Florida Senate - 2006 COMMITTEE AMENDMENT
Bill No. SB 2160
Barcode 434414
CHAMBER ACTION
Senate House
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11 The Committee on Judiciary (Baker) recommended the following
12 amendment:
13
14 Senate Amendment (with title amendment)
15 Delete everything after the enacting clause
16
17 and insert:
18 Section 1. Subsection (2) of section 766.110, Florida
19 Statutes, is amended to read:
20 766.110 Liability of health care facilities.--
21 (2) Every hospital licensed under chapter 395 may
22 carry liability insurance or adequately insure itself in an
23 amount of not less than $1.5 million per claim, $5 million
24 annual aggregate to cover all medical injuries to patients
25 resulting from negligent acts or omissions on the part of
26 those members of its medical staff who are covered thereby in
27 furtherance of the requirements of ss. 458.320 and 459.0085.
28 Notwithstanding s. 626.901, a licensed hospital may extend
29 insurance and self-insurance coverage to members of the
30 medical staff, including physicians' practices, individually
31 or through a group practice and other health care
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1 practitioners, as defined in s. 456.001(4), including students
2 preparing for licensure. Such coverage must be limited to
3 legal liability arising out of medical negligence within the
4 hospital premises as defined under s. 766.401. Self-insurance
5 Coverage extended hereunder to a member of a hospital's
6 medical staff meets the financial responsibility requirements
7 of ss. 458.320 and 459.0085 if the physician's coverage limits
8 are not less than the minimum limits established in ss.
9 458.320 and 459.0085 and the hospital is a verified trauma
10 center that has extended self-insurance coverage continuously
11 to members of its medical staff for activities both inside and
12 outside of the hospital. Any authorized insurer, approved
13 insurer as defined in s. 626.914(2), risk retention group as
14 defined in s. 627.942, or joint underwriting association
15 established under s. 627.351(4) which is authorized or
16 approved to write casualty insurance may make available, but
17 is shall not be required to write, such coverage. The hospital
18 may assess on an equitable and pro rata basis the following
19 individuals to whom it extends coverage pursuant to this
20 section professional health care providers for a portion of
21 the total hospital insurance cost for this coverage:
22 physicians licensed under chapter 458, osteopathic physicians
23 licensed under chapter 459, podiatric physicians licensed
24 under chapter 461, dentists licensed under chapter 466, and
25 nurses licensed under part I of chapter 464, and other health
26 professionals. The hospital may provide for a deductible
27 amount to be applied against any individual health care
28 provider found liable in a law suit in tort or for breach of
29 contract. The legislative intent in providing for the
30 deductible to be applied to individual health care providers
31 found negligent or in breach of contract is to instill in each
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1 individual health care provider the incentive to avoid the
2 risk of injury to the fullest extent and ensure that the
3 citizens of this state receive the highest quality health care
4 obtainable.
5 Section 2. Present subsections (6) and (7) of section
6 766.118, Florida Statutes, are renumbered as subsections (7)
7 and (8), respectively, and a new subsection (6) is added to
8 that section, to read:
9 766.118 Determination of noneconomic damages.--
10 (6) LIMITATION ON NONECONOMIC DAMAGES FOR NEGLIGENCE
11 OF CERTAIN HOSPITALS.--With respect to a complaint for
12 personal injury or wrongful death arising from medical
13 negligence, a hospital that has received an order from the
14 Agency for Health Care Administration pursuant to s. 766.402
15 which certifies that the facility complies with patient-safety
16 measures specified in s. 766.403 shall be liable for no more
17 than $500,000 in noneconomic damages, regardless of the number
18 of claimants, number of claims, or theory of liability,
19 including vicarious liability, arising from the same nucleus
20 of operative fact, notwithstanding any other provision of this
21 section.
22 Section 3. Section 766.401, Florida Statutes, is
23 created to read:
24 766.401 Definitions.--As used in this section and ss.
25 766.402-766.405, the term:
26 (1) "Affected patient" means a patient of a certified
27 patient-safety facility.
28 (2) "Affected practitioner" means any person,
29 including a physician, who is credentialed by the eligible
30 hospital to provide health care services in a certified
31 patient-safety facility.
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1 (3) "Agency" means the Agency for Health Care
2 Administration.
3 (4) "Certified patient-safety facility" means any
4 eligible hospital that, in accordance with an order from the
5 Agency for Health Care Administration, has adopted a
6 patient-safety plan.
