Health Care Acquired Infections Advisory Committee Appointed Roster October 1, 2007 Jim ...

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Health Care Acquired Infections Advisory Committee
Appointed Roster October 1, 2007
Jim Barnhart Jon Pelkey
Chief Executive Officer Quality Improvement & Medical Section Manager
Peace Harbor Hospital Department of Human Services, DMAP
Paul Cieslack, MD Mary Post
Manager, Acute & Communicable Manager, Infection Prevention and
Disease Prevention Control Program
Oregon Public Health Division Oregon Health and Sciences University
Lynn-Marie Crider Barbara Prowe
Public Policy Director Executive Director
Service Employees International Union, Oregon Coalition of Health Care
Local 49 Purchasers
Jim Dameron Rodger Sleven, MD
Administrator Physician
Oregon Patient Safety Commission Westhills Gastroenterology Associates,
PC
Kathleen Elias, RN
Administrator Jeanene Smith, MD, MPH
Regency Albany Administrator
Office for Oregon Health Policy &
Woody English, MD Research
Hospital Epidemiologist
Providence St Vincent Medical Center John Townes, MD
Assistant Professor of Medicine,
Ron Jamtgaard Division of Infectious Diseases
Retired Health Care IT Oregon Health and Sciences University
Mel Kohn, MD Dee Dee Vallier
State Epidemiologist Consumer
Department of Human Services, Public
Health Division, Office of Disease Staff
Prevention and Epidemiology Sean Kolmer, MPH
Research & Data Manager
Patricia Martinez, MD Office for Oregon Health Policy &
Chief Quality Officer Research
Asante Health Systems
James Oliver, MPH
Laura Mason Research Analyst
Clinical Risk Manager Office for Oregon Health Policy and
St. Charles Medical Center-Bend and Research
Cascade Healthcare Community
Shawna Kennedy-Walters
Policy & Analysis Assistant
Office for Oregon Health Policy and
Research

74th OREGON LEGISLATIVE ASSEMBLY--2007 Regular Session
Enrolled
House Bill 2524
Sponsored by Representatives TOMEI, GREENLICK; Representatives BARKER, BARNHART,
BOONE, BUCKLEY, CANNON, CLEM, COWAN, DINGFELDER, GALIZIO, GELSER,
GILLIAM, HOLVEY, LIM, NELSON, RILEY, ROSENBAUM, SHIELDS, WITT
CHAPTER .................................................
AN ACT
Relating to health care facility acquired infections; creating new provisions; amending ORS 442.445;
appropriating money; and declaring an emergency.
Be It Enacted by the People of the State of Oregon:
SECTION 1. The Legislative Assembly finds that Oregonians should be free from in-
fections acquired during the delivery of health care. Action taken in this state to prevent
health care acquired infections should be trustworthy, effective, transparent and reliable.
SECTION 2. As used in sections 1 to 6 of this 2007 Act:
(1) “Health care facility” has the meaning given that term in ORS 442.015.
(2) “Health care acquired infection” means a localized or systemic condition that:
(a) Results from an adverse reaction to the presence of an infectious agent or its toxin;
and
(b) Was not present or incubating at the time of admission to the health care facility.
(3) “Risk-adjusted methodology” means a standardized method used to ensure that in-
trinsic and extrinsic risk factors for a health care acquired infection are considered in the
calculation of health care acquired infection rates.
SECTION 3. (1) There is established in the Office for Oregon Health Policy and Research
the Oregon Health Care Acquired Infection Reporting Program. The program shall:
(a) Provide useful and credible infection measures, specific to each health care facility,
to consumers;
(b) Promote quality improvement in health care facilities; and
(c) Utilize existing quality improvement efforts to the extent practicable.
(2) The office shall adopt rules to:
(a) Require health care facilities to report to the office health care acquired infection
measures, including but not limited to health care acquired infection rates;
(b) Specify the health care acquired infection measures that health care facilities must
report; and
(c) Prescribe the form, manner and frequency of reports of health care acquired infection
measures by health care facilities.
(3) In prescribing the form, manner and frequency of reports of health care acquired in-
fection measures by health care facilities, to the extent practicable and appropriate to avoid
unnecessary duplication of reporting by facilities, the office shall align the requirements with
Enrolled House Bill 2524 (HB 2524-B) Page 1
the requirements for health care facilities to report similar data to the Department of Hu-
man Services and to the Centers for Medicare and Medicaid Services.
