2005 Regular Session
To: Public Health and Human Services
By: Representative Janus
AN ACT CREATE THE HOSPITAL INFECTIONS DISCLOSURE ACT; TO REQUIRE HOSPITALS TO COLLECT DATA ON HOSPITAL-ACQUIRED INFECTION RATES FOR THE SPECIFIC CLINICAL PROCEDURES DETERMINED BY THE STATE BOARD OF HEALTH BY REGULATION AND SUBMIT QUARTERLY REPORTS ON THEIR HOSPITAL-ACQUIRED INFECTION RATES TO THE STATE DEPARTMENT OF HEALTH; TO PROVIDE FOR THE APPOINTMENT OF AN ADVISORY COMMITTEE TO ASSIST THE DEPARTMENT IN THE DEVELOPMENT OF ALL ASPECTS OF THE DEPARTMENT'S METHODOLOGY FOR COLLECTING, ANALYZING AND DISCLOSING THE INFORMATION COLLECTED UNDER THIS ACT; TO DIRECT THE DEPARTMENT TO SUBMIT AN ANNUAL REPORT TO THE LEGISLATURE SUMMARIZING THE HOSPITAL QUARTERLY REPORTS; TO PROVIDE THAT HOSPITAL REPORTS AND DEPARTMENT DISCLOSURES SHALL NOT CONTAIN INFORMATION IDENTIFYING A PATIENT, EMPLOYEE OR LICENSED HEALTH CARE PROFESSIONAL IN CONNECTION WITH A SPECIFIC INFECTION INCIDENT; TO PROVIDE PENALTIES FOR VIOLATIONS OF THIS ACT; TO AMEND SECTION 41-9-15, MISSISSIPPI CODE OF 1972, TO CONFORM TO THE PRECEDING PROVISIONS; AND FOR RELATED PURPOSES.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MISSISSIPPI:
SECTION 1. This act may be cited as the Hospital Infections Disclosure Act.
SECTION 2. For purposes of this act:
(a) "Department" means the State Department of Health.
(b) "Hospital" means an acute care health care facility licensed as a hospital under Section 41-9-1 et seq.
(c) "Hospital-acquired infection" means a localized or systemic condition (i) that results from adverse reaction to the presence of an infectious agent(s) or its toxin(s) and (ii) that was not present or incubating at the time of admission to the hospital.
SECTION 3. (1) Individual hospitals shall collect data on hospital-acquired infection rates for the specific clinical procedures determined by the State Board of Health by regulation, including the following categories:
Surgical site infections;
(b) Ventilator-associated pneumonia;
(c) Central line-related bloodstream infections;
(d) Urinary tract infections; and
(e) Other categories as provided under subsection (4) of this section.
(2) (a) Hospitals shall submit quarterly reports on their hospital-acquired infection rates to the department. Quarterly reports shall be submitted to the department, in a format prescribed by regulation of the State Board of Health, by April 30, July 31, October 31 and January 31 of each year for the previous quarter. Data in quarterly reports must cover a period ending not earlier than one (1) month before submission of the report. Quarterly reports shall be made available to the public at each hospital and through the department. The first quarterly report is due on October 31, 2005.
(2) 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 for the other entity.
(3) (a) The executive director of the department shall appoint an advisory committee, including representatives from public and private hospitals (including from hospital infection control departments), direct 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 interests other than hospitals.
(b) The advisory committee shall assist 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.
(c) In developing the methodology for collecting and analyzing the infection rate data, the department and the advisory committee shall consider existing methodologies and systems for data collection, such as the Centers for Disease Control's National Nosocomial Infection Surveillance Program, or its successor; 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 to the public before any public disclosure of hospital-acquired infection rates.
(d) The department 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.
(4) The department, after consultation with the advisory committee, may require hospitals to collect data on hospital-acquired infection rates in categories in addition to those specifically set forth in subsection (1) of this section.
SECTION 4. (1) The department shall submit an annual report to the Legislature summarizing the hospital quarterly reports and shall publish the annual report on its website. The first annual report shall be submitted and published in 2006. The annual report required by this section may be included in the annual report published under Section 41-9-29. The department may issue quarterly informational bulletins at its discretion, summarizing all or part of the information submitted in the hospital quarterly reports.
(2) All reports issued by the department shall be risk adjusted.
(3) The annual report shall compare the risk-adjusted hospital-acquired infection rates collected under Section 3 of this act 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 also shall 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.
(4) The department shall publicize the annual 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.
(5) No hospital report or department disclosure may contain information identifying a patient, employee or licensed health care professional in connection with a specific infection incident.
SECTION 5. It is the expressed intent of the Legislature that a patient's right of confidentiality shall not be violated in any manner. Patient social security numbers and any other information that could be used to identify an individual patient shall not be released, notwithstanding any other provision of law.
SECTION 6. If the department determines that a hospital has violated any of the provisions of this act, the hospital may be subject to any of the following:
(a) Suspension or revocation of licensure or other sanctions relating to licensure under Section 41-9-1 et seq.
A civil penalty of up to One Thousand Dollars ($1,000.00) per day per
violation for each day the hospital is in violation of the act.
SECTION 7. The department shall be responsible for ensuring compliance with this act as a condition of licensure under Section 41-9-1 et seq. and shall enforce that compliance according to the provisions of Section 41-9-1 et seq.
SECTION 8. Section 41-9-15, Mississippi Code of 1972, is amended as follows:
41-9-15. The licensing agency, after notice and opportunity for hearing to the applicant or licensee, may deny, suspend or revoke a license in any case in which it finds that there has been a substantial failure to comply with the requirements established under Section 41-9-1 through 41-9-35 or the provisions of Section 1 through 7 of this act.
The notice shall be effected by registered mail, or by personal service, setting forth the particular reasons for the proposed action and a fixing date not less than thirty (30) days from the date of the mailing or service, at which the applicant or licensee shall be given an opportunity for a prompt and fair hearing. On the basis of any such hearing, or upon default of the applicant or licensee, the licensing agency shall make a determination specifying its findings of fact and conclusions of law. A copy of that determination shall be sent by registered mail or served personally upon the applicant or licensee. The decision revoking, suspending or denying the license or application shall become final thirty (30) days after it is so mailed or served, unless the applicant or licensee, within the thirty-day period, appeals the decision, under Section 41-9-31.
The procedure governing hearings authorized by this section shall be in accordance with rules promulgated by the licensing agency. A full and complete record shall be kept of all proceedings, and all testimony shall be reported but need not be transcribed unless the decision is appealed under Section 41-9-31. Witnesses may be subpoenaed by either party. Compensation shall be allowed to witnesses as in cases in the chancery court. Each party shall pay the expense of his own witnesses. The cost of the record shall be paid by the licensing agency. Any other party desiring a copy of the transcript shall pay * * * the reasonable cost of preparing the same.
SECTION 9. This act shall take effect and be in force from and after July 1, 2005.