7 (5) "Eligible hospital" or "licensed facility" means a
8 statutory teaching hospital, as defined by s. 408.07, which
9 maintains at least seven different accredited programs in
10 graduate medical education and has 100 or more full-time
11 equivalent resident physicians.
12 (6) "Health care provider" or "provider" means:
13 (a) An eligible hospital.
14 (b) A physician or a physician assistant licensed
15 under chapter 458.
16 (c) An osteopathic physician or an osteopathic
17 physician assistant licensed under chapter 459.
18 (d) A registered nurse, nurse midwife, licensed
19 practical nurse, or advanced registered nurse practitioner
20 licensed or registered under part I of chapter 464 or any
21 facility that employs nurses licensed or registered under part
22 I of chapter 464 to supply all or part of the care delivered
23 by that facility.
24 (e) A health care professional association and its
25 employees or a corporate medical group and its employees.
26 (f) Any other medical facility in which the primary
27 purpose is to deliver human medical diagnostic services or to
28 deliver nonsurgical human medical treatment, including an
29 office maintained by a provider.
30 (g) A free clinic that delivers only medical
31 diagnostic services or nonsurgical medical treatment free of
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1 charge to low-income persons not otherwise covered by Medicaid
2 or other programs for low-income persons.
3 (h) Any other health care professional, practitioner,
4 or provider, including a student enrolled in an accredited
5 program, who prepares the student for licensure as any one of
6 the professionals listed in this subsection.
7 (i) Any person, organization, or entity that is
8 vicariously liable under the theory of respondeat superior or
9 any other theory of legal liability for medical negligence
10 committed by any licensed professional listed in this
11 subsection.
12 (j) Any nonprofit corporation qualified as exempt from
13 federal income taxation under s. 501(a) of the Internal
14 Revenue Code and described in s. 501(c) of the Internal
15 Revenue Code, including any university or medical school that
16 employs licensed professionals listed in this subsection or
17 which delivers health care services provided by licensed
18 professionals listed in this subsection, any federally funded
19 community health center, and any volunteer corporation or
20 volunteer health care provider that delivers health care
21 services.
22 (7) "Health care practitioner" or "practitioner" means
23 any person, entity, or organization identified in subsection
24 (6), except for a hospital.
25 (8) "Adverse incident" has the same meaning as
26 provided in ss. 381.0271, 395.0197, 458.351, and 459.026.
27 (9) "Medical negligence" means medical malpractice,
28 whether grounded in tort or in contract, arising out of the
29 rendering of or failure to render medical care or services.
30 (10) "Person" means any individual, partnership,
31 corporation, association, or governmental unit.
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1 (11) "Premises" means those buildings, beds, and
2 equipment located at the address of the licensed facility and
3 all other buildings, beds, and equipment for the provision of
4 the hospital, ambulatory surgical, mobile surgical care,
5 primary care, or comprehensive health care under the dominion
6 and control of the licensee, including offices and locations
7 where the licensed facility offers medical care and treatment
8 to affected patients.
9 (12) "Statutory teaching hospital" or "teaching
10 hospital" has the same meaning as provided in s. 408.07.
11 Section 4. Section 766.402, Florida Statutes, is
12 created to read:
13 766.402 Agency approval of patient-safety plans.--
14 (1) An eligible hospital that has adopted a
15 patient-safety plan may petition the agency to enter an order
16 certifying approval of the hospital as a certified
17 patient-safety facility.
18 (2) In accordance with chapter 120, the agency shall
19 enter an order certifying approval of the certified
20 patient-safety facility upon a showing that, in furtherance of
21 an approach to patient safety:
22 (a) The petitioner has established safety measures for
23 the care and treatment of patients.
24 (b) The petitioner satisfies requirements for
25 patient-protection measures, as specified in s. 766.403.
26 (c) The petitioner satisfies all other requirements of
27 ss. 766.401-766.405.
28 (3) Upon entry of an order approving the petition, the
29 agency may conduct onsite examinations of the licensed
30 facility to assure continued compliance with the terms and
31 conditions of the order.
