32 of the 37 states with patient safety initiatives have developed some form of facility and/or physician provider reporting. Of the 18 States without any reporting programs, 13 have not developed any identifiable public or private patient safety initiatives, while 5 States (AR, HI, MI, MO, MS) developed Patient Safety Coalitions.
However, the Patient Safety coalitions/commissions in Arkansas and Missouri have been inactive since 2002 and 2004, respectively, whereas the Michigan Health and Safety Coalition (MH&SC) and the Hiwaii Patient Safety Task Force (PSTF) remain centrally involved and engaged in patient safety discussions with States legislators and multiple healthcare stakeholders in each state. Mississippi's Patient Safety Coalition (MPSC) began in April 2005.
While it is true that most states without reporting programs have not developed public patient safety initiatives, it should not be automatically assumed that states without reporting programs have not seriously evaluated reporting program options and/or have meaningful patient safety programs. Examples of exceptions include:
- ◊ Michigan
Michigan is perhaps the most stunning example of a State with an active patient safety program that does not include reporting programs. With its strong business base and prodding from corporate members of the Business Roundtable, Michigan initially embraced The Leapfrog Group, whose projects have a firm foothold throughout the State.
The Michigan Health and Safety Coalition (MH&SC) developed with strong collaborative support of all stakeholders, and the MH&SC has become the de facto patient safety coordinator for the State. In fact, the November 2005 report to the Governor that is available on its MH&SC website, has established an agenda for patient safety through 2008 that includes the development the Michigan Center for Patient Safety and options for reporting and analyzing adverse events and near-misses.
The Michigan Health and Hospital Association established its own Keystone Center for Patient Safety and Quality. The Keystone Center's statewide AHRQ-supported 'ICU Collaborative' project that began in 2003 in partnership with Dr. Peter Pronovost from Johns Hopkins University, has been phenomenally successful and rightly identifies Michigan as the State with the most aggressive pursuit of meaninful Patient Safety reform without yet developing publicly-mandated reporting.
- ◊ Missouri
Missouri investigated patient safety issues after Missouri's Governor issued an October 3, 2003 Executive Order that established the Missouri Commission on Patient Safety. The Commission ultimately returned a report in July 2004 [PDF] that included recommendations.
However, no public initiatives have evolved from the efforts and recommendation of that commission. One of the recommendations of the commisison was the creation of the Missouri Center for Patient Safety (MOCPS) that was founded as a private, not-for-profit corporation by the Missouri Hospital Association, the Missouri State Medical Association, and physician-dominated Primaris, the QIO for Missouri. As such, the MOCPS is entirely a healthcare provider initiative without public involvement or financial support. One of the charges of the commission was to develop a 'Consumer Coalition' within the MOCPS, but no consumer participation or membership exists on the MOCPS Board of Directors, and recommendations of the Governor's commission have yet to be instituted in mid-2006.
The Missouri Commission on Patient Safety was deactivated upon release of its report.
- ◊ Hawaii
Hawaii developed a collaborative investigation of patient safety issues when it established its Patient Safety Task Force (PSTF) in 2001. Although it was developed under the management and funding of the Hawaii Hospital Association, the PSTF membership includes representatives from hospitals, long-term care, home care and hospice, Hawaii Health Information Corporation (HHIC), and the Department of Health, as well as physician, nursing and pharmacy professionals, and a consumer/patient representative. The PSTF effectively functions as the State's patient safety coalition. These Hawaii stakeholders have worked collaboratively and in response to questions from with the Hawaii legislature and state agencies to address patient safety in Hawaii's healthcare facilities.
The PSTF has provided update reports to the legislature, e.g., ‘Healthcare Association of Hawaii Patient Safety Task Force Update to the Twenty-Fourth Legislature, 2005’ [PDF], regarding its managment and progress in addressing patient safety issues.
The PSTF collaborates with HHIC to serve as the Patient Safety Data Repository and Reporting System. HHIC, an independent, neutral health data organization, brings a focus on data standards and best practices in measurement and reporting of patient safety data. However, Hawaii has no event reporting programs beyond existing voluntary reporting of performance on Health Quality Initiative healthcare processes to CMS.