SF 983

as introduced - 84th Legislature (2005 - 2006) Posted on 12/15/2009 12:00am

A bill for an act
relating to health; expanding the Adverse Health Care
Events Reporting Act to include facility-acquired
infection rates; amending Minnesota Statutes 2004,
sections 144.7063, by adding a subdivision; 144.7065,
subdivisions 1, 6, 8, by adding a subdivision;
144.7067.

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

Section 1.

Minnesota Statutes 2004, section 144.7063, is
amended by adding a subdivision to read:

new text begin Subd. 3a. new text end

new text begin Facility-acquired
infection. new text end

new text begin "Facility-acquired infection" means a localized or
systemic condition that:
new text end

new text begin (1) results from an adverse reaction to the presence of an
infectious agent or its toxin; and
new text end

new text begin (2) was not present or incubating at the time of the
patient's admission to the facility.
new text end

Sec. 2.

Minnesota Statutes 2004, section 144.7065,
subdivision 1, is amended to read:

Subdivision 1.

Reports of adverse health care events
required.

new text begin (a) new text end Each facility shall report to the commissioner
the occurrence of any of the adverse health care events
described in subdivisions 2 to 7 as soon as is reasonably and
practically possible, but no later than 15 working days after
discovery of the event.

new text begin (b) Each facility shall collect the data described under
subdivision 7a and submit quarterly reports to the commissioner
by April 30, July 31, October 31, and January 31 each year for
the previous quarter. Data in the quarterly reports must cover
a period ending no earlier than one month prior to submission of
the report.
new text end

new text begin (c) new text end The deleted text begin report deleted text end new text begin reports new text end shall be filed in a format specified
by the commissioner and shall identify the facility but shall
not include any identifying information for any of the health
care professionals, facility employees, or patients involved.
The commissioner may consult with experts and organizations
familiar with patient safety when developing the format for
reporting and in further defining events in order to be
consistent with industry standards.

Sec. 3.

Minnesota Statutes 2004, section 144.7065,
subdivision 6, is amended to read:

Subd. 6.

Environmental events.

Events reportable under
this subdivision are:

(1) patient death or serious disability associated with an
electric shock while being cared for in a facility, excluding
events involving planned treatments such as electric
countershock;

(2) any incident in which a line designated for oxygen or
other gas to be delivered to a patient contains the wrong gas or
is contaminated by toxic substances;

(3) patient death or serious disability associated with a
burn incurred from any source while being cared for in a
facility;

(4) patient death associated with a fall while being cared
for in a facility; deleted text begin and
deleted text end

(5) patient death or serious disability associated with the
use or lack of restraints or bedrails while being cared for in a
facility new text begin ; and
new text end

new text begin (6) patient death or serious disability associated with a
facility-acquired infection new text end .

Sec. 4.

Minnesota Statutes 2004, section 144.7065, is
amended by adding a subdivision to read:

new text begin Subd. 7a. new text end

new text begin Facility-acquired infection rates. new text end

new text begin Each
facility shall collect data on facility-acquired infection rates
for clinical procedures determined by the commissioner and shall
include the following categories:
new text end

new text begin (1) surgical site infections;
new text end

new text begin (2) ventilator-associated pneumonia;
new text end

new text begin (3) central line-related bloodstream infections; and
new text end

new text begin (4) urinary tract infections.
new text end

new text begin The commissioner may require facilities to collect data for
additional categories.
new text end

Sec. 5.

Minnesota Statutes 2004, section 144.7065,
subdivision 8, is amended to read:

Subd. 8.

Root cause analysis; corrective action plan.

Following the occurrence of an adverse health care
event new text begin described in subdivisions 2 to 7 new text end , the facility must
conduct a root cause analysis of the event. Following the
analysis, the facility must: (1) implement a corrective action
plan to implement the findings of the analysis or (2) report to
the commissioner any reasons for not taking corrective action.
If the root cause analysis and the implementation of a
corrective action plan are complete at the time an event must be
reported, the findings of the analysis and the corrective action
plan must be included in the report of the event. The findings
of the root cause analysis and a copy of the corrective action
plan must otherwise be filed with the commissioner within 60
days of the event.

Sec. 6.

Minnesota Statutes 2004, section 144.7067, is
amended to read:

144.7067 COMMISSIONER DUTIES AND RESPONSIBILITIES.

Subdivision 1.

Establishment of reporting system.

(a)
The commissioner shall establish an adverse health event
reporting system designed to facilitate quality improvement in
the health care system. The reporting system shall not be
designed to punish errors by health care practitioners or health
care facility employees.

(b) The reporting system shall consist of:

(1) mandatory reporting by facilities of 27 adverse health
care events new text begin and of facility-acquired infection rates new text end ;

(2) mandatory completion of a root cause analysis and a
corrective action plan by the facility and reporting of the
findings of the analysis and the plan to the commissioner or
reporting of reasons for not taking corrective action;

(3) analysis of reported information by the commissioner to
determine patterns of systemic failure in the health care system
and successful methods to correct these failures;

(4) sanctions against facilities for failure to comply with
reporting system requirements; and

(5) communication from the commissioner to facilities,
health care purchasers, and the public to maximize the use of
the reporting system to improve health care quality.

(c) The commissioner is not authorized to select from or
between competing alternate acceptable medical practices.

Subd. 2.

Duty to analyze reports; communicate findings.

The commissioner shall:

(1) analyze adverse event reports, corrective action plans,
and findings of the root cause analyses to determine patterns of
systemic failure in the health care system and successful
methods to correct these failures;

(2) communicate to individual facilities the commissioner's
conclusions, if any, regarding an adverse event reported by the
facility;

(3) communicate with relevant health care facilities any
recommendations for corrective action resulting from the
commissioner's analysis of submissions from facilities; and

(4) publish an annual report:

(i) describing, by deleted text begin institution deleted text end new text begin facility new text end , adverse events
reported;

(ii) outlining, in aggregate, corrective action plans and
the findings of root cause analyses; deleted text begin and
deleted text end

(iii) new text begin comparing the risk-adjusted facility infection rates
for each facility describing findings, conclusions, and trends
concerning the overall prevalence of facility-acquired
infections in the state, including a comparison to prior years;
and
new text end

new text begin (iv) new text end making recommendations for modifications of state
health care operations.

Subd. 3.

Sanctions.

(a) The commissioner shall take
steps necessary to determine if adverse event reports, the
findings of the root cause analyses, and corrective action plans
are filed in a timely manner. The commissioner may sanction a
facility for:

(1) failure to file a timely adverse event report under
section 144.7065, subdivision 1 new text begin , paragraph (a), or a timely
facility-acquired infection data report under section 144.7065,
subdivision 1, paragraph (b) new text end ; or

(2) failure to conduct a root cause analysis, to implement
a corrective action plan, or to provide the findings of a root
cause analysis or corrective action plan in a timely fashion
under section 144.7065, subdivision 8.

(b) If a facility fails to develop and implement a
corrective action plan or report to the commissioner why
corrective action is not needed, the commissioner may suspend,
revoke, fail to renew, or place conditions on the license under
which the facility operates.

Sec. 7. new text begin EFFECTIVE DATE.
new text end

new text begin Sections 1 to 6 are effective January 1, 2006.
new text end