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1 (4) The order approving a petition under this section
2 remains in effect until revoked. The agency may revoke the
3 order upon reasonable notice to the eligible hospital that it
4 fails to comply with material requirements of s. 766.403 and
5 that the hospital has failed to cure stated deficiencies upon
6 reasonable notice. Revocation of an agency order pursuant to
7 s. 766.403 applies prospectively to any cause of action for
8 medical negligence which arises on or after the effective date
9 of the order of revocation.
10 (5) An order approving a petition under this section
11 is, as a matter of law, conclusive evidence that the hospital
12 complies with the applicable patient-safety requirements of s.
13 766.403. A hospital's noncompliance with the requirements of
14 s. 766.403 does not affect the limitations on damages
15 conferred by this section. Evidence of noncompliance with s.
16 766.403 is not admissible for any purpose in any action for
17 medical malpractice. This section, or any portion thereof, may
18 not give rise to an independent cause of action for damages
19 against any hospital.
20 Section 5. Section 766.403, Florida Statutes, is
21 created to read:
22 766.403 Patient-safety plans.--
23 (1) In order to satisfy the requirements of s.
24 766.402, the licensed facility shall have a patient-safety
25 plan, which provides that the facility shall:
26 (a) Have in place a process, either through the
27 facility's patient-safety committee or a similar body, for
28 coordinating the quality control, risk management, and
29 patient-relations functions of the facility and for reporting
30 to the facility's governing board at least quarterly regarding
31 such efforts.
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1 (b) Establish within the facility a system for
2 reporting near misses and agree to submit any information
3 collected to the Florida Patient Safety Corporation. Such
4 information must be submitted by the facility and made
5 available by the Patient Safety Corporation in accordance with
6 s. 381.0271(7).
7 (c) Design and make available to facility staff,
8 including medical staff, a patient-safety curriculum that
9 provides lecture and web-based training on recognized
10 patient-safety principles, which may include training in
11 communication skills, team-performance assessment and
12 training, risk-prevention strategies, and best practices and
13 evidence-based medicine. The licensed facility shall report
14 annually the programs presented to the agency.
15 (d) Implement a program to identify health care
16 providers on the facility's staff who may be eligible for an
17 early-intervention program that provides additional skills
18 assessment and training and offer such training to the staff
19 on a voluntary and confidential basis with established
20 mechanisms to assess program performance and results.
21 (e) Implement a simulation-based program for skills
22 assessment, training, and retraining of a facility's staff in
23 those tasks and activities that the agency identifies by rule.
24 (f) Designate a patient advocate who coordinates with
25 members of the medical staff and the facility's chief medical
26 officer regarding the disclosure of adverse medical incidents
27 to patients. In addition, the patient advocate shall
28 establish an advisory panel, consisting of providers, patients
29 or their families, and other health care consumers or consumer
30 groups to review general patient-safety concerns and other
31 issues related to relations among and between patients and
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1 providers and to identify areas where additional education and
2 program development may be appropriate.
3 (g) Establish a procedure to biennially review the
4 facility's patient-safety program and its compliance with the
5 requirements of this section. Such review shall be conducted
6 by an independent patient-safety organization as defined in s.
7 766.1016(1) or other professional organization approved by the
8 agency. The organization performing the review shall prepare a
9 written report that contains detailed findings and
10 recommendations. The report shall be forwarded to the
11 facility's risk manager or patient-safety officer, who may
12 make written comments in response. The report and any written
13 comments shall be presented to the governing board of the
14 licensed facility. A copy of the report and any of the
15 facility's responses to the findings and recommendations shall
16 be provided to the agency within 60 days after the date that
17 the governing board reviewed the report. The report is
18 confidential and exempt from production or discovery in any
19 civil action. Likewise, the report and the information
20 contained therein are not admissible as evidence for any
21 purpose in any action for medical negligence.
22 (h) Establish a system for the trending and tracking
23 of quality and patient-safety indicators that the agency may
24 identify by rule and a method for review of the data at least
25 semiannually by the facility's patient-safety committee.
26 (2) This section does not constitute an applicable
27 standard of care in any action for medical negligence or
28 otherwise create a private right of action, and evidence of
29 noncompliance with this section is not admissible for any
30 purpose in any action for medical negligence against any
31 health care provider.
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1 (3) This section does not prohibit the licensed
2 facility from implementing other measures for promoting
3 patient safety within the premises. This section does not
4 relieve the licensed facility from the duty to implement any
5 other patient-safety measure that is required by state law.
