CHAPTER 98. REPORTING OF HEALTH CARE-ASSOCIATED INFECTIONS AND PREVENTABLE ADVERSE EVENTS

State Codes and Statutes

Statutes > Texas > Health-and-safety-code > Title-2-health > Chapter-98-reporting-of-health-care-associated-infections-and-preventable-adverse-events

HEALTH AND SAFETY CODE

TITLE 2. HEALTH

SUBTITLE D. PREVENTION, CONTROL, AND REPORTS OF DISEASES

CHAPTER 98. REPORTING OF HEALTH CARE-ASSOCIATED INFECTIONS AND

PREVENTABLE ADVERSE EVENTS

Chapter 98, consisting of Secs. 98.001 to 98.151, was added by

Acts 2007, 80th Leg., R.S., Ch.

359, Sec. 1.

For another Chapter 98, consisting of Secs. 98.001 to 98.009,

added by Acts 2007, 80th Leg., R.S., Ch.

671, Sec. 3, see Sec. 98.001 et seq., post.

SUBCHAPTER A. GENERAL PROVISIONS

Sec. 98.001. DEFINITIONS. In this chapter:

(1) "Advisory panel" means the Advisory Panel on Health

Care-Associated Infections and Preventable Adverse Events.

(2) "Ambulatory surgical center" means a facility licensed under

Chapter 243.

(3) "Commissioner" means the commissioner of state health

services.

(4) "Department" means the Department of State Health Services.

(5) "Executive commissioner" means the executive commissioner of

the Health and Human Services Commission.

(6) "General hospital" means a general hospital licensed under

Chapter 241 or a hospital that provides surgical or obstetrical

services and that is maintained or operated by this state. The

term does not include a comprehensive medical rehabilitation

hospital.

(7) "Health care-associated infection" means a localized or

symptomatic condition resulting from an adverse reaction to an

infectious agent or its toxins to which a patient is exposed in

the course of the delivery of health care to the patient.

(8) "Health care facility" means a general hospital or an

ambulatory surgical center.

(9) "Infection rate" means the number of health care-associated

infections of a particular type at a health care facility divided

by a numerical measure over time of the population at risk for

contracting the infection, unless the term is modified by rule of

the executive commissioner to accomplish the purposes of this

chapter.

(10) "Pediatric and adolescent hospital" has the meaning

assigned by Section 241.003.

(11) "Reporting system" means the Texas Health Care-Associated

Infection and Preventable Adverse Events Reporting System.

(12) "Special care setting" means a unit or service of a general

hospital that provides treatment to inpatients who require

extraordinary care on a concentrated and continuous basis. The

term includes an adult intensive care unit, a burn intensive care

unit, and a critical care unit.

Added by Acts 2007, 80th Leg., R.S., Ch.

359, Sec. 1, eff. June 15, 2007.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

724, Sec. 2(b), eff. September 1, 2009.

Sec. 98.002. APPLICABILITY OF OTHER LAW. Chapter 2110,

Government Code, does not apply to the advisory panel created

under Subchapter B.

Added by Acts 2007, 80th Leg., R.S., Ch.

359, Sec. 1, eff. June 15, 2007.

SUBCHAPTER B. ADVISORY PANEL

Sec. 98.051. ESTABLISHMENT. The commissioner shall establish

the Advisory Panel on Health Care-Associated Infections and

Preventable Adverse Events within the department to guide the

implementation, development, maintenance, and evaluation of the

reporting system. The commissioner may establish one or more

subcommittees to assist the advisory panel in addressing health

care-associated infections and preventable adverse events

relating to hospital care provided to children or other special

patient populations.

Added by Acts 2007, 80th Leg., R.S., Ch.

359, Sec. 1, eff. June 15, 2007.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

724, Sec. 2(c), eff. September 1, 2009.

Sec. 98.052. MEMBERSHIP; TERM. (a) The advisory panel is

composed of 18 members as follows:

(1) two infection control professionals who:

(A) are certified by the Certification Board of Infection

Control and Epidemiology; and

(B) are practicing in hospitals in this state, at least one of

which must be a rural hospital;

(2) two infection control professionals who:

(A) are certified by the Certification Board of Infection

Control and Epidemiology; and

(B) are nurses licensed to engage in professional nursing under

Chapter 301, Occupations Code;

(3) three board-certified or board-eligible physicians who:

(A) are licensed to practice medicine in this state under

Chapter 155, Occupations Code, at least two of whom have active

medical staff privileges at a hospital in this state and at least

one of whom is a pediatric infectious disease physician with

expertise and experience in pediatric health care epidemiology;

(B) are active members of the Society for Healthcare

Epidemiology of America; and

performance improvement or infection control in health care

facilities;

(4) four additional professionals in quality assessment and

performance improvement;

(5) one officer of a general hospital;

(6) one officer of an ambulatory surgical center;

(7) three nonvoting members who are department employees

representing the department in epidemiology and the licensing of

hospitals or ambulatory surgical centers; and

(8) two members who represent the public as consumers.

