How Can States and Institutions Work Together to Create a Culture of Safety Concrete Actions to Improve Patient Safety

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How Can States and Institutions Work Together to
Create a Culture of SafetyConcrete Actions to
Improve Patient Safety
A State Perspective

• Scott Williams, M.D., M.P.H.
• Deputy Director,
• Utah Department of Health
• Salt Lake City, UT

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The States Role in Context

• Local Political and Partnership Climate
• High Profile Events
• Local Academic Experts
• Interested Politicians
• Regulatory Environment
• Organizational Relationships

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The Potential Roles of States

• Convener/ Common Ground
• Public Watchdog/ Impartial Endorser
• Industry Leveler
• Diverter of Unhelpful Solutions
• Funder
• Threatener of Traditional Regulation
• Regulator

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Liabilities of States Role

• Potentially unsafe environment
• Punitive regulatory actions
• Public disclosure
• Unacceptable administrative burdens
• Cost of compliance
• Reporting
• Unfulfilled promises
• Rapid decrease in errors
• Malpractice insurance premium

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Utahs Approach

• Patient Safety Report
• hlunix.hl.state.ut.us/hda/Reports/adverse_events.p
  df
• Sentinel Event Reporting Rule
• www.rules.utah.gov/publicat/code/r380/r380-200.htm
  
• Facility Patient Safety Program Rule
• www.rules.utah.gov/publicat/code/r380/r380-210.htm
  
• AHRQ Grant to Evaluate ICD Injury Codes
• HS11885

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Utahs Collaboration Factors

• Pressure relieving bedding to prevent pressure
  ulcers
• Real-time ultrasound guidance during central line
  insertion
• Appropriate provision of nutrition (emphasis on
  early enteral nutrition for critically ill or
  surgical patients)
• Patient self-management for warfarin (Coumadin)
  to achieve appropriate outpatient anticoagulation
  and prevent complications
• Patients to recall and restate informed consent
  information

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Public Information Strategies
Get out in front of issue stay on
message Medical errors occur in hospitals,
nursing homes, outpatient clinics, and at
home More reported events is good Serious
errors sometimes happen but we have mechanisms in
place to review them, determine the cause, and
prevent them from recurring Patients and
families are important partners
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AHRQs Patient Safety Corps

• Utahs wish list
• Lexicon standards
• What works (administrative)
• What works (clinical)
• Root cause analysis
• Developing financial resources
• Involving patients and families

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Lessons Learned

• Dont hesitate to jump when the window is open
• Ready, fire, aim
• Traditional regulation does not prevent errors
• States should pressure the industry to change
  and then be flexible and let them have the credit
• Test the effectiveness of existing capacity
  before proposing new structures
• Youre never finished