The Oregon Patient Safety Reporting Program: Learning through Sharing

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The Oregon Patient Safety Reporting
ProgramLearning through Sharing

• Gwen M. Dayton
• Vice President and General Counsel
• Oregon Association of Hospitals and Health
  Systems

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HB 2349

• Passed by 2003 Oregon Legislative Assembly
• Effective July 1, 2003

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Why did Oregon go down this road?

• Growing consensus about importance of public
  reporting of patient safety information
• IOM report released November, 1999
• Other national efforts
• JCAHO
• Medicare Conditions of Participation
• AHA/CMS voluntary hospital reporting program
• National Quality Forum
• Other states

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HB 2349 A Group Effort

• Oregon Association of Hospitals and Health
  Systems (OAHHS)
• Oregon Medical Association (OMA)
• Oregon Nurses Association (ONA)
• Oregon Health and Science University (OHSU)
• Kaiser
• Oregon Department of Human Services
• Regence Blue Cross
• Consumers
• Purchasers

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The Patient Safety Workgroup Goal

• Improve patient safety by reducing the risk of
  adverse events occurring in Oregons health care
  system and by encouraging a culture of patient
  safety in Oregon. Do this through non-punitive,
  non-regulatory system that encourages sharing of
  patient safety data and learning, in a public
  setting that maintains accountability

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Oregon Patient Safety Reporting Program

• Voluntary
• Participation is voluntary, but must report to
  2007 Legislative Assembly regarding mandatory
  system

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Oregon Patient Safety Reporting Program

• Not Regulatory
• No state regulatory agency has access to patient
  safety reports and data
• No enforcement action based on reporting of
  serious adverse event

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Oregon Patient Safety Reporting Program

• Accountable
• Participants who do not participate in good faith
  will be terminated
• Public Health Officer must certify the
  completeness and credibility of reports
• Auditing and oversight of participation, action
  plans

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Oregon Patient Safety Reporting Program

• Participants
• Hospitals, pharmacies, long term care
• facilities, renal dialysis centers, birthing
• centers, ambulatory surgical centers
• Not Physicians or other individual
  practitioners but

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Oregon Patient Safety Reporting Program

• Participant Obligation
• Participate for a minimum of one year
• Fully report serious adverse events to the
  Patient Safety Commission
• Report, and meet Commission standards for
  thorough and credible root cause analyses, action
  plans and acceptable follow-up of serious adverse
  events, and patient safety plans
• Provide written notification of occurrence of
  serious adverse event to patient affected by the
  event

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Oregon Patient Safety Reporting Program

• Serious adverse event means an objective
• and definable negative consequence of patient
• care, or the risk thereof, that is unanticipated,
• usually preventable and results in, or presents
• a significant risk of, patient death or serious
• physical injury
• Near misses not to be included in initial list
  of reportable events, but can be added later

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Oregon Patient Safety Reporting Program

• Oregon Patient Safety Commission
• A semi-independent state agency
• Non-regulatory
• Publicly accountable
• Mission Improve patient safety by reducing the
  risk of serious adverse events occurring in
  Oregons health care system and by encouraging a
  culture of patient safety in Oregon

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Oregon Patient Safety Reporting Program

• Board of Directors
• Appointed by Governor, confirmed by Oregon State
  Senate
• 17 members, including
• Consumers, providers, purchasers, insurers
• Public Health Officer

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Oregon Patient Safety Reporting Program

• For Participants
• Establish quality improvement techniques to
  reduce systems errors contributing to adverse
  events and
• Disseminate evidence-based prevention practices
  to improve patient outcomes
• Issue to participants
• Statistical analyses
• Recommendations regarding quality improvement
  techniques
• Recommendations regarding standard protocols and
• Recommendations regarding best patient safety
  practices
• Offer rewards and recognition to participants

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Oregon Patient Safety Reporting Program

• For the Public
• No report card
• Distribute written reports using aggregate,
  de-identified data from the program to describe
  statewide adverse event patterns. Reports shall
  include
• Types and frequencies of adverse events
• Yearly adverse event totals and trends
• Clusters of adverse events
• Demographics of patients involved in adverse
  events
• Systems factors associated with particular events
• Interventions to prevent frequent or high
  severity serious adverse events
• Consumer information regarding prevention of
  adverse events
• Maintain a website for public access to reports
  and names of participants
• Develop auditing and oversight criteria. 

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Oregon Patient Safety Reporting Program

• For the Legislature
• Periodic reports regarding the implementation of
  the program

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Oregon Patient Safety Reporting Program

• Confidentiality
• State public records laws do not apply to reports
  created or maintained by Commission that contain
  patient safety data
• State open meetings laws do not apply to meetings
  at which information identifying a participant or
  patient is discussed
• Patient safety data protected from disclosure in
  a lawsuit
• Participants, or employees of participants, may
  not be deposed or questioned about patient safety
  data
• BUT nothing in law intended to restrict access
  to patient records or any other information
  currently available
• Confidentiality written to cover any formal
  patient safety reporting program

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Oregon Patient Safety Reporting Program

• Cost
• Estimated 500,000 first year, 800,000 to 1
  million in subsequent years
• Cost paid
• Grants and foundations
• Participant fees
• State resources and expertise, as available

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Oregon Patient Safety Reporting Program

• Where We Are Today
• HB 2349 became law July 1, 2003
• Governor has recommended appointments to
  Commission
• Senate confirmed appointments in January, 2004
• Commission will begin hiring staff and developing
  program
• Reporting likely to begin in 2005