joint commission on health care 1 the role of state government in patient safety and medical error...

Joint Commission on Health Care

1

The Role of State Government in Patient Safety and Medical Error Reduction

Joseph J. HilbertSenior Health Policy Analyst

April 18, 2001


2Presentation Outline

JCHC Study of Patient Safety and Medical Errors

Virginia Legislation Related to Patient Safety - 2001 Session

Activities in Other States


3

HJR 9 of 2000 Directed JCHC to Review the 1999 IOM Report on

Patient Safety

JCHC developed 11 policy options for legislative consideration Take no action Resolution requesting VIPCS to expand membership, examine

feasibility and benefit of using patient level database to help identify and analyze occurrence of adverse medical events and medical errors, and advise General Assembly on status of its efforts to address patient safety

Resolution requesting VHI to examine feasibility of publishing “e-code” information, and examine feasibility of expanding reporting of e-codes

Legislation directing VDH to use patient level data to develop information concerning adverse medical events, and to review its regulations and inspection procedures to ensure they specifically address patient safety and medical error reduction


4JCHC Policy Options (continued)

Legislation directing Secretary of Health and Human Resources to establish voluntary reporting system to support development and dissemination of best practices for prevention of adverse medical events and errors

Legislation directing Department of Health Professions to develop educational and outreach program concerning patient safety and prevention of medical errors

Legislation directing DHP to develop regulations for continuing education to specifically address the promotion of patient safety and prevention of medical errors

Legislation requiring all individuals licensed by health regulatory boards to report professional, incompetent or substandard conduct or care by any other individual licensed by the same board; and providing immunity to any such individual who makes a report from civil or criminal liability resulting from such report


5JCHC Policy Options (continued)

Legislation requiring DMAS and DHRM to specifically incorporate promotion of patient safety and prevention of medical errors into their health plan and provider contract provisions relating to quality of care and quality improvement

Legislation directing VDH to amend MCHIP regulations to specifically include promotion of patient safety and prevention of medical errors as part of quality improvement requirements

Budget amendment directing MCV, UVA and EVMS to evaluate patient safety and medical error prevention issues and strategies in outpatient and physician office settings for the purpose of broadening the existing body of knowledge beyond the inpatient hospital setting


6

JCHC Action in Response to Policy Options

19 individuals/organizations submitted written comments in response to the JCHC report— No clear consensus as to which policy options should

be adopted, or what the legislative response should be JCHC adopted modified versions of Policy Options II and III

— Letter from JCHC chairman to VIPCS co-chairs— Letter from JCHC chairman to VHI Board of Directors

JCHC requests that VIPCS advise it as to the current status of progress at a future JCHC meeting


8

2001 Virginia Legislation Related to Patient Safety

HB 1826 - Establishes requirements for the registration of pharmacy technicians; pharmacists may supervise no more than four pharmacy technicians at one time; clarifies the duties that may be performed by a pharmacist or a pharmacy intern; Board of Pharmacy must adopt final regulations by 7/1/03 (passed)

SB 1371 - Requires the Board of Pharmacy to promulgate regulations requiring practicing prescribers who are authorized to prescribe controlled substances to issue prescriptions that have been typed, pre-printed, or electronically printed, and signed by the prescriber to ensure accuracy in compounding, processing, and dispensing (failed)


9

2001 Virginia Legislation Related to Patient Safety (continued)

SB 1125 - Establishes minimum nurse staffing standards and ratios for nursing homes — Each nursing home must have professional RNs to serve as

Director of Nursing and Nursing Supervisors— At least 1 RN or LPN per 15 residents during day shift— At least 1 RN or LPN per 20 residents during evening shift— At least 1 RN or LPN per 30 residents during night shift— At least 1 CAN per 5 residents during day and evening shifts— At least 1 CAN per 10 residents during the night shift— Actual staffing ratios must be posted on each wing and floor

(failed - referred to JCHC for study)


10

2001 Virginia Legislation Related to Patient Safety (continued)

HB 2780 - Hospitals must report to VDH all infections contracted by patients while in a hospital. VDH shall compile and analyze this data for use in facility regulation and protection of consumer health. VDH shall share data, while protecting patient anonymity, with OAG and DACS (failed)


12

Patient Safety and Medical Errors: A Road Map for State Action

(NASHP - March 2001)

States as Purchasers: Are they getting the most for their dollars?— Are patient safety issues considered in contracting decisions?

