ORS 442.835¹
Appointment of administrator

The Oregon Patient Safety Commission Board of Directors shall appoint an administrator of the Oregon Patient Safety Commission. Subject to the supervision of the board, the administrator has authority to direct the affairs of the commission. The administrator may not be a voting member of the board. [2003 c.686 §11]

Note: See note under 442.820 (Oregon Patient Safety Commission).

Note: Sections 4 to 6, 9, 12 and 16, chapter 686, Oregon Laws 2003, provide:

Sec. 4. Oregon Patient Safety Reporting Program; participants; reports. (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 [442.830 (Oregon Patient Safety Commission Board of Directors)], 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) 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 (Definitions);

(b) Long term care facilities as defined in ORS 442.015 (Definitions);

(c) Pharmacies licensed under ORS chapter 689;

(d) Ambulatory surgical centers as defined in ORS 442.015 (Definitions);

(e) Outpatient renal dialysis facilities as defined in ORS 442.015 (Definitions);

(f) Freestanding birthing centers as defined in ORS 442.015 (Definitions); 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 [442.820 (Oregon Patient Safety Commission) to 442.835 (Appointment of administrator) and sections 1, 4 to 6, 8 to 10 and 12, 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. [2003 c.686 §4]

Sec. 5. Patient safety data; use; disclosure. (1) Patient safety data reported to the Oregon Patient Safety Commission and information developed pursuant to the auditing and oversight described in section 4 (1) of this 2003 Act may not be disclosed to, subject to subpoena by or used by any state agency for purposes of any enforcement or regulatory action in relation to a participant.

(2) Nothing in sections 1 to 12 of this 2003 Act [442.820 (Oregon Patient Safety Commission) to 442.835 (Appointment of administrator) and sections 1, 4 to 6, 8 to 10 and 12, chapter 686, Oregon Laws 2003] may be construed to limit the regulatory or enforcement authority of any state agency and, except for patient safety data, state agencies have the same authority to access participant records or other information in the same manner and to the same extent as if sections 1 to 12 of this 2003 Act were not enacted.

(3) As used in this section, "state agency" has the meaning given that term in ORS 183.750 (State agency required to prepare public writings in readable form). [2003 c.686 §5]

Sec. 6. Fees. The Oregon Patient Safety Commission may assess fees on the entities described in section 4 (2)(a) to (f), chapter 686, Oregon Laws 2003, as determined by the Oregon Patient Safety Commission Board of Directors to fund the operating costs of the Oregon Patient Safety Reporting Program. [2003 c.686 §6; 2007 c.476 §2]

Sec. 9. Powers of board relating to Oregon Patient Safety Reporting Program; rules; confidentiality of patient safety data. (1) Except as otherwise provided in sections 1 to 12 of this 2003 Act [442.820 (Oregon Patient Safety Commission) to 442.835 (Appointment of administrator) and sections 1, 4 to 6, 8 to 10 and 12, chapter 686, Oregon Laws 2003], the Oregon Patient Safety Commission Board of Directors, or officials of the Oregon Patient Safety Commission acting under the authority of the board, shall exercise all the powers of the commission and shall govern the commission. The board shall adopt rules necessary for the implementation of the Oregon Patient Safety Reporting Program, including but not limited to:

(a) Developing a list of objective and definable serious adverse events to be reported by participants. In developing this list, the board shall consider similar lists developed in other states and nationally. The board may change the list from time to time. The first list developed by the board shall focus on serious adverse events that caused death or serious physical injury. Later lists may include, in the discretion of the board, serious adverse events that did not cause death or serious physical injury but posed a significant risk of death or a risk of significant physical injury.

(b) Developing a budget.

(c) Establishing a process to seek grants and other funding from federal and other sources.

(d) Establishing a method to determine participant fees, if necessary.

(e) Establishing auditing and oversight procedures, including a process to:

(A) Assess completeness of reports from participants;

(B) Assess credibility and thoroughness of root cause analyses submitted to the program;

(C) Assess the acceptability of action plans and participant follow-up on the action plan; and

(D) Obtain certification by the Public Health Officer on the completeness, credibility, thoroughness and acceptability of participant reports, root cause analyses and action plans.

(f) Establishing criteria for terminating a participant from the program. Incomplete reporting, failure to comply with section 4 (4) of this 2003 Act or failure to adequately implement an action plan are grounds for termination from the program.

(2) The board may not use or disclose patient safety data reported, collected or developed pursuant to sections 1 to 12 of this 2003 Act for purposes of any enforcement or regulatory action in relation to a participant.

(3) The board shall maintain the confidentiality of all patient safety data that identifies or could be reasonably used to identify a participant or an individual who is receiving or has received health care from the participant. [2003 c.686 §9]

Sec. 12. Patient safety data not admissible in civil actions. (1) Patient safety data and reports obtained by a patient safety reporting program from participants are confidential and privileged and are not admissible in evidence in any civil action, including but not limited to a judicial, administrative, arbitration or mediation proceeding. Patient safety data, patient safety activities and reports are not subject to:

(a) Civil or administrative subpoena;

(b) Discovery in connection with a civil action, including but not limited to a judicial, administrative, arbitration or mediation proceeding; or

(c) Disclosure under state public records law pursuant to section 2 (3) of this 2003 Act [442.820 (Oregon Patient Safety Commission) (3)] and, if permissible, federal public records laws.

(2) The privilege established under this section does not apply to records of a patient’s medical diagnosis and treatment and to records of a participant created in the ordinary course of business.

