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

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

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

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

4. Liabilities of 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 premium

5. Utah’s Approach • Patient Safety Report • hlunix.hl.state.ut.us/hda/Reports/adverse_events.pdf • Sentinel Event Reporting Rule • www.rules.utah.gov/publicat/code/r380/r380-200.htm • Facility Patient Safety Program Rule • www.rules.utah.gov/publicat/code/r380/r380-210.htm • 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” • 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 • Ready, fire, aim • Traditional regulation does not prevent errors • 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 • You’re never finished