(4) The office shall utilize, to the extent practicable and appropriate, a credible and reli-
able risk-adjusted methodology in analyzing the health care acquired infection measures re-
ported by health care facilities.
(5) The office shall provide health care acquired infection measures and related infor-
mation to health care facilities in a manner that promotes quality improvement in the health
care facilities.
(6) The office shall adopt rules prescribing the form, manner and frequency for public
disclosure of reported health care acquired infection measures. The office shall disclose up-
dated information to the public no less frequently than every six months beginning January
1, 2010, and no less frequently than every calendar quarter beginning January 1, 2011.
(7) Individually identifiable health information submitted to the office by health care fa-
cilities pursuant to this section may not be disclosed to, made subject to subpoena by or used
by any state agency for purposes of any enforcement or regulatory action in relation to a
participating health care facility.
SECTION 4. (1) There is established the Health Care Acquired Infection Advisory Com-
mittee to advise the Administrator of the Office for Oregon Health Policy and Research re-
garding the Oregon Health Care Acquired Infection Reporting Program. The advisory
committee shall consist of 16 members appointed by the administrator as follows:
(a) Seven of the members shall be health care providers or their designees, including:
(A) A hospital administrator who has expertise in infection control and who represents
a hospital that contains fewer than 100 beds;
(B) A hospital administrator who has expertise in infection control and who represents
a hospital that contains 100 or more beds;
(C) A long term care administrator;
(D) A hospital quality director;
(E) A physician with expertise in infectious disease;
(F) A registered nurse with interest and involvement in infection control; and
(G) A physician who practices in an ambulatory surgical center and who has interest and
involvement in infection control.
(b) Nine of the members shall be individuals who do not represent health care providers,
including:
(A) A consumer representative;
(B) A labor representative;
(C) An academic researcher;
(D) A health care purchasing representative;
(E) A representative of the Department of Human Services;
(F) A representative of the business community;
(G) A representative of the Oregon Patient Safety Commission who does not represent
a health care provider on the commission;
(H) The state epidemiologist; and
(I) A health insurer representative.
(2) The Administrator of the Office for Oregon Health Policy and Research and the ad-
visory committee shall evaluate on a regular basis the quality and accuracy of the data col-
lected and reported by health care facilities under section 3 of this 2007 Act and the
methodologies of the Office for Oregon Health Policy and Research for data collection,
analysis and public disclosure.
(3) Members of the advisory committee are not entitled to compensation and shall serve
as volunteers on the advisory committee.
(4) Each member of the advisory committee shall serve a term of two years.
(5) The advisory committee shall make recommendations to the administrator regarding:
Enrolled House Bill 2524 (HB 2524-B) Page 2
(a) The health care acquired infection measures that health care facilities must report,
which may include but are not limited to:
(A) Surgical site infections;
(B) Central line related bloodstream infections;
(C) Urinary tract infections; and
(D) Health care facility process measures designed to ensure quality and to reduce health
care acquired infections;
(b) Methods for evaluating and quantifying health care acquired infection measures that
align with other data collection and reporting methodologies of health care facilities and that
support participation in other quality interventions;
(c) Requiring different reportable health care acquired infection measures for differently
situated health care facilities as appropriate;
(d) A method to ensure that infections present upon admission to the health care facility
are excluded from the rates of health care acquired infection disclosed to the public for the
health care facility under sections 3 and 6 of this 2007 Act;
(e) Establishing a process for evaluating the health care acquired infection measures
reported under section 3 of this 2007 Act and for modifying the reporting requirements over
time as appropriate;
(f) Establishing a timetable to phase in the reporting and public disclosure of health care
acquired infection measures; and
(g) Procedures to protect the confidentiality of patients, health care professionals and
health care facility employees.
(6) The Office for Oregon Health Policy and Research shall adopt rules implementing the
Oregon Health Care Acquired Infection Reporting Program no later than July 1, 2008. Health
care facilities shall begin reporting health care acquired infection measures under section 3
of this 2007 Act no later than January 1, 2009.
SECTION 5. Notwithstanding the term of office specified by section 4 of this 2007 Act,
of the members first appointed to the Health Care Acquired Infection Advisory Committee:
(1) Five shall serve for terms ending January 1, 2010.
(2) Five shall serve for terms ending January 1, 2011.
(3) The remaining members shall serve for a term ending January 1, 2012.