(b) Members of the advisory panel serve two-year terms.

Added by Acts 2007, 80th Leg., R.S., Ch.

359, Sec. 1, eff. June 15, 2007.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

724, Sec. 2(d), eff. September 1, 2009.

Sec. 98.053. MEMBER ELIGIBILITY. (a) A person may not be a

member of the advisory panel if the person is required to

because of the person's activities for compensation on behalf of

a profession related to health care.

(b) A person may not be a member of the advisory panel if the

person is an officer, employee, or paid consultant of a Texas

trade association in the field of health care.

Added by Acts 2007, 80th Leg., R.S., Ch.

359, Sec. 1, eff. June 15, 2007.

Sec. 98.054. OFFICERS. The members of the advisory panel shall

elect a presiding officer and an assistant presiding officer from

among the members. The officers serve two-year terms.

Added by Acts 2007, 80th Leg., R.S., Ch.

359, Sec. 1, eff. June 15, 2007.

Sec. 98.055. COMPENSATION; EXPENSES. Members of the advisory

panel serve without compensation but are entitled to

reimbursement of the travel expenses incurred by the member while

conducting the business of the advisory panel from department

funds, in accordance with the General Appropriations Act.

Added by Acts 2007, 80th Leg., R.S., Ch.

359, Sec. 1, eff. June 15, 2007.

Sec. 98.056. VACANCY. A vacancy on the advisory panel shall be

filled by the commissioner.

Added by Acts 2007, 80th Leg., R.S., Ch.

359, Sec. 1, eff. June 15, 2007.

SUBCHAPTER C. DUTIES OF DEPARTMENT AND ADVISORY PANEL; REPORTING

SYSTEM

Sec. 98.101. RULEMAKING. (a) The executive commissioner may

adopt rules for the department to implement this chapter.

(b) The executive commissioner may not adopt rules that conflict

with or duplicate any federally mandated infection reporting

program or requirement.

Added by Acts 2007, 80th Leg., R.S., Ch.

359, Sec. 1, eff. June 15, 2007.

Sec. 98.102. DEPARTMENTAL RESPONSIBILITIES; REPORTING SYSTEM.

(a) The department shall establish the Texas Health

Care-Associated Infection and Preventable Adverse Events

Reporting System within the department. The purpose of the

reporting system is to provide for:

(1) the reporting of health care-associated infections by health

care facilities to the department;

(2) the reporting of health care-associated preventable adverse

events by health care facilities to the department;

(3) the public reporting of information regarding the health

care-associated infections by the department;

(4) the public reporting of information regarding health

care-associated preventable adverse events by the department; and

(5) the education and training of health care facility staff by

the department regarding this chapter.

(b) The reporting system shall provide a mechanism for this

state to collect data, at state expense, through a secure

electronic interface with health care facilities.

department must contain sufficient patient identifying

information to:

(1) avoid duplicate submission of records;

(2) allow the department to verify the accuracy and completeness

of the data reported; and

(3) for data reported under Section 98.103 or 98.104, allow the

department to risk adjust the facilities' infection rates.

(d) The department shall review the infection control and

reporting activities of health care facilities to ensure the data

provided by the facilities is valid and does not have unusual

data patterns or trends that suggest implausible infection rates.

Added by Acts 2007, 80th Leg., R.S., Ch.

359, Sec. 1, eff. June 15, 2007.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

724, Sec. 2(e), eff. September 1, 2009.

Sec. 98.103. REPORTABLE INFECTIONS. (a) A health care

facility, other than a pediatric and adolescent hospital, shall

report to the department the incidence of surgical site

infections, including the causative pathogen if the infection is

laboratory-confirmed, occurring in the following procedures:

(1) colon surgeries;

(2) hip arthroplasties;

(3) knee arthroplasties;

(4) abdominal hysterectomies;

(5) vaginal hysterectomies;

(6) coronary artery bypass grafts; and

(7) vascular procedures.

