- • Oregon Patient Safety Reporting Program
- ◊ Public/Private Cooperative Initiative
Oregon's confidential voluntary reporting of ‘serious adverse events’ is a unique public-private approach to medical error reporting. The 2003 legislation [Oregon Law 2003, Chapter 686] that created the Oregon Patient Safety Reporting Program enjoys broad sponsorship of multiple key stakeholders including the 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 (ODHS), Regence Blue Cross, and multiple consumer and purchaser groups, all of whom participated in the drafting of the legislation in 10 meetings between September, 2002 and April 2003. (see PDF file of FAQs)
- ◊ Voluntary Participation of Hospitals, Nursing Homes, and Pharmacies
Hospitals and other health centers can choose to participate. If they do, they must report all medical errors to the panel and notify affected patients in writing.
No public disclosure of provider-identified information is disclosed to the public, and no information is shared with regulatory state agencies. Case reports will be confidential, but the commission will publish yearly summaries of the data, suggesting trends, patterns and lessons learned. Participation in the program requires facilities to report serious adverse events. Definitions of these reportable events were adopted in 2005 for hospitals and will be available for Nursing Homes by 2006. After reporting these serious adverese events, participating facilities perform root cause analyses of such events, and develop and perform action plans established to prevent similar events. Full participation will be rewarded with significant protections and immunities. Participation of providers that fail to report and deal with serious errors will be terminated from the program and listed on the Web site as noncompliant.
- ◊ Oregon Patient Safety Commission (OPSC) Operations and Implentations
- – Organization of OPSC
The Oregon Patient Safety Reporting Program involves the establishment of a new ‘semi-independent state agency’ called the Oregon Patient Safety Commission (OPSC), that was formed in 2004 with public and private funding, public accountability, and non-regulatory control.
The Commission operates with 3 to 4.5 staff members, including a director, James Dameron, who was hired in April 2005. A new physician Chairman of the 17-member OPSC Board of Directors was elected in July 2005.
- – Finances
The OPSC does not receive state general fund dollars. Four sources of funding are available, including: 1) Participant fees-made up of entities subject to reporting, 2) In-kind services-staff time, office space, and equipment, 3) Grants for which the OPSC successful competes, and 4) Cash donations. Nineteen donors, mostly health provider and some professional organizations, contributed $270,000 through June 2005 [PDF file], and it is unclear how much of these moneys are one-time contributions and how much ongoing support will come from the Oregon public community.
At the OPSC May 24, 2005 meeting [PDF file], rules were approved allowing the OPSC to go forward with creation of Administrative Rules for the Commission as well as establishing budgetary rules to establish a biennial 2005-2007 budget of $ 945,299. In addition, a one-time budgetary expenditure of $50,000 for the bienneum as a place holder for IT development was discussed under the assumption that it might be expensed to build a web-based system (or something similar) for sharing data.
All facilities contribute to the operational cost of the program with hospital allocations based on numbers of discharges (see OPSC May 24, 2005 meeting [PDF File]). Fees to eligible organizations and entities will begin as the reporting is implemented. Hospitals will begin in October 2005 and Nursing Homes in January 2006. Fees from Hospitals, Nursing Homes and Pharmacies will comprise 80% of the core function budget.
- – Pilot Project and Implementation
As part of Oregon's voluntary and mandatory approaches, a pilot program began in early 2005 with signed agreements of 4 of 5 recruited hospitals, including Oregon Health and Science University (OHSU) in Portland, Providence Hood River Memorial Hospital in Hood River, Rogue Valley Medical Center in Medford, and St. Anthony Hospital in Pendleton. Phase I began with collection of 3 months of retrospective data, and Phase II followed with prospective data collection beginning in mid-2005. [see July 12, 2005 progress report PDF File) These pilot data and hospital experiences were then collated and analyzed to develop a reporting template and provide guidelines and expectations for participating hospitals in the voluntary reporting program, scheduled to begin in October 2005.
The OPSC launched its recruiting effort for participation of all Oregon hospitals on February 1, 2006 [PDF]. In an April 25, 2006 News Release [PDF], the OPSC announced that 41 of the State's 57 hospitals that render care to 90% of the Oregon population had signed up for the voluntary reporting effort.
Separate adverse event definitions for Nursing Homes were presented to the OPSC in mid-2005 with expectation of Nursing Home reporting to begin in January 2006.
- – Organization of OPSC
- ◊ Accountability to Legislature
A series of four annual reports to the legislature in 2004 through 2007 will provide legislatively-specified progress in the program development. The initial report was provided to the legislature and the Governor on January 10, 2005 [PDF]. The 2007 report to the legislature will provide feedback as to the success of the voluntary program, at which time possible conversion to a mandatory reporting program will be considered.
Despite the fact that the reporting program addresses reporting by medical facilities only, Oregon's health care provider community is aware that it must embrace this voluntary non-punitive program or face a mandatory effort in the future that would increase regulation and possibly medical malpractice exposure. The Oregon program is important because it provides a unique opportunity to assess whether a voluntary non-punitive program that addresses public accountability can perform as well as other existing mandatory regulatory schemes in other states.
- ◊ Public/Private Cooperative Initiative
- • Oregon Hospital Outcomes (OHO) Project
A voluntary physician-led effort that has led to publication of most of Oregon's coronary artery surgery outcomes is the Oregon Hospital Outcomes (OHO) Project. The OHO project was launched in 2000 by Dr. Scott Page, a retired cardiac surgeon, and Health Data Research (HDR) with the endorsement of the Oregon Medical Association (OMA). It was created to encourage hospitals and surgeons to participate in a program designed to improve the quality of patient care and accountability in Oregon's healthcare system.
Cardiac outcomes reports in 2003 and 2004 included only unidentified institutions from the group of volunteer heart centers. However, in October 2005, OHO published facility-identified CABG surgery outcomes for 10 of Oregon's 12 cardiac surgery programs for 2002- 2004 [PDF].
The published data excludes ‘high-risk’ patients with pre-operatively predicted mortalities exceding 5%, as determined by HDR's Cardiac Risk Predictor software. This group of patients was excluded since statistical risk models do not work well in this small group, which makes up 11% of all isolated CABG surgery patients, and because there was concern that publishing results of high-risk surgeries might discourage surgeons from operating on high-risk patients who may be in most need of the surgery, often in emergency circumstances. Therefore, the OHO analysis includes 89% of all isolated CABG surgeries.
- • Other Oregon Patient Safety Commission Initiatives
The OPSC has a full plate and limited available resources to effect implementation of the OPS Reporting Program. However, as the central organization for patient safety in the State of Oregon, the OPSC addresses patient safety issues beyond the reporting program.
The Institute for Healthcare Improvement approached the OPSC to serve as a primary ‘node’ for the IHI's 100K Lives Campaign. The OPSC decided in its May 24, 2005 meeting [PDF file] to serve as an Oregon ‘node’ for this IHI project. While some of the support provides publicity to the 100K Lives Campaign, the OPSC approved ". . a .5 FTE staff position with three functions: 1. support the pilot; 2. begin outreach to hospitals in anticipation of a rollout of the entire reporting program. 3. support IHI 100,000 Lives Campaign." With effectively no more than 0.25 FTE to support the campaign, the OPSC role is one of recruitment of hospitals for participation. OMPRO agreed to provide technical assistance for some of the 6 practices identified in the 100K Lives Campaign as a "partner with the Commission in being a ‘node.’" [July 12, 2005 minutes – PDF file]
Other future Oregon patient safety initiatives are likely to be reviewed by the OPSC.