6 The Legislature intends that the patient-safety measures
7 specified in this section are in addition to all other
8 patient-safety measures required by state law, federal law,
9 and applicable accreditation standards for licensed
10 facilities.
11 (4) A review, report, or other document created,
12 produced, delivered, or discussed pursuant to this section is
13 not discoverable or admissible as evidence in any legal
14 action.
15 Section 6. Section 766.404, Florida Statutes, is
16 created to read:
17 766.404 Annual report.--
18 (1) Each certified patient-safety facility shall
19 submit an annual report to the agency containing information
20 and data reasonably required by the agency to evaluate
21 performance and effectiveness of its patient-safety plan.
22 However, information may not be submitted or disclosed in
23 violation of any patient's right to privacy under state or
24 federal law.
25 (2) The agency shall aggregate information and data
26 submitted by all certified patient-safety facilities, and each
27 year, on or before March 1, the agency shall submit a report
28 to the President of the Senate and the Speaker of the House of
29 Representatives which evaluates the performance and
30 effectiveness of the approach to enhancing patient safety and
31 limiting provider liability in certified patient-safety
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1 facilities. The report must include, but need not be limited
2 to, pertinent data concerning:
3 (a) The number and names of certified patient-safety
4 facilities;
5 (b) The number and types of patient-protection
6 measures currently in effect in these facilities;
7 (c) The number of affected patients;
8 (d) The number of surgical procedures on affected
9 patients;
10 (e) The number of medical incidents, claims of medical
11 malpractice, and claims resulting in indemnity;
12 (f) The average time for resolution of contested and
13 uncontested claims of medical malpractice;
14 (g) The percentage of claims which result in civil
15 trials;
16 (h) The percentage of civil trials which result in
17 adverse judgments against affected facilities;
18 (i) The number and average size of an indemnity paid
19 to claimants;
20 (j) The estimated liability expense, inclusive of
21 medical liability insurance premiums; and
22 (k) The percentage of medical liability expense,
23 inclusive of medical liability insurance premiums, which is
24 borne by affected practitioners in certified patient-safety
25 facilities.
26
27 The report may also include other information and data that
28 the agency deems appropriate to gauge the cost and benefit of
29 patient-safety plans.
30 (3) The agency's annual report to the President of the
31 Senate and the Speaker of the House of Representatives may
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1 include relevant information and data obtained from the Office
2 of Insurance Regulation within the Department of Financial
3 Services concerning the availability and affordability of
4 enterprise-wide medical liability insurance coverage for
5 affected facilities and the availability and affordability of
6 insurance policies for individual practitioners which contain
7 coverage exclusions for acts of medical negligence in
8 facilities that indemnify health practitioners. The Office of
9 Insurance Regulation shall cooperate with the agency in the
10 reporting of information and data specified in this
11 subsection.
12 (4) Reports submitted to the agency by certified
13 patient-safety facilities pursuant to this section are public
14 records under chapter 119. However, these reports, and the
15 information contained therein, are not admissible as evidence
16 in a court of law in any action.
17 Section 7. Section 766.405, Florida Statutes, is
18 created to read:
19 766.405 Damages in malpractice actions against certain
20 hospitals that meet patient-safety requirements; agency
21 approval of patient-safety measures.--
22 (1) In recognition of their essential role in training
23 future health care providers and in providing innovative
24 medical care for this state's residents, in recognition of
25 their commitment to treating indigent patients, and further in
26 recognition that teaching hospitals, as defined in s. 408.07,
27 provide benefits to the residents of this state through their
28 roles in improving the quality of medical care, training of
29 health care providers, and caring for indigent patients, the
30 limits of liability for medical malpractice arising out of the
31 rendering of, or the failure to render, medical care by all
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1 such hospitals shall be determined in accordance with the
2 requirements of this section.
3 (2) Upon entry of an order and for the entire period
4 of time that the order remains in effect, the damages
5 recoverable from an eligible hospital covered by the order and
6 from its full-time employee physicians and full-time and
7 part-time non-physician employees and agents in actions
8 arising from medical negligence shall be determined in
9 accordance with the following provisions:
10 (a) Noneconomic damages shall be limited to a maximum
11 of $500,000, regardless of the number of claimants, number of
12 claims, or the theory of liability pursuant to s. 766.118(6).
