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Can You Minimize Health Care Costs by Improving Patient Safety?

Session 2: How Can States and Institutions Work To Create a Culture of Safety?

Presentation by Scott Williams

Via the World Wide Web and telephone, the second session of a Web-assisted audio teleconference series occurred on September 30, 2002. The User Liaison Program (ULP) of the Agency for Healthcare Research and Quality (AHRQ) developed and sponsored the program.

This is the text version of the slide presentation.

Slide 1

Image of Scott Williams, M.D., M.P.H., Deputy Director, Utah Department of Health, Salt Lake City Utah.

Slide 2

The State's Role in Context

Local political and partnership climate.

  • High profile events.
  • Local academic experts.
  • Interested politicians.
  • Regulatory environment.
  • Organizational relationship.

Slide 3

The Potential Roles of States

  • Convener/Common Ground.
  • Public Watchdog/Impartial Endorser.
  • Industry Leveler.
  • Diverter of Unhelpful Solutions.
  • Funder.
  • Threatener of Traditional Regulation.
  • Regulator.

Slide 4

Liabilities of the State's Role

  • Potentially unsafe environment.
    • Punitive regulatory actions.
    • Public Disclosure.
  • Unacceptable administrative burdens.
    • Cost of compliance.
    • Reporting.
  • Unfulfilled promises.
    • Rapid decrease in errors.
    • Malpractice insurance premiums.

Slide 5

Utah's Approach

  • Patient Safety Report
  • Sentinel Event Reporting Rule
  • Facility Patient Safety Program Rule
  • AHRQ Grant to Evaluate ICD Injury Codes

Slide 6

Utah's Collaboration Factors

  • IOM report.
  • Experiences of UDOH Director and Deputy.
  • Availability of some early data.
  • Leadership of hospital association, local experts.
  • State's intent to move forward.
  • State's willingness to let industry take lead.
  • Lack of high profile event or legislative interest.

Slide 7

Public information strategies include:

Get out in front of issue & stay on message:

"Medical errors occur in hospitals, nursing homes, outpatient clinics, and at home."

"More reported events is good."

"Serious errors sometimes happen but we have mechanisms in place to review them, determine the cause, and prevent them from recurring."

"Patients and families are important."

Slide 8

AHRQ's Patient Safety Corps

Utah's "wish list"

  • Lexicon and standards.
  • What works (administrative).
  • What works (clinical).
  • Root cause analysis.
  • Developing financial resources.
  • Involving patients and families.

Slide 9

Lessons learned

  • Don't hesitate to jump when the window is open.
  • Ready, fire, aim.
  • Traditional regulation does not prevent errors.
  • States should pressure the industry to change and then be more flexible and let them have credit.
  • Test the effectiveness of existing capacity before proposing new structures.
  • You're never finished.

Current as of March 2003

Internet Citation:

Text Version of Presentation by Scott Williams. Can You Minimize Health Care Costs by Improving Patient Safety? Session 2: How Can States and Institutions Work To Create a Culture of Safety?. Agency for Healthcare Research and Quality, Rockville, MD.

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