Senate Bill 2360

AN ACT ENTITLED THE "HOSPITAL INFECTIONS DISCLOSURE ACT OF 2010"; TO PROVIDE DEFINITIONS; TO EMPOWER AND DIRECT THE STATE DEPARTMENT OF HEALTH TO REQUIRE ACUTE CARE HOSPITALS AND AMBULATORY SURGICAL FACILITIES TO COLLECT AND PROVIDE STATISTICAL QUARTERLY REPORTS ON HOSPITAL-ACQUIRED INFECTION RATES FOR SPECIFIC CLINICAL PROCEDURES; TO PROVIDE FOR THE APPOINTMENT OF AN ADVISORY COMMITTEE TO ASSIST THE DEPARTMENT IN DEVELOPING A METHODOLOGY FOR SAID REPORTS; TO PROVIDE FOR CONFIDENTIALITY; TO PROVIDE CIVIL PENALTIES FOR NONCOMPLIANCE WITH SAID REPORTING REQUIREMENTS; TO AMEND SECTIONS 41-9-15, 41-75-11 AND 41-9-63, MISSISSIPPI CODE OF 1972, IN CONFORMITY THERETO; AND FOR RELATED PURPOSES.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MISSISSIPPI:

SECTION 1. This act shall be known and may be cited as the "Hospital Infections Disclosure Act of 2010."

SECTION 2. For purposes of this act:

(a) "Department" means the Mississippi Department of Health.

(b) "Hospital" means an acute care health care facility licensed under the provisions of Sections 41-9-1 through 41-9-35, Mississippi Code of 1972, and a hospital-affiliated or freestanding outpatient ambulatory surgical facility licensed under the provisions of Section 41-75-1 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 department by regulation, including the following categories:

(a) Surgical site infections;

(b) Ventilator-associated pneumonia;

(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, 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 to the report.

(b) 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 parent hospital.

(3) (a) The executive director of the department shall appoint an advisory committee, including representatives of 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. In developing the methodology for collecting and analyzing the infection rate 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.

(4) 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 (1).

SECTION 4. (1) The department shall annually submit to the Legislature a report summarizing the hospital quarterly reports and shall publish the annual report on its Web site. The first annual report shall be submitted and published in 2010. 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 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.

(4) 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.

(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. A determination that a hospital has violated the provisions of this act may result in any of the following:

(a) Termination of licensure or other sanctions relating to licensure.

(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.

SECTION 7. The department shall be responsible for ensuring compliance with this act as a condition of licensure and shall enforce such compliance according to the provisions of Sections 41-9-1 through 41-9-35 and Section 41-75-1 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, 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 Sections 41-9-1 through 41-9-35, which shall specifically include the provisions of the Hospital Infections Disclosure Act of 2010, Sections 1 through 7 of this act.

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.

SECTION 9. Section 41-75-11, Mississippi Code of 1972, is amended as follows:

41-75-11. The licensing agency after notice and opportunity for a 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 this chapter, specifically including the provisions of the Hospital Infections Disclosure Act of 2010, Sections 1 through 7 of this act. Such notice shall be effected by registered mail, or by personal service setting forth the particular reasons for the proposed action and fixing a date not less than thirty (30) days from the date of such mailing or such service, at which time 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 to the chancery court in the county in which such facility is located in the manner prescribed in Section 43-11-23, Mississippi Code of 1972. 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 recorded but need not be transcribed unless the decision is appealed pursuant to Section 43-11-23, Mississippi Code of 1972. 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 provided any other party desiring a copy of the transcript shall pay therefor the reasonable cost of preparing the same.

SECTION 10. Section 41-9-63, Mississippi Code of 1972, is amended as follows:

41-9-63. All hospitals, their officers or employees and medical and nursing personnel practicing therein, shall with reasonable promptness prepare, make and maintain true and accurate hospital records complying with such methods and minimum standards as may be prescribed from time to time by rules and regulations adopted by the licensing agency, which shall specifically include the requirements of the Hospital Infections Disclosure Act of 2010, Sections 1 through 7 of this act.

SECTION 11. This act shall take effect and be in force from and after July 1, 2010.