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SECOND REGULAR SESSION
HOUSE BILL NO. 1951
103RD GENERAL ASSEMBL Y
INTRODUCED BY REPRESENT A TIVE BOSLEY .
4871H.01I JOSEPH ENGLER, Chief Clerk
AN ACT
T o repeal section 193.145, RSMo, and to enact in lieu thereof six new sections relating to
health care.
Be it enacted by the General Assembly of the state of Missouri, as follows:
Section A. Section 193.145, RSMo, is repealed and six new sections enacted in lieu
2 thereof, to be known as sections 192.1005, 192.1010, 192.1015, 192.1020, 193.145, and
3 197.178, to read as follows:
192.1005. Sections 192.1005 to 192.1020 shall be known and may be cited as the
2 "Missouri Dignity in Pr egnancy and Childbirth Act".
192.1010. For purposes of sections 192.1005 to 192.1020, the following terms
2 mean:
3 (1) "Implicit bias", a bias in judgment or behavior that res ults fr om subtle
4 cognitive pr ocesses, including implicit pr ejudice and implicit ster eotypes that often
5 operate at a level below conscious awar eness and without intentional contro l;
6 (2) "Implicit prej udice", pr ejudicial negative feelings or beliefs about a grou p
7 that a person holds without being awar e of such feelings or beliefs;
8 (3) "Implicit stereo types", the unconscious attributions of particular qualities to
9 a member of a certain social grou p. Implicit stere otypes ar e influenced by experience
10 and ar e based on learning associations between various qualities and social categories,
11 including race and gender;
12 (4) "Perinatal car e", the prov ision of care during pr egnancy , labor , delivery , and
13 postpartum and neonatal periods;
EXPLANA TION — Matter enclosed in bold-faced brackets [thus] in the above bill is not enacted and is
intended to be omitted from the law . Matter in bold-face type in the above bill is proposed language.
14 (5) "Pr egnancy-r elated death", the death of a person while pregn ant or within
15 thr ee hundr ed sixty-five days of the end of a pr egnancy , rega rdless of the duration or
16 site of the pr egnancy , fr om any cause relat ed to, or aggravated by , the preg nancy or its
17 management, but not fr om accidental or incidental causes.
192.1015. 1. Any hospital, clinic, or other health care facility that pr ovides
2 perinatal car e shall implement an evidence-based implicit bias progra m for all health
3 car e pr oviders involved in the perinatal care of patients within that facility .
4 2. An implicit bias pro gram implemented under subsection 1 of this section shall
5 include all of the following:
6 (1) Identification of previ ous or curr ent unconscious biases and misinformation;
7 (2) Identification of personal, interpersonal, institutional, structural, and
8 cultural barriers to inclusion;
9 (3) Corre ctive measur es to decr ease implicit bias at the interpersonal and
10 institutional levels, including ongoing policies and practices for that purpose;
11 (4) Information on the effects, including, but not limited to, ongoing personal
12 effects, of historical and contemporary exclusion and oppr ession of minority
1 3 communities;
14 (5) Information about cultural identity acr oss racial or ethnic grou ps;
15 (6) Information about communicating mor e effectively acr oss identities,
16 including racial, ethnic, rel igious, and gender identities;
17 (7) Discussion on power dynamics and organizational decision-making;
18 (8) Discussion on health inequities within the perinatal car e field, including
19 information on how implicit bias impacts maternal and infant health outcomes;
20 (9) Perspectives of diverse, local constituency gro ups and experts on particular
21 racial, identity , cultural, and pr ovider -community relat ions issues in the community;
22 and
23 (10) Information on repr oductive justice.
24 3. (1) A health car e pr ovider described in subsection 1 of this section shall
25 complete initial basic training thr ough the implicit bias pr ogram based on the
26 components described in subsection 2 of this section.
27 (2) Upon completion of the initial basic training, a health care pr ovider shall
28 complete a refr esher course under the implicit bias progr am every two years ther eafter ,
29 or on a mor e fr equent basis if deemed necessary by the facility , in order to keep curr ent
30 with changing racial, identity , and cultural tren ds and best practices in decr easing
31 interpersonal and institutional implicit bias.
32 4. A facility described in subsection 1 of this section shall pr ovide a certificate of
33 training completion to another facility or a training attendee upon requ est. A facility
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34 may accept a certificate of completion fro m another facility described in subsection 1 of
35 this section to satisfy the training r equir ement described in subsection 3 of this section
36 for a health car e pr ovider who works in mor e than one facility .
37 5. Notwithstanding subsections 1 to 4 of this section, if a physician involved in
38 the perinatal care of patients is not dir ectly employed by a facility , the facility shall offer
39 the training to the physician.
192.1020. 1. The department of health and senior services shall track data on
2 sever e maternal morbidity including, but not limited to, all of the following health
3 conditions:
4 (1) Obstetric hemorrhage;
5 (2) Hypertension;
6 (3) Pr eeclampsia and eclampsia;
7 (4) V enous thr omboembolism;
8 (5) Sepsis;
9 (6) Cerebr ovascular accident; and
10 (7) Amniotic fluid embolism.
