4 patient safety centers target ambulatory surgery

All 6 programs will target hospitals

Six states have enacted legislation supporting creation of state patient safety centers, and four of those states (Florida, Massachusetts, Oregon, and Pennsylvania) will focus on ambulatory surgery centers. All six, which also include Maryland and New York, will focus on hospitals.

A recent report from the National Academy for State Health Policy in Portland, ME, examined the models in use in the six states.

The effort grew out of the 1999 Institute of Medicine (IOM) report that documented 98,000 deaths per year in the United States due to medical errors, says report author Jill Rosenthal, project manager at the National Academy of State Health Policy. "The IOM recommended two types of reporting systems: state mandatory reporting for serious adverse events and a voluntary system for near misses," she says. "The safety centers are a way of implementing the voluntary reporting."

The report says that all six patient safety centers studied are legislatively authorized or endorsed in some manner. That authorization distinguishes them from other state or public/private patient safety programs or coalitions.

Four of the centers are housed within their state governments, while two are outside of but still have legislatively authorized affiliations with the state governments. Financial support for patient safety centers comes primarily from fees, grants, and appropriations.

A similar goal

Although patient safety centers may have different governing structures, operations, and activities, they are similar in their mission statements: All six have statements on improving, ensuring, or promoting patient safety. The most universal function, common to all six centers surveyed, is to educate providers about best practices to improve patient safety, Rosenthal says. Other common roles include identifying causes of patient safety problems, fostering a culture of safety, developing collaborative relationships among patient safety stakeholders, and educating consumers about patient safety.

Five of the six states with centers have separate mandatory reporting systems for serious adverse events, and those systems are housed in state regulatory agencies. Several centers have access to the data in those systems and will assist with their analysis. Three of the states chose to develop within their patient safety centers a voluntary reporting system for less serious errors, intended to complement the mandatory systems already in place.

The types of data and methods of collection and analysis used by the centers vary. Rosenthal says some interesting and unique activities of patient safety centers include:

  • Florida will examine ways to reward providers who implement evidence-based medical practices and will recommend core competencies in patient safety for health professional curricula.
  • Massachusetts has developed a patient safety ombudsman program to work with patients, families, and consumers on patient safety-related problems and also plans to address health system and individual practitioner accountability.
  • Pennsylvania’s statute includes a provision for a discount in medical malpractice liability insurance premiums for facilities that can demonstrate a reduction in serious events following adoption of center recommendations.

What will the public see? 

All of the patient safety centers plan to make some information available to the public. If the centers have reporting systems, they will publicly report only data patterns using aggregate de-identified data that do not name facilities. Maryland and Oregon also will provide information on which facilities are participating in the reporting systems. Only New York provides facility — and provider-specific outcome information (which is contained within its physician profiling system) and outcome measure reports.

The impact of state patient safety centers remains to be seen, Rosenthal notes. "Despite the lack of rigorous indicators, patient safety centers ultimately will have to demonstrate gains in patient safety," she adds. "If they are unable to do this, pressure will no doubt build from regulators, purchasers, and the public for more draconian measures."

Source/Resource

For more information on the report, contact:

  • Jill Rosenthal, Project Manager, National Academy of State Health Policy, Portland, ME. Phone: (207) 874-6524. E-mail: jrosenthal@nashp.org.
  • To access a free copy of the report or find links for the state patient safety centers, go to the National Academy of State Health Policy’s web site (www.nashp.org). Under "Quality and Patient Safety," click on "New: State Patient Safety Centers," then "State Patient Safety Centers: A new approach to promote patient safety."