(b) A pediatric and adolescent hospital shall report the

incidence of surgical site infections, including the causative

pathogen if the infection is laboratory-confirmed, occurring in

the following procedures to the department:

(1) cardiac procedures, excluding thoracic cardiac procedures;

(2) ventriculoperitoneal shunt procedures; and

(3) spinal surgery with instrumentation.

department:

(1) the incidence of laboratory-confirmed central

line-associated primary bloodstream infections, including the

causative pathogen, occurring in any special care setting in the

hospital; and

(2) the incidence of respiratory syncytial virus occurring in

any pediatric inpatient unit in the hospital.

(d) The department shall ensure that the health care-associated

infections a health care facility is required to report under

this section have the meanings assigned by the federal Centers

for Disease Control and Prevention.

(e) Effective September 1, 2009, this section does not apply to

the reporting of methicillin-resistant Staphylococcus aureus

infections by a health care facility located in an area served by

a health authority participating in the pilot program established

under Section 81.0445. This subsection expires September 1, 2011.

Added by Acts 2007, 80th Leg., R.S., Ch.

359, Sec. 1, eff. June 15, 2007.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

369, Sec. 2, eff. June 19, 2009.

Acts 2009, 81st Leg., R.S., Ch.

724, Sec. 1, eff. September 1, 2009.

Sec. 98.104. ALTERNATIVE FOR REPORTABLE SURGICAL SITE

INFECTIONS. A health care facility that does not perform at

least an average of 50 procedures per month of the procedures

listed in Section 98.103(a) or (b), as modified under Section

98.105, is not required to comply with the reporting requirements

of Section 98.103 but instead shall report to the department the

surgical site infections relating to the three surgical

procedures most frequently performed at the facility, based on

the list of surgical procedures promulgated by the federal

Centers for Disease Control and Prevention's National Healthcare

Safety Network or its successor.

Added by Acts 2007, 80th Leg., R.S., Ch.

359, Sec. 1, eff. June 15, 2007.

Sec. 98.1045. REPORTING OF PREVENTABLE ADVERSE EVENTS. (a)

Each health care facility shall report to the department the

occurrence of any of the following preventable adverse events

involving the facility's patient:

(1) a health care-associated adverse condition or event for

which the Medicare program will not provide additional payment to

the facility under a policy adopted by the federal Centers for

Medicare and Medicaid Services; and

(2) subject to Subsection (b), an event included in the list of

adverse events identified by the National Quality Forum that is

not included under Subdivision (1).

(b) The executive commissioner may exclude an adverse event

described by Subsection (a)(2) from the reporting requirement of

Subsection (a) if the executive commissioner, in consultation

with the advisory panel, determines that the adverse event is not

an appropriate indicator of a preventable adverse event.

Added by Acts 2009, 81st Leg., R.S., Ch.

724, Sec. 2(f), eff. September 1, 2009.

Sec. 98.105. REPORTING SYSTEM MODIFICATIONS. Based on the

recommendations of the advisory panel, the executive commissioner

by rule may modify in accordance with this chapter the list of

procedures that are reportable under Section 98.103 or 98.104.

The modifications must be based on changes in reporting

guidelines and in definitions established by the federal Centers

for Disease Control and Prevention.

Added by Acts 2007, 80th Leg., R.S., Ch.

359, Sec. 1, eff. June 15, 2007.

Sec. 98.106. DEPARTMENTAL SUMMARY. (a) The department shall

compile and make available to the public a summary, by health

care facility, of:

(1) the infections reported by facilities under Sections 98.103

and 98.104; and

(2) the preventable adverse events reported by facilities under

Section 98.1045.

(b) Information included in the departmental summary with

respect to infections reported by facilities under Sections

98.103 and 98.104 must be risk adjusted and include a comparison

of the risk-adjusted infection rates for each health care

facility in this state that is required to submit a report under

Sections 98.103 and 98.104.

shall publish the departmental summary in a format that is easy

to read.

(d) The department shall publish the departmental summary at

least annually and may publish the summary more frequently as the

department considers appropriate.

(e) The executive commissioner by rule shall allow a health care

facility to submit concise written comments regarding information

contained in the departmental summary that relates to the

facility. The department shall attach the facility's comments to

the public report and the comments must be in the same format as

the summary.

(f) The disclosure of written comments to the department by a

health care facility as provided by Subsection (e) does not

constitute a waiver of a privilege or protection under Section

98.109.

(g) The department shall make the departmental summary available

on an Internet website administered by the department and may

make the summary available through other formats accessible to

the public. The website must contain a statement informing the

public of the option to report suspected health care-associated

infections and preventable adverse events to the department.

Added by Acts 2007, 80th Leg., R.S., Ch.