SECTION 6. (1) In addition to any report required pursuant to section 3 of this 2007 Act,
on or before April 30 of each year, the Administrator of the Office for Oregon Health Policy
and Research shall prepare an annual report summarizing the health care facility reports
submitted pursuant to section 3 of this 2007 Act. The Office for Oregon Health Policy and
Research shall make the reports available to the public in the manner provided in ORS
192.243 and to the Legislative Assembly in the manner provided in ORS 192.245. The first
report shall be made available no later than January 1, 2010.
(2) The annual report shall, for each health care facility in the state, compare the health
care acquired infection measures reported under section 3 of this 2007 Act. The office, in
consultation with the Health Care Acquired Infection Advisory Committee, shall provide the
information in the report in a format that is as easily comprehensible as possible.
(3) The annual report may include findings, conclusions and trends concerning the health
care acquired infection measures reported under section 3 of this 2007 Act, a comparison to
the health care acquired infection measures reported in prior years and any policy recom-
mendations.
(4) The office shall publicize the annual report and its availability to interested persons,
including providers, media organizations, health insurers, health maintenance organizations,
purchasers of health insurance, organized labor, consumer and patient advocacy groups and
individual consumers.
Enrolled House Bill 2524 (HB 2524-B) Page 3
(5) The annual report and quarterly reports under this section and section 3 of this 2007
Act may not contain information that identifies a patient, a licensed health care professional
or an employee of a health care facility in connection with a specific infection incident.
SECTION 7. ORS 442.445 is amended to read:
442.445. (1) Any health care facility that fails to perform as required in ORS 442.400 to 442.463
or section 3 of this 2007 Act and rules of the Office for Oregon Health Policy and Research may
be subject to a civil penalty.
(2) The Administrator of the Office for Oregon Health Policy and Research shall adopt a
schedule of penalties not to exceed $500 per day of violation, determined by the severity of the vi-
olation.
(3) Civil penalties under this section shall be imposed as provided in ORS 183.745.
(4) Civil penalties imposed under this section may be remitted or mitigated upon such terms and
conditions as the administrator considers proper and consistent with the public health and safety.
(5) Civil penalties incurred under any law of this state are not allowable as costs for the purpose
of rate determination or for reimbursement by a third-party payer.
SECTION 8. ORS 442.445, as amended by section 7 of this 2007 Act, is amended to read:
442.445. (1) Any health care facility that fails to perform as required in ORS 442.400 to 442.463
[or section 3 of this 2007 Act] and rules of the Office for Oregon Health Policy and Research may
be subject to a civil penalty.
(2) The Administrator of the Office for Oregon Health Policy and Research shall adopt a
schedule of penalties not to exceed $500 per day of violation, determined by the severity of the vi-
olation.
(3) Civil penalties under this section shall be imposed as provided in ORS 183.745.
(4) Civil penalties imposed under this section may be remitted or mitigated upon such terms and
conditions as the administrator considers proper and consistent with the public health and safety.
(5) Civil penalties incurred under any law of this state are not allowable as costs for the purpose
of rate determination or for reimbursement by a third-party payer.
SECTION 9. The amendments to ORS 442.445 by section 8 of this 2007 Act become oper-
ative on January 2, 2018.
SECTION 10. Except as provided in section 11 of this 2007 Act, sections 1 to 6 of this 2007
Act and the amendments to ORS 442.445 section 7 of this 2007 Act become operative on
January 1, 2008.
SECTION 11. Before the operative date specified in section 10 of this 2007 Act, the Ad-
ministrator of the Office for Oregon Health Policy and Research may take any action nec-
essary to exercise the duties conferred on the administrator by sections 1 to 6 of this 2007
Act and the amendments to ORS 442.445 by section 7 of this 2007 Act on and after the op-
erative date specified in section 10 of this 2007 Act.
SECTION 12. Sections 1 to 6 of this 2007 Act are repealed on January 2, 2018.
SECTION 13. In addition to and not in lieu of any other appropriation, there is appro-
priated to the Oregon Department of Administrative Services, for the biennium beginning
July 1, 2007, out of the General Fund, the amount of $201,467, which may be expended for
carrying out the provisions of sections 1 to 6 and 11 of this 2007 Act.
SECTION 14. This 2007 Act being necessary for the immediate preservation of the public
peace, health and safety, an emergency is declared to exist, and this 2007 Act takes effect
July 1, 2007.