11 2. The data on sever e maternal morbidity collected under subsection 1 of this
12 section shall be published at least once every thr ee years after all of the following have
13 occurr ed:
14 (1) The data has been aggr egated by state region s as defined by the department
15 of health and senior services to ensur e data r eflects how region alized car e systems are or
16 should be collaborating to impr ove maternal health outcomes or other smaller r egional
17 sorting based on standard statistical methods for accurate dissemination of public
18 health data without risking a confidentiality or other disclosur e br each; and
19 (2) The data has been disaggr egated by racial and ethnic identity .
20 3. The department of health and senior services shall track data on preg nancy-
21 r elated deaths including, but not limited to, all of the conditions listed in subsection 1 of
22 this section, indirect obstetric deaths, and other maternal disorders pr edominantly
23 r elated to pregn ancy and complications pr edominantly rela ted to the puerperium.
24 4. The data on pr egnancy-re lated deaths collected under subsection 3 of this
25 section shall be published, at least once every thr ee years, after all of the following have
26 occurr ed:
27 (1) The data has been aggr egated by state region s as defined by the department
28 of health and senior services to ensur e data r eflects how region alized car e systems are or
29 should be collaborating to impr ove maternal health outcomes or other smaller r egional
30 sorting based on standard statistical methods for accurate dissemination of public
31 health data without risking a confidentiality or other disclosur e br each; and
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32 (2) The data has been disaggr egated by racial and ethnic identity .
193.145. 1. A certificate of death for each death which occurs in this state shall be
2 filed with the local registrar , or as otherwise directed by the state registrar , within five days
3 after death and shall be registered if such certificate has been completed and filed pursuant to
4 this section. All data providers in the death registration process, including, but not limited to,
5 the state registrar , local registrars, the state medical examiner , county medical examiners,
6 coroners, funeral directors or persons acting as such, embalmers, sheriffs, attending
7 physicians and resident physicians, physician assistants, assistant physicians, advanced
8 practice registered nurses, and the chief medical of ficers of licensed health care facilities, and
9 other public or private institutions providing medical care, treatment, or confinement to
10 persons, shall be required to use and utilize any electronic death registration system required
11 and adopted under subsection 1 of section 193.265 within six months of the system being
12 certified by the director of the department of health and senior services, or the director's
13 designee, to be operational and available to all data providers in the death registration process.
14 2. If the place of death is unknown but the dead body is found in this state, the
15 certificate of death shall be completed and filed pursuant to the provisions of this section.
16 The place where the body is found shall be shown as the place of death. The date of death
17 shall be the date on which the remains were found.
18 3. When death occurs in a moving conveyance in the United States and the body is
19 first removed from the conveyance in this state, the death shall be registered in this state and
20 the place where the body is first removed shall be considered the place of death. When a
21 death occurs on a moving conveyance while in international waters or air space or in a foreign
22 country or its air space and the body is first removed from the conveyance in this state, the
23 death shall be registered in this state but the certificate shall show the actual place of death if
24 such place may be determined.
25 4. The funeral director or person in char ge of final disposition of the dead body shall
26 file the certificate of death. The funeral director or person in char ge of the final disposition of
27 the dead body shall obtain or verify and enter into the electronic death registration system:
28 (1) The personal data from the next of kin or the best qualified person or source
29 available;
30 (2) The medical certification from the person responsible for such certification if
31 designated to do so under subsection 5 of this section; [ and ]
32 (3) Information indicating whether the decedent was pr egnant at the time of
33 death, or within a year prior to the death, if known, as determined by observation,
34 autopsy , or review of the medical record. The electr onic death reg istration system shall
35 captur e additional information reg arding the pr egnancy status of the decedent
36 consistent with the data elements on the U.S. Standard Certificate of Death. This
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37 subdivision shall not be interpret ed to req uire the performance of a preg nancy test on a
38 decedent or to req uire a r eview of medical r ecords in order to determine pregn ancy; and
39 (4) Any other information or data that may be required to be placed on a death
40 certificate or entered into the electronic death certificate system including, but not limited to,
41 the name and license number of the embalmer .
42 5. The medical certification shall be completed, attested to its accuracy either by
43 signature or an electronic process approved by the department, and returned to the funeral
44 director or person in char ge of final disposition within seventy-two hours after death by the
45 physician, physician assistant, assistant physician, or advanced practice registered nurse in
46 char ge of the patient's care for the illness or condition which resulted in death. In the absence
47 of the physician, physician assistant, assistant physician, or advanced practice registered
48 nurse or with the physician's, physician assistant's, assistant physician's, or advanced practice
49 registered nurse's approval the certificate may be completed and attested to its accuracy either
50 by signature or an approved electronic process by the physician's associate physician, the
51 chief medical of ficer of the institution in which death occurred, or the physician who
52 performed an autopsy upon the decedent, provided such individual has access to the medical
53 history of the case, views the deceased at or after death and death is due to natural causes.
