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Opportunities and Recommendations for State-Federal Coordination to Improve Health System Performance: A Focus on Patient Safety

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NASHP convened a roundtable of state and national health policy leaders in October 2009 to discuss opportunities for states and the federal government to develop congruent policies to promote patient safety.  This brief summarizes recommendations that emerged from that meeting.  Participants identified four criteria to use in selecting issues for state-federal coordination: (1) degree of readiness for change, (2) symbolic value and potential to send broad messages about priorities, (3) potential to avoid harm from non-aligned policies, and (4) potential for cost savings.  Considering these criteria, participants recommended three topics as especially worthy of future dialogue: reducing healthcare-associated infections (HAIs), decreasing preventable hospital readmissions, and avoiding hospitalizations for ambulatory care-sensitive (ACS) conditions.

Patient Safety Brief 159.6 KB

 

Nonpayment for Preventable Events and Conditions: Aligning State and Federal Policies To Drive Health System Improvement

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NASHP synthesized background information about state and federal policies that deny or reduce payment for adverse events. In October 2009, NASHP convened high-level state and national leaders to discuss 1) issues related to nonpayment of adverse events and 2) priority issues for state/federal dialogue.  This report examines policies implemented by the Medicare program and state agencies in twelve states (Colorado, Kansas, Maine, Maryland, Massachusetts, Minnesota, Missouri, New Jersey, New York, Oregon, Pennsylvania and Washington).  Key lessons are included.  Participants see aligning federal and state nonpayment policies as one area in which future alignment between federal and state policies can advance health system reform.

Patient Safety 372.9 KB

 

An Act to Reduce Medical Errors and Improve Patient Health: A Case Study from Maine

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Among recommendations to address medical errors, the Institute of Medicine (IOM) called for the creation of a nationwide mandatory reporting system for adverse events that result in death or serious injury, implemented through state collection of standardized data.  This briefing reviews the system in Maine. Health care facilities are required to report sentinel events to the state Department of Human Services Division of Licensure and Certification. The Division reviews the events and takes appropriate action. Reports are confidential and privileged, and reporters are immune from liability for reporting events. The Division will develop an annual report of summary data. Facilities that knowingly violate the act are subject to fine. Funding for two positions and information system development was provided.

Mandatory_reporting_ME.pdf 119.2 KB

 

Data Feedback Tools

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Feedback from reported data can help foster needed change within an institution. It can offer providers information on best practices and help prioritize critical issues in need of attention. It can also help purchasers and consumers exert external pressure for change and improvement by providing information about health care facility safety. Finally, it can assure the public that the issue is being addressed, improving the public trust.
Challenges associated with feedback
Providers have indicated that lack of data feedback from reporting systems is a disincentive to report. They view reporting systems that do not provide feedback as data graveyards, a burden that provides no benefits. Reporting systems can dispel this notion by disseminating useful information that can be used to spur change and offer helpful and effective “lessons learned.” Providing users with an easy and efficient way to access meaningful data can be challenging for states.  These challenges include determining what data sets are appropriate and useful to disseminate, creating user-friendly formats for disseminating information, targeting the appropriate audience, and determining the most useful mechanisms for disseminating the information in order to reach the intended audience.

 
 

Data Collection Tools

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Consistency in reporting is essential to analysis. States need consistent, reliable data in reporting systems in order to extract useful information. This section of the toolbox contains information and tools that may help states increase the number of reports and ensure that the reports they do receive are complete and accurate so that the resulting information is as useful as possible.
 

USER’S GUIDE FOR FACILITIES

Nevada Sentinel Event Guides ||  Nevada
Unusual Incident Reporting System ||  Tennessee
Hospital Frequently Asked Questions ||  California
Occurrence Reporting Manual ||  Colorado
Directions For Reporting Adverse Events (see Appendix B, Part I) ||  Connecticut
Adverse Incident Reporting Guide
Code 15 Reporting Instructions
Annual Report Instructions
Online Reporting Instructions
Hospital Event Instructions ||  Georgia
Hospital Patient Incident Instructions ||  Georgia
Patient Safety Decision Tree (see Appendix E) ||  Maryland
Hospital Fax Reporting of Incidents and Abuse General Instructions ||  Massachusetts
Additional Instructions and Guidance ||  Massachusetts
Reporting Requirements Across Agencies ||  Massachusetts

 

Background Information

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This section of the toolbox includes information from the 26 states and the District of Columbia with legislation or regulation related to hospital reporting of adverse events to a state agency.  It includes background information on the reporting systems to provide context.  It includes authorizing statutes or regulations, advisory groups, websites, and other useful information.
 

State Reporting of Medical Errors and Adverse Events: Results of a 50-State Survey

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This report describes results of a state survey of legislative and regulatory requirements for reporting medical errors and adverse events in hospital settings. The paper addresses the following: which states require mandatory reporting systems, what type of data is reported, how states use the data, who has access to the data, and the type of technical assistance states need to improve their systems.

Adverse Events Survey 2000 1.2 MB

Patient Safety and Medical Errors: A Road Map for State Action

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This report provides state executive and legislative branch officials with a framework for considering how they might coordinate with government and private stakeholders to address medical errors and patient safety in their states. The report outlines mechanisms to estimate the number of medical errors that occur and actions that states can take to improve patient safety in their various roles as purchasers, providers, regulators, educators, conveners, and policymakers.

patient_safety_roadmap.pdf 193 KB

 

State Responses to the Problem of Medical Errors: An Analysis of Recent State Legislative Proposals

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This report analyzes the 61 medical error-related bills introduced by state policy makers in 2001. It also provides up-to-date information on bills introduced or enacted during the 1999 and 2000 sessions, including information on how states are implementing laws enacted in 1999 and 2000. State proposals to reduce medical errors fall into eight categories, reflecting the key strategies state policy makers are using to address the problem in their respective jurisdictions. These strategies include: system-wide analysis; reporting systems; conditions of licensure; medication error reduction; minimum staffing requirements; financial incentives; appropriations; and public disclosure requirements.


State Responses Medical Errors 753.9 KB

 

State Patient Safety Centers: A New Approach to Promote Patient Safety

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As of 2004, six states (FL, MD, MA, NY, OR, PA) have enacted legislation supporting the creation of state patient safety centers to help address the problem of medical errors. This report examines the various models states have adopted in designing these centers and includes discussions of how the centers operate and monitor performance. The report also summarizes recommendations from center staff to other states that may be interested in following in their footsteps.

patient_safety_centers.pdf 354.8 KB

 

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