Enrolled House Bill 2524 (HB 2524-B) Page 4
Passed by House June 22, 2007 Received by Governor:
........................M.,........................................................., 2007
.............................................................................
Approved:
Chief Clerk of House
........................M.,........................................................., 2007
.............................................................................
Speaker of House
.............................................................................
Passed by Senate June 25, 2007 Governor
Filed in Office of Secretary of State:
.............................................................................
........................M.,........................................................., 2007
President of Senate
.............................................................................
Secretary of State
Enrolled House Bill 2524 (HB 2524-B) Page 5
ID Task Name Duration Start Finish Predecessors 7, '07 Oct 14, '07
M T W T F S S M T
1 Administrative Rules 190 days? Tue 10/9/07 Mon 6/30/08
2 Prescribe HCAI to report 26 days? Tue 10/9/07 Tue 11/13/07
3 Outcome measures 26 days? Tue 10/9/07 Tue 11/13/07
4 Surgical Site Infections 26 days? Tue 10/9/07 Tue 11/13/07
5 Central line related bloodstream infections 26 days? Tue 10/9/07 Tue 11/13/07
6 Urinary tract infections 26 days? Tue 10/9/07 Tue 11/13/07
7 Process measures 26 days? Tue 10/9/07 Tue 11/13/07
8 Prioritization 20 days? Wed 11/14/07 Tue 12/11/07 3
9 Rolling reporting 20 days? Wed 11/14/07 Tue 12/11/07 3
10 Develop collection methodology 1 day? Tue 1/8/08 Tue 1/8/08 9
11 Prioritization of facility type 1 day? Tue 1/8/08 Tue 1/8/08 9
12 Hospitals 1 day? Tue 1/8/08 Tue 1/8/08
13 Format 1 day? Tue 1/8/08 Tue 1/8/08
14 Training development 1 day? Tue 1/8/08 Tue 1/8/08
15 Implementation plan 1 day? Tue 1/8/08 Tue 1/8/08
16 Ambulatory surgery centers 1 day? Tue 1/8/08 Tue 1/8/08
17 Format 1 day? Tue 1/8/08 Tue 1/8/08
18 Training development 1 day? Tue 1/8/08 Tue 1/8/08
19 Implementation plan 1 day? Tue 1/8/08 Tue 1/8/08
20 Long term care facilities 1 day? Tue 1/8/08 Tue 1/8/08
21 Format 1 day? Tue 1/8/08 Tue 1/8/08
22 Training development 1 day? Tue 1/8/08 Tue 1/8/08
23 Implementation plan 1 day? Tue 1/8/08 Tue 1/8/08
24 Birthing centers 1 day? Tue 1/8/08 Tue 1/8/08
25 Format 1 day? Tue 1/8/08 Tue 1/8/08
26 Training development 1 day? Tue 1/8/08 Tue 1/8/08
27 Implementation plan 1 day? Tue 1/8/08 Tue 1/8/08
28 Outpatient renal dialysis facility 1 day? Tue 1/8/08 Tue 1/8/08
29 Format 1 day? Tue 1/8/08 Tue 1/8/08
30 Training development 1 day? Tue 1/8/08 Tue 1/8/08
31 Implementation plan 1 day? Tue 1/8/08 Tue 1/8/08
32 Analysis Methodology 1 day? Tue 3/11/08 Tue 3/11/08 10
Task Milestone External Tasks
Project: HCAIAC timeline 07 to 10.mpp
Split Summary External Milestone
Date: Mon 10/8/07
Progress Project Summary Deadline
Page 1
ID Task Name Duration Start Finish Predecessors 7, '07 Oct 14, '07
M T W T F S S M T
33 Unit of analysis 1 day? Tue 3/11/08 Tue 3/11/08
34 Outcome measures 1 day? Tue 3/11/08 Tue 3/11/08
35 Risk adjustment methods 1 day? Tue 3/11/08 Tue 3/11/08
36 Process Measures 1 day? Tue 3/11/08 Tue 3/11/08
37 Reporting 1 day? Tue 5/6/08 Tue 5/6/08 32
38 Grouping methods 1 day? Tue 5/6/08 Tue 5/6/08
39 Update reports requirements 1 day? Tue 5/6/08 Tue 5/6/08
40 Annual report requirements 1 day? Tue 5/6/08 Tue 5/6/08
41 Rules public meetings 1 day? Fri 5/30/08 Fri 5/30/08 37
42 Submit final rules to AG 1 day? Mon 6/30/08 Mon 6/30/08 41
43 Implement reporting program 67 days? Tue 9/30/08 Wed 12/31/08 1
44 Training facilities 1 day? Tue 9/30/08 Tue 9/30/08
45 Build/test/beta test reporting 1 day? Tue 9/30/08 Tue 9/30/08 44SS
46 Finalize reporting system 1 day? Wed 12/31/08 Wed 12/31/08 45
47 Facilities begin reporting 1 day Thu 1/1/09 Thu 1/1/09 46
48 Public reporting (Year 1) 260 days Fri 12/4/09 Thu 12/2/10 47SS
