1. How Can States and Institutions Work Together to Create a Culture of Safety Concrete Actions to Improve Patient Safety Scott Williams, M.D., M.P.H. Deputy Director, Utah Department of Health Salt Lake City, UT A State Perspective

2. The State’s Role in Context Local Political and Partnership Climate High Profile Events High Profile Events Local Academic Experts Local Academic Experts Interested Politicians Interested Politicians Regulatory Environment Regulatory Environment Organizational Relationships Organizational Relationships

3. The Potential Roles of States Convener/ Common Ground Convener/ Common Ground Public Watchdog/ Impartial Endorser Public Watchdog/ Impartial Endorser Industry Leveler Industry Leveler Diverter of Unhelpful Solutions Diverter of Unhelpful Solutions Funder Funder Threatener of Traditional Regulation Threatener of Traditional Regulation Regulator Regulator

4. Liabilities of State’s Role Potentially unsafe environment Potentially unsafe environment – Punitive regulatory actions – Public disclosure Unacceptable administrative burdens Unacceptable administrative burdens – Cost of compliance – Reporting Unfulfilled promises Unfulfilled promises – Rapid decrease in errors – Malpractice insurance premium

5. Utah’s Approach Patient Safety Report Patient Safety Report – hlunix.hl.state.ut.us/hda/Reports/adverse_events.pdf Sentinel Event Reporting Rule Sentinel Event Reporting Rule – www.rules.utah.gov/publicat/code/r380/r380-200.htm Facility Patient Safety Program Rule Facility Patient Safety Program Rule – www.rules.utah.gov/publicat/code/r380/r380-210.htm AHRQ Grant to Evaluate ICD Injury Codes AHRQ Grant to Evaluate ICD Injury Codes – HS11885

6. Utah’s Collaboration Factors – Pressure relieving bedding to prevent pressure ulcers – Real-time ultrasound guidance during central line insertion – Appropriate provision of nutrition (emphasis on early enteral nutrition for critically ill or surgical patients) – Patient self-management for warfarin (Coumadin) to achieve appropriate outpatient anticoagulation and prevent complications – Patients to recall and restate informed consent information

7. Public Information Strategies 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 partners”

8. AHRQ’s Patient Safety Corps Utah’s “wish list” Utah’s “wish list” – Lexicon & standards – What works (administrative) – What works (clinical) – Root cause analysis – Developing financial resources – Involving patients and families

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