75th OREGON LEGISLATIVE ASSEMBLY--2009 Regular Session
NOTE: Matter within { + braces and plus signs + } in an
amended section is new. Matter within { - braces and minus
signs - } is existing law to be omitted. New sections are within
{ + braces and plus signs + } .
LC 1330
Senate Bill 23
Printed pursuant to Senate Interim Rule 213.28 by order of the
President of the Senate in conformance with presession filing
rules, indicating neither advocacy nor opposition on the part
of the President (at the request of Senate Interim Committee on
Health and Human Services for Oregon Patient Safety Commission)
SUMMARY
The following summary is not prepared by the sponsors of the
measure and is not a part of the body thereof subject to
consideration by the Legislative Assembly. It is an editor's
brief statement of the essential features of the measure as
introduced.
Establishes Oregon Patient Safety Commission as central agency
for collection of data and analyses by patient safety
organizations in Oregon. Requires commission to submit biennial
general fund budget request to Oregon Department of
Administrative Services. Requires commission to analyze statewide
patient safety data, to compare statewide data to federal data
and to report findings. Authorizes commission to use Department
of Revenue Collections Unit to recover unpaid fees. Removes
sunset on Oregon Patient Safety Reporting Program.
A BILL FOR AN ACT
Relating to Oregon Patient Safety Commission; creating new
provisions; and amending ORS 442.820 and sections 1, 4 and 16,
chapter 686, Oregon Laws 2003.
Be It Enacted by the People of the State of Oregon:
SECTION 1. { + Sections 2 and 3 of this 2009 Act are added to
and made a part of sections 1 to 12, chapter 686, Oregon Laws
2003. + }
SECTION 2. { + (1) The Oregon Patient Safety Commission is the
central agency in Oregon responsible for the collection of data
and analyses produced by all entities in Oregon that are
certified by the United States Department of Health and Human
Services under 42 U.S.C. 299b-24 as patient safety organizations.
(2) The commission shall incorporate the data and analyses
collected under this section in the preparation of reports
required by section 4, chapter 686, Oregon Laws 2003. + }
SECTION 3. { + (1) By September 1 of each even-numbered year,
the Oregon Patient Safety Commission shall submit to the Oregon
Department of Administrative Services a requested amount for a
general fund appropriation for the following biennium. The
department shall include and submit the funding request to the
Legislative Assembly as part of the Governor's biennial budget.
Notwithstanding ORS 182.456 to 182.472, any appropriation of
general funds shall be subject to review and approval by the
Legislative Assembly and to future modification by the Emergency
Board or the Legislative Assembly. Any request approved by the
Legislative Assembly shall be appropriated to the department for
direct allocation to the commission.
(2) The commission request for a general fund appropriation
shall be prepared as part of and in accordance with the budget
process described in ORS 182.462. + }
SECTION 4. Section 1, chapter 686, Oregon Laws 2003, is amended
to read:
{ + Sec. 1. + } As used in sections 1 to 12 { + , chapter
686, Oregon Laws 2003 + } { - of this 2003 Act - } :
(1) 'Participant' means an entity that reports patient safety
data to { - a - } { + the Oregon + } Patient Safety Reporting
Program, and any agent, employee, consultant, representative,
volunteer or medical staff member of the entity.
(2) 'Patient safety activities' includes but is not limited to:
(a) The collection and analysis of patient safety data by a
participant;
(b) The collection and analysis of patient safety data by the
Oregon Patient Safety Commission established in { - section 2
of this 2003 Act - } { + ORS 442.820 + };
(c) The utilization of patient safety data by participants;
(d) The utilization of patient safety data by the Oregon
Patient Safety Commission to improve the quality of care with
respect to patient safety and to provide assistance to health
care providers to minimize patient risk; and
(e) Oral and written communication regarding patient safety
data among two or more participants with the intent of making a
disclosure to or preparing a report to be submitted to
{ - a - } { + the + } patient safety reporting program.
(3) 'Patient safety data' means oral communication or written
reports, data, records, memoranda, analyses, deliberative work,
statements, root cause analyses or action plans that are
collected or developed to improve patient safety or health care
quality that:
(a) Are prepared by a participant for the purpose of reporting
patient safety data voluntarily to { - a - } { + the + }
patient safety reporting program, or that are communicated among
two or more participants with the intent of making a disclosure
to or preparing a report to be submitted to { - a - }
{ + the + } patient safety reporting program; { - or - }
{ + (b) Are collected or prepared by a patient safety
organization certified by the United States Department of Health
and Human Services under 42 U.S.C. 299b-24; or + }
{ - (b) - } { + (c) + } Are created by or at the direction
of the patient safety reporting program, including communication,
reports, notes or records created in the course of an
investigation undertaken at the direction of the Oregon Patient
Safety Commission.
(4) 'Patient safety reporting program' { - includes but is
not limited to - } { + means + } the Oregon Patient Safety
Reporting Program created in section 4 { + , chapter 686, Oregon
Laws 2003. + } { - of this 2003 Act and any other patient
safety reporting program established to improve the safety and
quality of patient care. - }
(5) 'Serious adverse event' means an objective and definable
negative consequence of patient care, or the risk thereof, that
is unanticipated, usually preventable and results in, or presents
a significant risk of, patient death or serious physical injury.
