Patient Safety and Professional Accountability

CMS wants to make Colorado the safest state in the country for patients to receive medical care. To that end, two years ago, we created the Ad Hoc Workgroup on Patient Safety and Professional Accountability. Comprising physicians from around the state and numerous specialties, and including legal experts and patient safety advocates from the consumer and hospital arenas, the Workgroup has crafted a long-term strategy to achieve these ends:

Goal:

To pursue as a high priority and as an important component of health care reform, the re-design of patient safety systems through approaches that unify all stakeholders in health care delivery and make Colorado the safest state in the nation in which to receive medical care.

Objectives:

• Develop new approaches to delivering health care and addressing adverse events that minimize the potential for harm, swiftly help injured patients, hold physicians appropriately accountable, create opportunities to learn from adverse events and make the changes that will prevent recurrence. 
• Continue to define and position medical liability issues as patient safety and health care delivery issues, not simply legal or tort issues, with both internal and external audiences, while maintaining Colorado’s stable medical liability climate.

The Workgroup is pursuing and supporting a number of initiatives to achieve these objectives. Highlights include:

• “Early disclosure and compensation” approaches in the hospital setting. Working with COPIC, the Colorado Hospital Assn. and other stakeholders, CMS will develop and implement models that facilitate prompt internal reporting and investigation of adverse events and near misses; open discussions with patients and families of the investigations’ findings; prompt compensation when appropriate; and robust system changes to minimize the potential for recurrence.
• Pilot projects that combine early disclosure and recourse to specialized courts for those cases that can’t be addressed satisfactorily through the hospital-based disclosure and compensation approach.
• “Compensation funds” that reimburse medical costs for certain categories of injured patients without requiring lengthy, drawn-out court battles over negligence.
• Patient education campaigns, spearheaded by Workgroup member Patty Skolnik, to increase patient engagement and informed, shared decision-making.
• Changes to Colorado’s peer review statute to enhance accountability and preserve confidentiality while making peer review systems more consistent and objective. Our efforts on this front will center on the following guiding principles:

                       - Improves patient safety and contribute to ongoing education
                         within the health care system
                       - Improves provider accountability
                       - Is fair
                       - Is standardized where possible so results are consistent
                       - Contains safeguards to minimize the potential for abuse
                       - Minimizes adversarial situations
                       - Promotes teamwork among stakeholders

•  “Maintenance of licensure” requirements to demonstrate physicians’ commitment to ongoing professional development and enhancing proficiency. This is consistent with the Workgroup’s philosophy that patient safety begins with physician licensure. Our proposed MOL approach will deem board-certified physicians to be in compliance, and establish parameters for non-certified physicians to comply.

IN 2010, CMS introduced a “Patient Safety Act” bill in the Colorado legislature to advance many of these concepts, including making it easier for patients to find out what happened after an adverse event and make changes to keep it from occurring again. While the bill was defeated, numerous legislators from both parties strongly supported our approach. And, one component of the bill – enabling health care facilities to share information about potentially dangerous employees – was subsequently added to another bill that passed resoundingly.

CMS also supports Think About It Colorado, a public awareness campaign designed to spark a statewide conversation about patient safety and to drive reform in this critical area. The campaign asks Coloradans to “Imagine a Safer and Healthier Colorado” because that’s the first step towards making it a reality.