The State of Georgia has two state medical error reporting programs, beyond the voluntary JCAHO sentinel event reporting program. All enjoy data and confidentiality protections from Georgia's Peer Review Law, OCGA §§ 31-7-130 to 31-7-133.
- • Partnership for Health and Accountability (PHA) Reporting Program
The Partnership for Health and Accountability (PHA) is a collaborative public/private program that was created by the Georgia Hospital Association (GHA) in 2000. The GHA reporting program owes its success in part to federal and state agencies.
The Georgia Hospital Associations PHA program was a medical error demonstration project, supported by a AHRQ grant for which the GHA successfully completed. Grant #U18 HS11918 created a statewide, voluntary, peer review-protected, medical error reporting system for hospitals in Georgia with funding of from 9/27/2001 through 1/31/2005.
Furthermore, beginning in 2001, participation in this voluntary PHA program was coerced when hospital contracts with the Georgia Department of Community Health (DCH)1 required hospital participation in a qualified patient safety program, thereby permitting hospitals to keep their eligibility to bill under Medicaid and Medicare. The GHA's voluntary error reduction program met the DCH patient safety program criteria. As a result of the state's support, hospital participation in GHA's program increased substantially at that time.
The PHA has a peer-review-protected system and provides a neutral forum for the voluntary reporting, studying, and learning from errors that includes 'near-misses.' The PHA approach addresses analysis of outcome, process, medication use, patient safety issues, medical events, and event reporting data. Data is collated and provided back to the participating institution.
Public disclosure is limited to some hospital-linked Prevention Quality Indicators (PQI) that appear in the State of Health of Georgia Updates.2 In addition, via its periodical Insights, the PHA publishes hospital-specific participation in patient safety initiatives and the performance of Georgia hospitals using the CMS Health Quality Initiative (HQI) measures used in Hospital Compare. The PHA publishes no hospital-identified data from its voluntary event reporting program.
1 In 1999, Georgia created the Department of Community Health (DCH), consolidating four existing agencies involved in purchasing, planning, and regulating health care, including Medical Assistance, the State Health Benefit Plan, and the State Health Planning Agency. OCGA §§ 31-2-1 to 31-2-8 created the Department of Community Health in 1999 to serve as the lead planning agency for all health issues in the state such as health care policy, purchasing, planning and regulation.
2 PQIs are a set of 16 measures developed by AHRQ that can be used with hospital inpatient discharge data to identify quality of care for "ambulatory care-sensitive conditions." These are conditions for which good outpatient care can potentially prevent the need for hospitalization or for which early intervention can prevent complications or more severe disease.
- • Department of Human Resources (DHR) Reporting Program
The Georgia Department of Human Resources, which has regulatory control of hospitals, adopted regulations that were effective December 12, 2002 for mandatory reporting of “patient incidents.”
The hospital regulations (OCRR chapter 290-9-7) provide details for the reporting of patient incidents, which, unlike the PHA voluntary reporting program, do not include ‘near misses’. As demonstrated in the Definitions section, some dissimilarities exist among JCAHO's Reviewable Sentinel Events, the PHA's Accountability and Health Safety (A&HS) Committee definitions, and the Department of Human Resources definitions for hospitals. Reportable events for hospitals, ESRD facilities, and clinical laboratories are also different.
There is no indication provided in the regulations as to the ultimate goal or intent for reporting these ‘patient incidents,’ given that the program was developed while the voluntary PHA initiative was enjoying success. Furthermore, the feedback loop of accountability between the Department of Human Resources and the medical facilities is ill-defined. There are specific requirements for 'root cause analyses' in all three sets of regulations (Hospitals, ESRD, and Clinical Labs), and facilities are required to ...
"complete and retain on site a written report of the results of the investigation within forty-five (45) days of the discovery of the incident. The complete report of the investigation shall be available to the Department for inspection at the facility..."[OCCR § 290-9-7-.07(2)(a)3]
It is not clear how many of these reports are reviewed by the DHR on site at the facility or what the feedback might be. Since these reports never leave the facility, it is apparent that sharing of experiences among facilities is not an intended purpose of these reports.
The reports of incidents are managed confidentially by DHR, and the contents are not releasable under law. Aggregate information is collected and evaluated internally. Some information is disseminated in global broadcasts to facilities and consumers regarding patient safety issues. While it is clear that 'near-misses' are reported only in the PHA program, it is also apparent that there is an overlap in reportable events across the two state program, even though the hospital reporting programs are completely separate.