2005 Regular Session
To: Public Health and Welfare; Appropriations
By: Senator(s) Tollison
AN ACT ENTITLED THE HOSPITAL INFECTIONS DISCLOSURE ACT TO DIRECT HOSPITALS TO COLLECT DATA ON HOSPITAL-ACQUIRED INFECTION RATES FOR CERTAIN CLINICAL PROCEDURES; TO PROVIDE FOR THE APPOINTMENT OF AN ADVISORY COUNCIL TO DEVELOP A METHOD FOR COLLECTING SUCH DATA; TO PROVIDE FOR ANNUAL REPORTS; TO PROVIDE FOR CONFIDENTIALITY; TO PROVIDE CIVIL PENALTIES FOR NONCOMPLIANCE; TO AMEND SECTIONS 41-9-15 AND 41-9-17, MISSISSIPPI CODE OF 1972, TO PROVIDE THAT COMPLIANCE WITH INFECTIONS DISCLOSURE REQUIREMENT IS A CONDITION FOR ISSUANCE AND RENEWAL OF A HOSPITAL'S LICENSE; AND FOR RELATED PURPOSES.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MISSISSIPPI:
SECTION 1. (1) This act may be cited as the Hospital Infections Disclosure Act.
(2) For purposes of this act:
(a) "Department" means the Mississippi State Department of Health.
(b) "Hospital" means an acute care health care facility licensed 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.
(3) (a) Individual hospitals shall collect data on hospital-acquired infection rates for the specific clinical procedures determined by the department by regulation, including the following categories:
(i) Surgical site infections;
(ii) Ventilator-associated pneumonia;
(iii) Central line-related bloodstream infections;
(iv) Urinary tract infections; and
(v) Other categories as provided under subsection (4) of this section.
(b) 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, to the department by April 30, July 31, October 31 and January 31 each year for the previous quarter. Data in quarterly reports must cover a period ending not earlier than one (1) month prior to submission of the report. Quarterly reports shall be made available to the public at each hospital and through the department. The first quarterly report shall be due in 2006. 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.
(4) The Executive Director of the Mississippi State Department of Health shall appoint an advisory committee, including representatives from public and private hospitals, 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. 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. In developing the methodology for collecting and analyzing the infection rata data, the department and 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 prior to any public disclosure of hospital-acquired infection rates. 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. The department may, after consultation with the advisory committee, require hospitals to collect data on hospital-acquired infection rates in categories additional to those set forth in subsection (3).
(5) 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 in 2007. The department may issue quarterly informational bulletins at its discretion, summarizing all or part of the information submitted in the hospital quarterly reports. All reports issued by the department shall be risk adjusted. The annual report shall compare the risk-adjusted hospital-acquired infection rates, collected under Section 1 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 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. The department shall publicize the report and its availability as widely as practicable 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.
(6) 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. It is the 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.
(7) A determination that a hospital has violated the provisions of this section may result in any of the following:
(a) Termination of licensure or other sanctions relating to licensure under Section 41-9-15.
(b) 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, to be imposed by the department.
(8) The department shall be responsible for ensuring compliance with this section as a condition of licensure and shall enforce such compliance.
SECTION 2. 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, is authorized to 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.
Such 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 such 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 such 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 such thirty-day period, appeals the decision, pursuant to 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 pursuant to 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 therefor the reasonable cost of preparing the same.
The licensing agency shall be responsible for ensuring compliance with hospital-acquired infections disclosure requirements in Section 1 of Senate Bill No. 2893, 2005 Regular Session, and may impose a civil penalty of One Thousand Dollars ($1,000.00) per day per violation for each day the hospital is in violation of such requirements.
SECTION 3. Section 41-9-17, Mississippi Code of 1972, is amended as follows:
41-9-17. The licensing agency shall adopt, amend, promulgate and enforce such rules, regulations and standards with respect to all hospitals to be licensed under Section 41-9-11 as may be designed to further the accomplishment of the purposes of Sections 41-9-1 through 41-9-35 in promoting safe and adequate treatment of individuals in hospitals in the interest of public health, safety and welfare. Any rule, regulation or standard adopted hereunder shall be considered as promulgated and effective from and after the time the same is recorded and indexed in a book to be maintained by the licensing agency in its main office in the State of Mississippi, entitled "Minimum Standard of Operation for Mississippi Hospitals." Said book shall be open and available to all hospitals and the public generally at all reasonable times. Upon the adoption of any such rule, regulation or standard, the licensing agency shall mail copies thereof to all hospitals in the state which have filed with said agency their names and addresses for this purpose, but the failure to mail the same or the failure of the hospital to receive the same shall in nowise affect the validity thereof. No such rules, regulations or standards shall be adopted or enforced which would have the effect of denying a license to a hospital or other institution required to be licensed, solely by reason of the school or system of practice employed or permitted to be employed therein.
In addition, the licensing agency shall ensure compliance with the hospital-acquired infection disclosure requirements of Section 1 of Senate Bill No. 2893, 2005 Regular Session, as a condition of licensure under this chapter.
SECTION 4. This act shall take effect and be in force from and after July 1, 2005.