SECTION 5. ORS 442.820 is amended to read:
442.820. (1) The Oregon Patient Safety Commission is
established as a semi-independent state agency subject to ORS
182.456 to 182.472. The commission shall exercise and carry out
all powers, rights and privileges that are expressly conferred
upon it, are implied by law or are incident to such powers.
(2) The mission of the commission is to improve patient safety
by reducing the risk of serious adverse events occurring in
Oregon's health care system and by encouraging a culture of
patient safety in Oregon. To accomplish this mission, the
commission shall:
(a) Establish a confidential, voluntary serious adverse event
reporting system to identify serious adverse events;
(b) Establish quality improvement techniques to reduce systems'
errors contributing to serious adverse events; and
(c) Disseminate evidence-based prevention practices to improve
patient outcomes.
(3) ORS 192.410 to 192.505 do not apply to public records
created or maintained by the commission that contain patient
safety data or to reports obtained by the program.
(4) ORS 192.610 to 192.690 do not apply to portions of a
meeting of the Oregon Patient Safety Commission Board of
Directors, or subcommittees or advisory committees established by
the board, to consider information that identifies a participant
or patient and the written minutes of that portion of the
meeting.
{ + (5) Notwithstanding ORS 182.460, ORS 293.250 applies to
the commission for the purpose of collecting from participants
fees established under section 6, chapter 686, Oregon Laws 2003,
that are owed to the commission and are past due. + }
SECTION 6. Section 4, chapter 686, Oregon Laws 2003, is amended
to read:
{ + Sec. 4. + } (1) The Oregon Patient Safety Reporting
Program is created in the Oregon Patient Safety Commission to
develop a serious adverse event reporting system. The program
shall include but is not limited to:
(a) Reporting by participants, in a timely manner and in the
form determined by the Oregon Patient Safety Commission Board of
Directors established in { - section 7 of this 2003 Act - }
{ + ORS 442.830 + }, of the following:
(A) Serious adverse events;
(B) Root cause analyses of serious adverse events;
(C) Action plans established to prevent similar serious adverse
events; and
(D) Patient safety plans establishing procedures and protocols.
(b) Analyzing reported serious adverse events, root cause
analyses and action plans to develop and disseminate information
to improve the quality of care with respect to patient safety.
This information shall be made available to participants and
shall include but is not limited to:
(A) Statistical analyses;
(B) Recommendations regarding quality improvement techniques;
(C) Recommendations regarding standard protocols; and
(D) Recommendations regarding best patient safety practices.
(c) Providing technical assistance to participants, including
but not limited to recommendations and advice regarding
methodology, communication, dissemination of information, data
collection, security and confidentiality.
(d) Auditing participant reporting to assess the level of
reporting of serious adverse events, root cause analyses and
action plans.
(e) Overseeing action plans to assess whether participants are
taking sufficient steps to prevent the occurrence of serious
adverse events.
(f) Creating incentives to improve and reward participation,
including but not limited to providing:
(A) Feedback to participants; and
(B) Rewards and recognition to participants.
(g) Distributing written reports using aggregate, de-identified
data from the program to describe statewide serious adverse event
patterns and maintaining a website to facilitate public access to
reports, as well as a list of names of participants. The reports
shall include but are not limited to:
(A) The types and frequencies of serious adverse events;
(B) Yearly serious adverse event totals and trends;
(C) Clusters of serious adverse events;
(D) Demographics of patients involved in serious adverse
events, including the frequency and types of serious adverse
events associated with language barriers or ethnicity;
(E) Systems' factors associated with particular serious adverse
events;
(F) Interventions to prevent frequent or high severity serious
adverse events; { - and - }
{ + (G) Analyses of statewide patient safety data in Oregon
and comparisons of that data to national patient safety data;
and + }
{ - (G) - } { + (H) + } Appropriate consumer information
regarding prevention of serious adverse events.
(2) Participation in the program is voluntary. The following
entities are eligible to participate:
(a) Hospitals as defined in ORS 442.015;
(b) Long term care facilities as defined in ORS 442.015;
(c) Pharmacies licensed under ORS chapter 689;
(d) Ambulatory surgical centers as defined in ORS 442.015;
(e) Outpatient renal dialysis facilities as defined in ORS
442.015;
(f) Freestanding birthing centers as defined in ORS 442.015;
and
(g) Independent professional health care societies or
associations.
(3) Reports or other information developed and disseminated by
the program may not contain or reveal the name of or other
identifiable information with respect to a particular participant
providing information to the commission for the purposes of
sections 1 to 12 { - of this 2003 Act - } , { + chapter 686,
Oregon Laws 2003, + } or to any individual identified in the
report or information, and upon whose patient safety data,
patient safety activities and reports the commission has relied
in developing and disseminating information pursuant to this
section.
(4) After a serious adverse event occurs, a participant must
provide written notification in a timely manner to each patient
served by the participant who is affected by the event. Notice
provided under this subsection may not be construed as an
admission of liability in a civil action.
SECTION 7. Section 16, chapter 686, Oregon Laws 2003, as
amended by section 4, chapter 476, Oregon Laws 2007, is amended
to read:
{ + Sec. 16. + } { - Sections 1, 4, 5, 6, 9, 10 and 12 - }
{ + Sections 8 and 10 + }, chapter 686, Oregon Laws 2003,
{ - and section 3 of this 2007 Act - } are repealed on January
2, 2010.
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