(3) Patient safety data, collected or developed for the purpose of and with the intent to communicate with or to make a disclosure or report to the patient safety reporting program, that are contained in the business records of the participant are confidential and not subject to civil or administrative subpoena or to discovery in a civil action, including but not limited to a judicial, administrative, arbitration or mediation proceeding.

(4) The following persons are not subject to an action for civil damages for affirmative actions taken, acts of omission or statements made in good faith:

(a) A person serving on the Oregon Patient Safety Commission Board of Directors;

(b) A person serving on a committee established by the board;

(c) A person communicating information to the Oregon Patient Safety Reporting Program; or

(d) A person conducting a study or investigation on behalf of the program.

(5) A participant or a representative of the Oregon Patient Safety Reporting Program may not be examined in any civil action, including but not limited to a judicial, administrative, arbitration or mediation proceeding, as to whether a communication of any kind, including oral and written communication, has been made or shared with another participant or with the program regarding patient safety data, patient safety activities, reports, records, memoranda, analyses, deliberative work, statements or root cause analyses, provided the communication was made with the intent of making a disclosure to or preparing a report to be submitted to the Oregon Patient Safety Commission.

(6) Nothing in this section may be construed to:

(a) Limit or discourage patient safety activities of or among participants or the voluntary reporting of patient safety data by one or more participants, individually or jointly, to a patient safety reporting program;

(b) Affect other privileges that are available under federal or state laws that provide greater peer review or confidentiality protections than do the protections afforded under sections 1 to 12 of this 2003 Act [442.820 (Oregon Patient Safety Commission) to 442.835 (Appointment of administrator) and sections 1, 4 to 6, 8 to 10 and 12, chapter 686, Oregon Laws 2003];

(c) Preempt or otherwise affect mandatory reporting requirements under Oregon law or licensing or certification requirements of state or federal law; or

(d) Diminish obligations of participants to comply with state and federal laws pertaining to quality assurance, personnel management and infection control requirements.

(7) Reporting or sharing of patient safety data by a participant is not a waiver of any privilege or protection established under sections 1 to 12 of this 2003 Act or other Oregon law. [2003 c.686 §12]

Sec. 16. Sections 1, 4, 5, 6, 9, 10 and 12, chapter 686, Oregon Laws 2003, and section 3 of this 2007 Act [section 3, chapter 476, Oregon Laws 2007,] are repealed on January 2, 2010. [2003 c.686 §16; 2007 c.476 §4]

Note: Section 3, chapter 476, Oregon Laws 2007, provides:

Sec. 3. Limit on amounts collected to fund Oregon Patient Safety Reporting Program. (1) Amounts collected by the Oregon Patient Safety Commission under section 6, chapter 686, Oregon Laws 2003, may not exceed $1.5 million for the fiscal year beginning on July 1, 2007, and ending on June 30, 2008.

(2) The dollar amount specified in subsection (1) of this section shall be adjusted annually by the commission based upon the change in the Consumer Price Index as defined in ORS 327.006 (Definitions) for every fiscal year beginning on or after July 1, 2008. [2007 c.476 §3]

Note: Sections 1 to 6 and 12, chapter 838, Oregon Laws 2007, provide:

Sec. 1. The Legislative Assembly finds that Oregonians should be free from infections 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. [2007 c.838 §1]

Sec. 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 (Definitions).

(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 intrinsic and extrinsic risk factors for a health care acquired infection are considered in the calculation of health care acquired infection rates. [2007 c.838 §2]

Sec. 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 infection 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 the requirements for health care facilities to report similar data to the Department of Human Services and to the Centers for Medicare and Medicaid Services.

(4) The office shall utilize, to the extent practicable and appropriate, a credible and reliable risk-adjusted methodology in analyzing the health care acquired infection measures reported by health care facilities.

(5) The office shall provide health care acquired infection measures and related information 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 updated 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 facilities 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. [2007 c.838 §3]

Sec. 4. (1) There is established the Health Care Acquired Infection Advisory Committee to advise the Administrator of the Office for Oregon Health Policy and Research regarding 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 advisory committee shall evaluate on a regular basis the quality and accuracy of the data collected 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:

(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. [2007 c.838 §4]

Sec. 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. [2007 c.838 §5]

Sec. 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 (Availability of report on Internet) and to the Legislative Assembly in the manner provided in ORS 192.245 (Form of report to legislature). 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 recommendations.

(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.

(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. [2007 c.838 §6]

Sec. 12. Sections 1 to 6 of this 2007 Act are repealed on January 2, 2018. [2007 c.838 §12]

Chapter 442

Atty. Gen. Opinions

Participa­tion of hospital owners or administrators in joint review of hospital expenses, services, (1978) Vol 38, p 2060; State Health Planning and Develop­ment Agency's responsibility to evaluate and act upon nursing home budget and rate increase notifica­tions where posi­tions and funds are deleted from agency's budget, (1979) Vol 40, p 56; health systems agency's failure to review or submit recommenda­tion and findings on applica­tion for certificate of need, (1979) Vol 40, p 135

1 Legislative Counsel Committee, CHAPTER 442—Health Planning, https://­www.­oregonlegislature.­gov/­bills_laws/­Archive/­2007ors442.­pdf (2007) (last ac­cessed Feb. 12, 2009).
 
2 Legislative Counsel Committee, Annotations to the Oregon Revised Stat­utes, Cumulative Supplement - 2007, Chapter 442, https://­www.­oregonlegislature.­gov/­bills_laws/­ors/­442ano.­htm (2007) (last ac­cessed Feb. 12, 2009).
 
3 OregonLaws.org assembles these lists by analyzing references between Sections. Each listed item refers back to the current Section in its own text. The result reveals relationships in the code that may not have otherwise been apparent. Currency Information