CO Code § 25-3-702 (2021)
2021 Colorado Code|Title 25 - Public Health and Environment|Article 3 - Hospitals|Part 7 - Colorado Hospital Report Card Act|§ 25-3-702. Comprehensive Hospital Information System - Executive Director - Duties - Definitions

     The executive director shall approve a comprehensive hospital information system to provide for the collection, compilation, coordination, analysis, indexing, and utilization of both purposefully collected and extant hospital-related data and statistics to produce and report comparable and uniform health information and statistics that shall be utilized in the development and production of the report card described in section 25-3-703. The executive director shall designate or contract with any individual or entity he or she deems appropriate to carry out the purposes of this part 7.      The association selected pursuant to subsection (3) of this section shall review and prepare the nursing-sensitive quality measures set forth in this paragraph (b) for inclusion in the hospital information system and hospital report card developed pursuant to this part 7. In reviewing and preparing to implement the nursing-sensitive quality measures, the association shall determine whether the measures should be reported for the hospital as a whole or by unit level of a hospital. In making its determinations pursuant to this paragraph (b), the association shall involve and seek input from no more than seven direct-care nurses who have been recommended by the governor. (b) (I) The association selected pursuant to subsection (3) of this section shall review and prepare the nursing-sensitive quality measures set forth in this paragraph (b) for inclusion in the hospital information system and hospital report card developed pursuant to this part 7. In reviewing and preparing to implement the nursing-sensitive quality measures, the association shall determine whether the measures should be reported for the hospital as a whole or by unit level of a hospital. In making its determinations pursuant to this paragraph (b), the association shall involve and seek input from no more than seven direct-care nurses who have been recommended by the governor.    The association shall collect, review, and implement the following nursing-sensitive quality measures as soon as practicable:   Practice environment scale or PES, as defined by the national quality forum, which is the nursing work index that measures the composite score and individual scores for the following subscales: Nurse participation in hospital affairs; nursing foundations for quality of care; nurse manager ability, leadership, and support of nurses; staffing and resource adequacy; and collegiality of nurse-physician relations; and    Registered nurse education and certification.       The association shall collect, review, and implement the following nursing-sensitive quality measures, as defined by the national quality forum, no later than November 30, 2010:   Skill mix;    The nursing hours per patient day;    Voluntary turnover;    Patient falls prevalence rate; and    Patient falls with injury.       The association shall identify a process or mechanism to allow access to or use of the data collected pursuant to this paragraph (b), as appropriate, for research purposes.    The association may exempt from the requirements of this paragraph (b) a licensed or certified hospital that has not more than one hundred licensed beds.    As used in this paragraph (b):   “Direct-care nurse” means a registered nurse who is engaged in direct patient care responsibilities in an inpatient hospital unit setting for more than fifty percent of his or her working hours.    (Deleted by amendment, L. 2010, (SB 10-217), ch. 315, p. 1474, § 1, effective May 27, 2010.)    “National quality forum” means the private, not-for-profit membership organization created to develop and implement a national strategy for health-care quality measurement and reporting, or its successor organization.             In order to implement this section the executive director or his or her designee shall:   Develop and implement a long-range plan for making available clinical outcomes and data that will allow consumers to compare health-care services;    On or before May 15, 2007, submit an initial plan and an annual update to the plan and a report on the status of implementation to the governor and to the public, via a website. The plan shall identify the process and time frames for implementation, barriers to implementation, and recommendations of changes in the law that may be enacted by the general assembly to eliminate the barriers.    Make available clinical outcomes measures from general hospitals licensed pursuant to this article and public hospitals certified pursuant to section 25-1.5-103 (1)(a). When determining which data to report, the executive director or designee shall consider:   Inclusion of data on all patients regardless of the payer source for Colorado hospitals and other information that may be required for either individual or group purchasers to assess the value of the product;    Use of standardized clinical outcomes measures recognized by national organizations that establish standards to measure the performance of health-care providers;    Data that is severity and acuity adjusted using statistical methods that show variation in reported outcomes, where applicable, and data that has passed standard edits;    Reporting the results with separate documents containing the technical specification and measures;    Standardization in reporting; and    Disclosure of the methodology of reporting.            The executive director shall select a duly constituted association of hospitals for assistance in carrying out the purposes of this part 7 and shall rely upon the advice and assistance of the selected association. The association shall provide the executive director with a copy of the association's organizational documents and any rules or regulations governing the association's activities and a list of the association's members. The association shall provide to the executive director a plan outlining the association's inclusion and consideration of the interests of health-care consumers, including health plans and employers, in the process of carrying out the purposes of this part 7. The name and address of a representative of the organization, who is a resident of this state, upon whom notices or orders of the executive director may be served shall be provided to the executive director. The executive director shall have the authority to examine the collection, analysis, and validity of the data used as a basis for the reporting required in this part 7.    The executive director may refuse to accept, or may suspend or revoke the acceptance of, an association for any of the following reasons:   It reasonably appears that the association will not be able to carry out the purpose of this part 7.    The association does not provide to the executive director a plan outlining the association's inclusion and consideration of the interests of health-care consumers, including health plans and employers, in the process of carrying out the purposes of this part 7.    On or before April 15, 2007, the association does not submit a plan to the executive director and report on the status of its implementation satisfactory to the executive director.    The association fails to meet other applicable requirements prescribed in this part 7.       There shall not be liability on the part of, nor shall a cause of action of any nature arise against, the association or its agents, employees, directors, or authorized designees of the executive director for actions taken or omitted in the performance of their powers and duties under this section.         In the event the executive director refuses to accept, or suspends or revokes the acceptance of, an association previously accepted for assistance in carrying out the purposes of this part 7 for any of the reasons set forth in this part 7, there shall be created in the state department the Colorado commission for hospital statistics, referred to in this subsection (4) as the “commission”, to carry out the purposes of this part 7.    The commission shall consist of nine members, who shall be appointed by the governor with the consent of the senate, as follows:   Three members representing hospitals licensed under this article;    Two members representing licensed health-care providers; and    Four members representing consumers or businesses without any direct interest in hospitals licensed under this article.       At no time shall the commission have more than five members of any one political party. Members of the commission shall be compensated for actual and necessary expenses incurred in the conduct of official business.    The commission shall annually elect the chairman of the commission from its members. A majority of the commission shall constitute a quorum.    The commission shall meet at least once during each calendar quarter. Meeting dates shall be set upon written request by three or more members of the commission or by a call of the chairman upon five days' notice to the members.    Action of the commission shall not be taken except upon the affirmative vote of a majority of a quorum of the commission.    All meetings of the commission shall be open to the public pursuant to section 24-6-402, C.R.S.        History. Source: L. 2006: Entire part added, p. 1576, § 1, effective August 7. L. 2008: (1) amended, p. 709, § 1, effective August 5. L. 2010: (1)(b)(II)(B) and (1)(b)(VI)(B) amended,(SB 10-217), ch. 315, p. 1474, § 1, effective May 27. L. 2017: (2)(b) amended,(SB 17-056), ch. 33, p. 93, § 4, effective March 16.    Editor's note:   This section was originally numbered as § 25-3-602 in House Bill 06-1278 but has been renumbered on revision for ease of location.