Joint purchasing agreements among agencies to provide greater leverage over quality?

States as Providers: Are their health care facilities as safe as they can be?— Have proven medication safety practices been implemented and

staff educated about up-to-date medication information? States as Regulators: How can states monitor patient safety?

— What information does the state receive from JCAHO following a survey? If needed, can you work with JCAHO to get additional information?


13

Patient Safety and Medical Errors: A Road Map for State Action

(cont.)

States as Educators: The power of information— Has the state identified an entity responsible for

providing consumers with information about patient safety issues?

— Does the state have an ombudsman program to advocate for patients?

States as Conveners: Taking a collaborative approach— Has the state considered convening a task force to

bring together various state agencies? Are the task force goals clearly delineated? How will progress be benchmarked and measured?


14

Current State Programs Addressing Medical Errors: An Analysis of Mandatory Reporting and

Other Initiatives (NASHP-January 2001)

State systems developed for purposes other than explicit oversight of medical errors

Despite weaknesses, these systems provide additional indicators to track patient safety issues and strengthen hospital oversight

Not a single solution to a complex problem, but a means to identify and respond to the most serious adverse events

Conceptual, political, and practical difficulties in establishing these programs should not be underestimated


15

NASHP Plans to Complete Additional Patient Safety Reports

Cost Implications of Administering State Mandatory Reporting Programs (Draft - March 2001)

A guide to inform legislative decision making when contemplating the adoption of reporting requirements (not yet drafted)


16

Florida Commission on Excellence in Health Care

Established during 2000 Session in response to concerns surrounding patient safety and medical error issues. “The Legislature finds that additional focus on strengthening health care delivery systems by eliminating avoidable mistakes in the diagnosis and treatment… holds tremendous promise to increase the quality of health care services available…, thereby reducing costs associated with medical mistakes and malpractice, and in turn increasing access to health care in the state.”

43 members drawn from public and private sectors Charged with developing a statewide strategy for improving the

health care delivery system through meaningful reporting standards, data collection and review, and quality measurement


17

Florida Commission on Excellence in Health Care - Recommendations

Establish Interagency Council for Patient Safety and Excellence in Health Care— Ensure coordination between agencies and close gaps in data collection;

Identify and compile quality of care data; — Develop a mechanism for quality measurement and data analysis and

reporting, to include a public report utilizing a risk-adjusted methodology with protections for confidential information

— Within existing adverse event reporting system, corrective actions taken following incidents should be disseminated; Best practices identified through analysis of quality indicators should be disseminated; Aggregated quality data should be made available to assigned users on a secure, limited access Internet-based system

— Voluntary, non-punitive reporting system for reporting of errors that could result in injury; system should include confidentiality protections


18

Florida Commission on Excellence in Health Care - Recommendations

(cont.)

Establish Center for Patient Safety and Excellence in Health Care— Collect and establish a statewide database on health care

errors, adverse incidents, and near misses, maximizing the use of existing data

— Analyze statewide data on health care errors in procedures, products and systems and prepare an aggregate report for dissemination

— Serve as the clearinghouse, in conjunction with regulatory bodies, to disseminate information on patient safety

— Develop a model patient safety education and training program, and encourage medical schools and teaching hospitals to incorporate the program into their curriculums


19

Role of State Governments - Conclusion

State governments are trying to identify the most effective means to analyze patient safety and to obtain improvements

Funding opportunities for state initiatives may emerge through Congressional action or through federal agencies such as AHRQ, CDC, or HCFA

A comprehensive approach that addresses multiple state roles will be required in order to be effective

“A basic level of safety should be assured for all health care consumers - an efficient effective regulatory component is critical to accomplishing that goal” (Florida Commission on Excellence in Health Care)

The events that result in medical errors are not likely to disappear without serious attention from all stakeholders

joint commission on health care 1 the role of state government in patient safety and medical error...

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