13 (b) Awards of economic damages shall be offset by
14 payments from collateral sources, as defined by s. 766.202(2),
15 and any set-offs available under ss. 46.015 and 768.041.
16 Awards for future economic losses shall be offset by future
17 collateral source payments.
18 (c) After being offset by collateral sources, awards
19 of future economic damages shall, at the option of the
20 eligible hospital, be reduced by the court to present value or
21 paid through periodic payments in the form of an annuity or a
22 reversionary trust. A company that underwrites an annuity to
23 pay future economic damages shall have a rating of "A" or
24 higher by A.M. Best Company. The terms of the reversionary
25 instrument used to periodically pay future economic damages
26 must be approved by the court. Such approval may not be
27 unreasonably withheld.
28 (3) The limitations on damages in subsection (2) apply
29 prospectively to causes of action for medical negligence which
30 arise on or after the effective date of the order.
31 Section 8. Section 766.406, Florida Statutes, is
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1 created to read:
2 766.406 Rulemaking authority.--The agency may adopt
3 rules to administer ss. 766.401-766.405.
4 Section 9. If any provision of this act or its
5 application to any person or circumstance is held invalid, the
6 invalidity does not affect other provisions or applications of
7 the act which can be given effect without the invalid
8 provision or application, and to this end, the provisions of
9 this act are severable.
10 Section 10. The sum of $226,984 in recurring funds
11 from the Health Care Trust Fund and the sum of $72,057 in
12 nonrecurring funds from the Health Care Trust Fund are
13 appropriated, and 3 full time equivalent positions and
14 associated salary rate of $127,817 are authorized to the
15 Agency for Health Care Administration for the 2006-2007 fiscal
16 year, for the purpose of implementing the provisions of this
17 act.
18 Section 11. This act shall take effect upon becoming a
19 law.
20
21
22 ================ T I T L E A M E N D M E N T ===============
23 And the title is amended as follows:
24 Delete everything before the enacting clause
25
26 and insert:
27 A bill to be entitled
28 An act relating to medical malpractice
29 insurance; amending s. 766.110, F.S.;
30 specifying certain authorized insurers who may
31 make available liability insurance; amending s.
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1 766.118, F.S.; providing a limitation on
2 noneconomic damages for a hospital facility
3 that complies with certain patient-safety
4 measures; creating s. 766.401, F.S.; providing
5 definitions; creating s. 766.402, F.S.;
6 authorizing an eligible hospital to petition
7 the agency for an order certifying the hospital
8 as a certified patient-safety facility;
9 providing requirements for certification as a
10 patient-safety facility; authorizing the agency
11 to conduct onsite examinations; providing for
12 revocation of an order certifying approval of a
13 certified patient-safety facility; providing
14 that an order certifying the approval of a
15 certified patient-safety facility is conclusive
16 evidence of compliance with statutory
17 patient-safety requirements; providing that
18 evidence of noncompliance is not admissible for
19 any action for medical malpractice; creating s.
20 766.403, F.S.; providing requirements for a
21 hospital to demonstrate that it is engaged in a
22 common enterprise for the care and treatment of
23 patients; specifying required patient-safety
24 measures; prohibiting a report or document
25 generated under the act from being admissible
26 or discoverable as evidence; creating s.
27 766.404, F.S.; requiring a certified
28 patient-safety facility to submit an annual
29 report to the agency and the Legislature;
30 providing requirements for the annual report;
31 providing that the annual report may include
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1 certain information from the Office of
2 Insurance Regulation within the Department of
3 Financial Services; providing that the annual
4 report is subject to public-records
5 requirements but is not admissible as evidence
6 in a legal proceeding; creating s. 766.405,
7 F.S.; providing for limitations on damages for
8 eligible hospitals that are certified for
9 compliance with certain patient-safety
10 measures; creating s. 766.406, F.S.; providing
11 rulemaking authority; providing for
12 severability; providing an appropriation;
13 providing an effective date.