49 Annual report 1 mon Fri 12/4/09 Thu 12/31/09 47
50 Update reporting #1 6 mons Fri 1/1/10 Thu 6/17/10 49
51 Update reporting #2 6 mons Fri 6/18/10 Thu 12/2/10 50
52 Public reporting (Year 2) 240 days? Fri 12/3/10 Thu 11/3/11
53 Annual report 1 day? Fri 4/29/11 Fri 4/29/11 48
54 Update #1 3 mons Fri 12/3/10 Thu 2/24/11 51
55 Update #2 3 mons Fri 2/25/11 Thu 5/19/11 54
56 Update #3 3 mons Fri 5/20/11 Thu 8/11/11 55
57 Update #4 3 mons Fri 8/12/11 Thu 11/3/11 56
Task Milestone External Tasks
Project: HCAIAC timeline 07 to 10.mpp
Split Summary External Milestone
Date: Mon 10/8/07
Progress Project Summary Deadline
Page 2
Health Care Acquired Infections
CChhaarrtteerr
Advisory Committee
Project Name: Health Care Acquire Infections Reporting Program
Project Sponsor: Jeanene Smith, MD, MPH Estimated Start Date: 10/9/2007
Project Owner: Sean Kolmer, MPH Duration: 4 years
Introduction and History
What it is?
(cid:120) Creates a health care acquired infections reporting program in Oregon and the Health Care Acquired Infections
Advisory Committee to advise OHPR in the development of the program.
Why are we doing it?
The U.S. Centers for Disease Control and Prevention (CDC) estimates that healthcare associated infections are one of the
top ten leading causes of death in the United States.1In Oregon:
(cid:120) The average estimated cost per stay at Oregon hospitals is approximately $32,000 higher for a patient with a
healthcare associated infection compared to a patient without a healthcare associated infection. 2
(cid:120) The estimated excess Medicaid costs in Oregon for healthcare associated infections exceeded $2.4 million in 2005. 2
(cid:120) The estimated excess costs in Oregon for all payers for healthcare associated infections exceeded $15 million in
2005. 2
(cid:120) The excess costs are not explained by differences in age, gender, co morbidities, or severity of illness. 2
1http://www.cdc.gov/ncidod/dhqp/hai.html
2http://www.oregon.gov/DAS/OHPPR/RSCH/docs/HAI111406.pdf
Objectives:
The advisory committee shall:
1. Prescribe what health care acquired infection measures that health care facilities must report, which may include but
are not limited to:
(cid:120) Surgical site infections;
(cid:120) Central line related bloodstream infections;
(cid:120) Urinary tract infections; and
(cid:120) Health care facility process measures designed to ensure quality and to reduce health care acquired
infections
2. Develop methods for evaluating and quantifying health care acquired infection measures that align with other data
collection and reporting methodologies of health care facilities and that support participation in other quality
interventions
3. Requiring different reportable health care acquired infection measures for differently situated health care facilities as
appropriate
4. A method to ensure that infections present upon admission to the health care facility are excluded from the rates of
health care acquired infection disclosed to the public
5. Establishing a process for evaluating the health care acquired infection measures reported and for modifying the
reporting requirements over time as appropriate;
6. Establishing a timetable to phase in the reporting and public disclosure of health care acquired infection measures
7. Procedures to protect the confidentiality of patients, health care professionals and health care facility employees.
Scope of reporting program:
Who
1. All health care facilities defined in ORS 442.015 (means a hospital, a long term care facility, an ambulatory surgical
center, a freestanding birthing center or an outpatient renal dialysis facility.)
When
1. First facilities start reporting in no later than January 1, 2009
2. Timetable of introducing type of facility into reporting to be determined by the committee.
How report
1. Updated release of data on biannual and then quarterly basis.
2. Annual report no later than April 31 of year.