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

1
The Role of State Government in Patient Safety
and Medical Error Reduction
Joseph J. Hilbert Senior Health Policy Analyst
April 18, 2001
2
Presentation 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

4
JCHC 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

5
JCHC 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

7
Presentation Outline

• JCHC Study of Patient Safety and Medical Errors
• Virginia Legislation Related to Patient Safety -
  2001 Session
• Activities in Other States

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)

11
Presentation Outline

• JCHC Study of Patient Safety and Medical Errors
• Virginia Legislation Related to Patient Safety -
  2001 Session
• Activities in Other States

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