outcome measures issued by the department may be risk-adjusted using
NHSN methodology or other nationally accepted methodology,
to adjust for the differences
among hospitals as reviewed and recommended by the
hospital-acquired infections and
prevention advisory committee.
(c) The annual report
shall compare hospital-acquired infection data as recommended by
the advisory committee, collected under subsection
(9)(b), for each individual hospital in the
state. The department, in consultation with the advisory
committee, shall make this comparison as
easy to comprehend as possible. The report shall also
include an executive summary, written in
plain language that shall include, but not be limited to, a
discussion of findings, conclusions, and
trends concerning the overall state of hospital-acquired
infections in the state, including a
comparison to prior years. The report may include policy
recommendations, as appropriate.
(d) The department
shall publicize the report and its availability as widely as practical to
interested parties, including, but not limited to, hospitals, providers,
media organizations, health
insurers, health maintenance organizations, purchasers of
health insurance, organized labor,
consumer or patient advocacy groups, and individual consumers.
The annual report shall be made
available to any person upon request.
(e) No hospital report
of department disclosure may contain information identifying a
patient, employee, or licensed health care professional in
connection with a specific infection
incident.
(10) Consideration of
pressure ulcer occurrence; and
(11) Other related
issues as requested by the director.
(b) The members of the
health care quality performance steering committee shall include
one member of the house of representatives, to be
appointed by the speaker; one member of the
senate, to be appointed by the president of the senate; the
director or director's designee of the
department of human services; the director or the director's
designee of the department of mental
health, retardation, and hospitals; the director or the
director's designee of the department of
elderly affairs; and thirteen (13) members to be appointed by
the director of the department of
health to include persons representing
facilities/providers, the medical and nursing professions, the business
community, organized
labor, consumers, and health insurers and health plans and
other parties committed to health care
quality.
SECTION 2. This act shall take effect upon passage.
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LC02883
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