359, Sec. 1, eff. June 15, 2007.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

724, Sec. 2(g), eff. September 1, 2009.

Sec. 98.107. EDUCATION AND TRAINING REGARDING REPORTING SYSTEM.

The department shall provide education and training for health

care facility staff regarding this chapter. The training must be

reasonable in scope and focus primarily on:

(1) the implementation and management of a facility reporting

mechanism;

(2) characteristics of the reporting system, including public

reporting by the department and facility reporting to the

department;

(3) confidentiality; and

(4) legal protections.

Added by Acts 2007, 80th Leg., R.S., Ch.

359, Sec. 1, eff. June 15, 2007.

Sec. 98.108. FREQUENCY OF REPORTING. In consultation with the

advisory panel, the executive commissioner by rule shall

establish the frequency of reporting by health care facilities

required under Sections 98.103, 98.104, and 98.1045. Facilities

may not be required to report more frequently than quarterly.

Added by Acts 2007, 80th Leg., R.S., Ch.

359, Sec. 1, eff. June 15, 2007.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

724, Sec. 2(h), eff. September 1, 2009.

Sec. 98.109. CONFIDENTIALITY; PRIVILEGE. (a) Except as

provided by Sections 98.106 and 98.110, all information and

materials obtained or compiled or reported by the department

under this chapter or compiled or reported by a health care

facility under this chapter, and all related information and

materials, are confidential and:

(1) are not subject to disclosure under Chapter 552, Government

Code, or discovery, subpoena, or other means of legal compulsion

for release to any person; and

(2) may not be admitted as evidence or otherwise disclosed in

any civil, criminal, or administrative proceeding.

(b) The confidentiality protections under Subsection (a) apply

without regard to whether the information or materials are

obtained from or compiled or reported by a health care facility

or an entity that has an ownership or management interest in a

facility.

(b-1) A state employee or officer may not be examined in a

civil, criminal, or special proceeding, or any other proceeding,

regarding the existence or contents of information or materials

obtained, compiled, or reported by the department under this

chapter.

is not a waiver of a privilege or protection granted under law.

(d) The provisions of this section regarding the confidentiality

of information or materials compiled or reported by a health care

facility in compliance with or as authorized under this chapter

do not restrict access, to the extent authorized by law, by the

patient or the patient's legally authorized representative to

records of the patient's medical diagnosis or treatment or to

other primary health records.

(e) A department summary or disclosure may not contain

information identifying a patient, employee, contractor,

volunteer, consultant, health care professional, student, or

trainee in connection with a specific incident.

Added by Acts 2007, 80th Leg., R.S., Ch.

359, Sec. 1, eff. June 15, 2007.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

724, Sec. 2(i), eff. September 1, 2009.

Sec. 98.110. DISCLOSURE AMONG CERTAIN AGENCIES. Notwithstanding

any other law, the department may disclose information reported

by health care facilities under Section 98.103, 98.104, or

98.1045 to other programs within the department, to the Health

and Human Services Commission, and to other health and human

services agencies, as defined by Section 531.001, Government

Code, for public health research or analysis purposes only,

provided that the research or analysis relates to health

care-associated infections or preventable adverse events. The

privilege and confidentiality provisions contained in this

chapter apply to such disclosures.

Added by Acts 2007, 80th Leg., R.S., Ch.

359, Sec. 1, eff. June 15, 2007.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

724, Sec. 2(j), eff. September 1, 2009.

Sec. 98.111. CIVIL ACTION. Published infection rates or

preventable adverse events may not be used in a civil action to

establish a standard of care applicable to a health care

facility.

Added by Acts 2007, 80th Leg., R.S., Ch.

359, Sec. 1, eff. June 15, 2007.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

724, Sec. 2(j), eff. September 1, 2009.

SUBCHAPTER D. ENFORCEMENT

Sec. 98.151. VIOLATIONS. (a) Except as provided by Subsection

(b), a general hospital that violates this chapter or a rule

adopted under this chapter is subject to the enforcement

provisions of Subchapter C, Chapter 241, and rules adopted and

enforced under that subchapter as if the hospital violated

Chapter 241 or a rule adopted under that chapter.

(b) Subsection (a) does not apply to a comprehensive medical

rehabilitation hospital as defined in Section 241.003.

a rule adopted under this chapter is subject to the enforcement

provisions of Chapter 243 and rules adopted and enforced under

that chapter as if the center violated Chapter 243 or a rule

adopted under that chapter.

Added by Acts 2007, 80th Leg., R.S., Ch.

359, Sec. 1, eff. June 15, 2007.

State Codes and Statutes

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