54 The person authorized to complete the medical certification may , in writing, designate any
55 other person to enter the medical certification information into the electronic death
56 registration system if the person authorized to complete the medical certificate has physically
57 or by electronic process signed a statement stating the cause of death. Any persons
58 completing the medical certification or entering data into the electronic death registration
59 system shall be immune from civil liability for such certification completion, data entry , or
60 determination of the cause of death, absent gross negligence or willful misconduct. The state
61 registrar may approve alternate methods of obtaining and processing the medical certification
62 and filing the death certificate. The Social Security number of any individual who has died
63 shall be placed in the records relating to the death and recorded on the death certificate.
64 6. When death occurs from natural causes more than thirty-six hours after the
65 decedent was last treated by a physician, physician assistant, assistant physician, or advanced
66 practice registered nurse, the case shall be referred to the county medical examiner or coroner
67 or physician or local registrar for investigation to determine and certify the cause of death. If
68 the death is determined to be of a natural cause, the medical examiner or coroner or local
69 registrar shall refer the certificate of death to the attending physician, physician assistant,
70 assistant physician, or advanced practice registered nurse for such certification. If the
71 attending physician, physician assistant, assistant physician, or advanced practice registered
72 nurse refuses or is otherwise unavailable, the medical examiner or coroner or local registrar
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73 shall attest to the accuracy of the certificate of death either by signature or an approved
74 electronic process within thirty-six hours.
75 7. If the circumstances suggest that the death was caused by other than natural causes,
76 the medical examiner or coroner shall determine the cause of death and shall, either by
77 signature or an approved electronic process, complete and attest to the accuracy of the
78 medical certification within seventy-two hours after taking char ge of the case.
79 8. If the cause of death cannot be determined within seventy-two hours after death,
80 the attending medical examiner , coroner , attending physician, physician assistant, assistant
81 physician, advanced practice registered nurse, or local registrar shall give the funeral director ,
82 or person in char ge of final disposition of the dead body , notice of the reason for the delay ,
83 and final disposition of the body shall not be made until authorized by the medical examiner ,
84 coroner , attending physician, physician assistant, assistant physician, advanced practice
85 registered nurse, or local registrar .
86 9. When a death is presumed to have occurred within this state but the body cannot be
87 located, a death certificate may be prepared by the state registrar upon receipt of an order of a
88 court of competent jurisdiction which shall include the finding of facts required to complete
89 the death certificate. Such a death certificate shall be marked "Presumptive", show on its face
90 the date of registration, and identify the court and the date of decree.
91 10. (1) The department of health and senior services shall notify all physicians,
92 physician assistants, assistant physicians, and advanced practice registered nurses licensed
93 under chapters 334 and 335 of the requirements regarding the use of the electronic vital
94 records system provided for in this section.
95 (2) On or before August 30, 2015, the department of health and senior services,
96 division of community and public health shall create a working group comprised of
97 representation from the Missouri electronic vital records system users and recipients of death
98 certificates used for professional purposes to evaluate the Missouri electronic vital records
99 system, develop recommendations to improve the efficien cy and usability of the system, and
100 to report such findings and recommendations to the general assembly no later than January 1,
101 2016.
102 1 1. Notwithstanding any provision of law to the contrary , if a coroner or deputy
103 coroner is not current with or is without the approved training under chapter 58, the
104 department of health and senior services shall prohibit such coroner from attesting to the
105 accuracy of a certificate of death. No person elected or appointed to the office of coroner can
106 assume such elected of fice until the training required under section 58.030 has been
107 completed and a certificate of completion has been issued. In the event a coroner cannot
108 fulfill his or her duties or is no longer qualified to attest to the accuracy of a death certificate,
109 the sheriff of the county shall appoint a medical professional to attest death certificates until
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110 such time as the coroner can resume his or her duties or another coroner is appointed or
111 elected to the of fice.
197.178. 1. Each hospital shall pr ovide each patient, upon admission or as soon
2 ther eafter as r easonably practicable, written information regar ding the following rights
3 of the patient:
4 (1) The right to be informed of continuing health car e requi rem ents following
5 discharge fr om the hospital;
6 (2) The right to be informed that, if the patient so authorizes, a friend or family
7 member may be pr ovided information about the patient's continuing health car e
8 r equir ements following discharge fr om the hospital;
9 (3) The right to participate actively in decisions re garding medical care . T o the
10 extent permitted by law , participation shall include the right to ref use tr eatment;
11 (4) The right to appr opriate pain assessment and tr eatment;
12 (5) The right to be fr ee of discrimination on the basis of any pr otected status as
13 set forth in chapter 213; and
14 (6) The right to information on how to file a complaint with the following:
15 (a) The department of health and senior services;
16 (b) The Missouri commission on human rights; and
17 (c) The state board of regi stration for the healing arts.
18 2. A hospital may include the information req uired by this section with other
19 notices to the patient r egarding patient rights. If a hospital chooses to include this
20 information along with existing notices to the patient regard ing patient rights, any
21 newly r equir ed information shall be pr ovided when the hospital exhausts its existing
22 inventory of written materials and prints new written materials.
✔
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