- • 37 States with Patient Safety Initiatives
State initiatives addressing patient safety exist in many recognizable forms. In this summary, an attempt has been made to assess involvement in public and private initiatives that are designed to reach out to every facility and/or healthcare provider.1 For purposes of this analysis, 5 different forms of public or private Patient Safety Initiatives are addressed including:
- 1. Adverse Event Reporting (with/without Physician Reporting) that has evolved in 28 States beginning in the mid-1970s,
- 2. Patient Safety Coalitions (PSC) that evolved in 19 states since their inception in 1997; 16 of these States maintain active PSCs in 2006.
- 3. Outcomes Reporting of cardiac and non-cardiac procedure outcomes and outcomes assessment of targetted patient groups or diagnoses that have evolved in 14 States since 1990,
- 4. Other Reporting Options that do not fit into other categories – (2 state initiatives reporting medication-errors and 1 reporting JCAHO's National Patient Safety Goals (NPSGs) compliance comprise this category), and
- 5. Patient Safety Centers that coordinate public/private patient safety initiatives in 6 states since 2000.]
1 Not included in this analysis are Patient Safety reporting initiatives that extend to all States and that reflect facility-level initiatives as opposed to initiatives that reflect public policy or privately-supported consensus.
Examples include CMS' Hospital Compare initiative that grades compliance with healthcare processes in limited numbers of targeted health conditions for over 4,000 participating hospitals nationwide. The participation of facilities in voluntary initiatives sponsored by The Leapfrog Group, the Institute for Healthcare Improvement (IHI), and other private patient safety / medication-reporting groups similarly extend throughout most States.
HOWEVER, participation in these voluntary initiatives are aimed at facilities, and facilitly participation does not necessarily reflect public policy or consensus across States; decisions regarding participation are made at the facility level. Information regarding participation in these initiatives is available at the websites for these entities.
- • 32 States with one or more Reporting Programs
State reporting programs are diverse and often tailored to meet policy or individual goals of the State. As demonstrated in the adjacent map, reporting programs exist in some form in 32 states and do not exist in any form in 18 states and the District of Columbia.
In States where reporting programs exist, they are 90% mandatory, reflecting public policy of the State. However, in some States, public policy does not support reporting programs and/or gives way to the policy initiatives of private stakeholders. Programs in these States are voluntary and derive from the singular or joint efforts of private organizations, usually the State Hospital Association and/or the State's Quality Improvement Organizations, with occasional private funding from non-public stakeholders. Sometimes pubic and private initiatives are addressed collaboratively with funding and administrative support reflecting local circumstances/compromises.
- • Examples of Marked Variations in Public Policy Across States
Clearly State reporting programs are not monolithic, and they often are in flux and evolve with changes in support and budgets. Public policy often reflects an amalgamation of public and private supports. For example,
- ◊ Minnesota
Minnesota has implemented only one type of reporting program, . . . i.e., event reporting. The mandatory Minnesota program began reporting in 2004 using the NQF's 27 ‘Never’ Events. The program was only sustained in its first year of operations because of the generous financial support of private stakeholders and the management of the Minnesota Hospital Association. The program was turned over entirely to the State regulatory authority in December 2004.
- ◊ Oregon
Oregon's confidential voluntary reporting of ‘serious adverse events’ evolved from medical error reporting legislation [Oregon Law 2003, Chapter 686] that created the Oregon Patient Safety Reporting Program under management of the The Oregon Patient Safety Commission (OPSC) that was created as a semi-independent, non-regulatory state agency. The legislation was generated by broad sponsorship of multiple key stakeholders who continue to support the program both financially and operationally. Facilities participate voluntarily and contribute to the operational costs, and State legislators are apprised of operations by annual reports.
Consistent with Oregon's "voluntary" approach, the privately-funded Oregon Hospital Outcome (OHO) Project has provided risk-adjusted Coronary Artery Bypass surgery outcomes for 2002-2004 low-risk patients from 10 of Oregon's 12 heart centers that agreed to participate.
- ◊ Maryland
Maryland has a similar collaborative process that includes a mandatory adverse event reporting to the State regulatory authority and a voluntary Maryland Patient Safety Center (MPSC ) that is designed to receive ‘near-miss’ medical errors and promote public/private collaborations. The MPSC is funded and operated in its first 3-years of operation by the Maryland Hospital Association and Delmarva Foundation, the QIO for Maryland. However, state-approved increases in hospital rates [PDF] serve to alleviate the burden on hospitals and exemplifies the collaboration between the State and key healthcare stakeholders.
- ◊ Pennsylvania
Maryland's next-door neighbor Pennsylvania, reflects a State in which publicly mandated outcomes reporting and adverse event reporting programs are imposed upon affected stakeholders with a strong regulatory flavor lacking apparent willing collaboration with the provider community. For example, the Pennsylvania Health Care Cost Containment Council (PHC4) publishes facility (and cardiac physician-provider) report cards for costs and/or outcomes performances across multiple sectors of healthcare, using data generated from facility-mandated reporting. Web-published provider responses to these reports commonly reflect defensive, if not adversarial, responses to the State reports and suggest a dirth of willing collaboration with the provider community.
In addition, an ambitious and outwardly successful Pennsylvania Patient Safety Reporting System (PA-PSRS) was created as part of Medical Malpractice legislation. The mandatory program has been implemented with funding from annual assessments of $2.5M to $3.0M upon healthcare facilities, who also incur additional operational costs to comply with imposed reporting requirements.
- ◊ New York
New York policy reflects a very 'hands-on' regulatory flavor with a combination of outcomes reporting and adverse event reporting programs. New York was the first state in 1990 to impose mandatory cardiac procedure reporting of mortality and other outcomes with public identification of the hospitals and the physicians performing those procedures. In addition to documented improvement in mortality outcomes across the State, interventions by State regulatory agencies have led to changes in the mix of physician and facility providers performing cardiac procedures.
The New York Patient Occurrence Reporting and Tracking System (NYPORTS) is one of the more successful and well-supported adverse event reporting programs across all US States, and New York State officials have made strong efforts to provide meaningful feedback to facility providers. However, the NY State Health Department, in addressing the department's perception of significant under-reporting of adverse events, has often raised the spectre of regulatory authority, and threatened non-reporting facilities, stating,
"For those hospitals that have ignored these critical reporting requirements, we will identify you, single you out and sanction you in a public forum." [PDF - Health Affairs, p. 287, May/June 2001]
- ◊ Minnesota
- • Organization of Discussion of Reporting Programs
The analysis of States that follows is segregated into 7 distinct sections (including this Introduction), so as to provide historical perspective and discuss public and private reporting options and those States that have no patient safety initiatives or reporting initiatives under the umbrella of public policy. Patient Safety Coalitions, patient safety initiatives that reflect variable degrees of public and private collaboration and effectiveness across States, are analyzed and discussed elsewhere. Five sections include discussions and links for each of 4 major reporting option categories, plus a discussion of non-reporting States. These reviews are followed by a summary section.