14
WHEREAS, the Legislature finds that this state is in
15
the midst of a prolonged medical malpractice insurance crisis
16
that has serious adverse effects on patients, practitioners,
17
licensed health care facilities, and all residents of this
18
state, and
19
WHEREAS, the Legislature finds that hospitals are
20
central components of the modern health care delivery system,
21
and
22
WHEREAS, the Legislature finds that the medical
23
malpractice insurance crisis in this state can be alleviated
24
by the adoption of innovative approaches for patient safety in
25
teaching hospitals, which can lead to a reduction in medical
26
errors coupled with a limitation on noneconomic damages that
27
can be awarded against a teaching hospital that implements
28
such innovative approaches, and
29
WHEREAS, the Legislature finds statutory incentives are
30
necessary to facilitate innovative approaches for patient
31
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1 safety in hospitals and that such incentives and
2 patient-safety measures will benefit all persons seeking
3 health care services in this state, and
4 WHEREAS, the Legislature finds that coupling patient
5 safety measures and a limitation on provider liability in
6 teaching hospitals will lead to a reduction in the frequency
7 and severity of incidents of medical malpractice in hospitals,
8 and
9 WHEREAS, the Legislature finds that a reduction in the
10 frequency and severity of incidents of medical malpractice in
11 hospitals will reduce attorney's fees and other expenses
12 inherent in the medical liability system, and
13 WHEREAS, the Legislature finds that there is no
14 alternative method that addresses the overpowering public
15 necessity to implement patient-safety measures and limit
16 provider liability, and
17 WHEREAS, the Legislature finds that making high-quality
18 health care available to the residents of this state is an
19 overpowering public necessity, and
20 WHEREAS, the Legislature finds that medical education
21 in this state is an overpowering public necessity, and
22 WHEREAS, the Legislature finds that statutory teaching
23 hospitals are essential for high-quality medical care and
24 medical education in this state, and
25 WHEREAS, the Legislature finds that the critical
26 mission of statutory teaching hospitals is severely undermined
27 by the ongoing medical malpractice crisis, and
28 WHEREAS, and the Legislature finds that teaching
29 hospitals are appropriate health care facilities for the
30 implementation of innovative approaches to enhancing patient
31 safety and limiting provider liability, and severity of
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1 incidents of medical malpractice in hospitals will reduce
2 attorney's fees and other expenses inherent in the medical
3 liability system, and
4 WHEREAS, the Legislature finds that there is no
5 alternative method that addresses the overpowering public
6 necessity to implement patient-safety measures and limit
7 provider liability, and
8 WHEREAS, the Legislature finds that making high-quality
9 health care available to the residents of this state is an
10 overpowering public necessity, and
11 WHEREAS, the Legislature finds that medical education
12 in this state is an overpowering public necessity, and
13 WHEREAS, the Legislature finds that statutory teaching
14 hospitals are essential for high-quality medical care and
15 medical education in this state, and
16 WHEREAS, the Legislature finds that the critical
17 mission of statutory teaching hospitals is severely undermined
18 by the ongoing medical malpractice crisis, and
19 WHEREAS, and the Legislature finds that teaching
20 hospitals are appropriate health care facilities for the
21 implementation of innovative approaches to enhancing patient
22 safety and limiting provider liability, and
23 WHEREAS, the Legislature finds an overpowering public
24 necessity to impose reasonable limitations on actions for
25 medical malpractice against teaching hospitals in furtherance
26 of the critical public interest in promoting access to
27 high-quality medical care, medical education, and innovative
28 approaches to patient safety and provider liability, and
29 WHEREAS, the Legislature finds an overpowering public
30 necessity for teaching hospitals to implement innovative
31 measures for patient safety and limit provider liability in
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1 order to generate empirical data for state policymakers
2 concerning the effectiveness of these measures. Such data may
3 lead to broader application of these measures in a wider array
4 of hospitals after a reasonable period of evaluation and
5 review, and
6 WHEREAS, the Legislature finds an overpowering public
7 necessity to promote the academic mission of teaching
8 hospitals, and
9 WHEREAS, the Legislature finds that the academic
10 mission of these medical facilities is materially enhanced by
11 statutory authority for the implementation of innovative
12 approaches to promoting patient safety and limiting provider
13 liability, and
14 WHEREAS, innovative approaches to patient safety can be
15 carefully studied and learned by medical students, medical
16 school faculty, and affiliated physicians in appropriate
17 clinical settings, thereby enlarging the body of knowledge
18 concerning patient safety and provider liability which is
19 essential for advancement of patient safety, reduction of
20 expenses inherent in the medical liability system, and
21 curtailment of the medical malpractice insurance crisis in
22 this state.
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