Governor's Task Force on Patient Safety



Staffing Levels

Recommendation: Amendment to the Hospital Licensing regulations to establish the necessity for a multi-disciplinary team approach in the original and ongoing development and daily implementation of classification systems for staffing. Direct care professionals from disciplines providing care to the patients (i.e. registered nurses, physical therapists, pharmacists, respiratory care, etc.) should be involved in development and implementation of classification systems for staffing.

  • Nursing staffing level systems should be based on patient acuity, nursing assessment (done by a registered professional nurse) of the patient and how sick the patient is, how much care they need, and other additional criteria established by the hospital. This nursing assessment should be performed by a registered professional nurse directly responsible patient care. This would require case-by-case or shift-by-shift assessment. Use “best practice” standards which currently exist to guide staffing levels.
  • Identification of staffing levels to be available to the public. Assessment and evaluation of the systems established should be performed at least annually.

Performance of specified activities by licensed staff only

(No Specifics have been considered for recommendation by the Task Force to date)

Assuring Qualifications and Competence of Staff for specified units within hospitals

Recommendation: Ensure hospital policies are established for each specialized and non-specialized unit (pediatrics, ICU, NICU, cardiac) regarding needed competencies in order to be assigned to that unit.

  • Personnel not documented as competent for a given unit could not be assigned there without direct supervision until appropriately trained.
  • The status of an employee involved in patient care should be reviewed at least every year vis-a-vis their qualification and competency. (This should not be construed to imply that formal credentialing would be required any more than once every 2 years as stipulated in the Health Care Credentials and Data Collection Act.)
  • The policy should involve review of credentials, qualifications and competence by peers, and could include, as well, medical and hospital administration representation for non-physicians.

Reporting System

Recommendation: The Task Force agrees and recommends that there should be implemented some type of blame-free or non-punitive reporting system for patient safety data. Any patient safety reporting system established should maintain the confidentiality of the patient and providers involved and be exempted from Freedom of Information. The basic structure of such a system should be framed to ensure:

  • Reporting of patient safety events in hospitals would be made to an entity other than a regulatory body. Possibilities could include a statutorily modified Health Care Cost Containment Council, a newly created Commission on Patient Safety, a Center within the Department of Public Health – organizationally separate from the regulatory functions, or a non-government group like the Patient Safety Foundation under contract with the State.
  • The agency would have to: establish standards and processes for data collection including what would be mandatory and voluntary; prepare and disseminate frequent reports on patient safety issues to the General Assembly, state agencies, providers and community groups; and, establish “triggering” protocols for referral to regulatory agencies.
  • Consideration should be given to beginning a reporting system in a pilot stage in order to ascertain needed data and information in order to provide useful information for both the institutions and consumers, as well as study the economic impact necessary to build the reporting system at the institution level. At a future date after study and analysis, this process could be applied to all institutions.
  • Reporting should be mandatory for all licensed institutions. The information reported should include:
  1. type of professional license of the providers involved in the incident
  2. type of error
  3. patient sex and date of admission
  4. system / incident evaluation conducted
  5. determined root cause of the incident
  6. plan for correction implemented to address the root cause
  7. institution would be required to be maintain identifiable information related to the incident

Coordination/Information Sharing between State agencies

Recommendation: The State Agencies with a role in regulation of health care should:

  • Establish a work group to review their activities and processes to determine where overlap and inefficiencies may exist and where changes could be made. These recommendations should be made to the Directors and the Governor.
  • A formal process for referral of potential licensure actions across state agencies should be established. The process should identify information that could or should be gathered by the initial agency in the facility to avoid duplicative visits by agencies if unnecessary and less intrusion into the health care delivery system.

Clearinghouse for Best Practices

Recommendation: The Task Force membership agree that the establishment or identification of a clearinghouse for best practices would be useful for the health care community and patients in Illinois. This function could be either housed within a state government agency or contract with an outside group. The Clearinghouse would be charged to:

  • Analyze and formulate information including “best practices” with case studies to be used in training sessions that could be utilized by industry, government and professional associations and the public.
  • Develop a website exchange with links to other sites containing information on best practices and resources.

Reporting of Repeat Offenders to DPR

No specific recommendations were included for this point as the membership of the Task Force believe that this related back to a reporting system and the inclusion of “trigger points” that would result in referral to the regulatory agency.

Drug and Alcohol Impaired Health Care Providers

Recommendation: The members of the Task Force concur with the Department of Professional Regulation’s goal to develop a uniform system for identification and disposition of cases involving drug and alcohol impaired healthcare professionals. IDPR should move forward with development and introduction of legislation establishing a system that would allow for appropriate monitoring and evaluation of individuals who have been identified as being impaired. The system should assure appropriate counseling and treatment as needed but should also assure timely referral for disciplinary action when appropriate.\l

Other Areas of Recommendation:

  • Recommend to the Governor that further study and recommendations will be needed in this area. For that reason some permanent group should be designated to work with this issue and to continue the process of specific reviews and assignments. The Governor could do this by extending the “life” of this Task Force, seeking legislation to establish a new Committee or establish a standing Committee of the State Board of Health with added membership to work further on the issues. Consumer representation should be included in whatever group is designated to continue the work started with this Task Force.
  • Further specific review is needed in a number of areas including:
  1. Issues related to reporting not reflected in current document: Are there things that can be done to encourage reporting within the hospital setting; Is there a way to address or stop retaliation for reporting; Are there things that could be put into place similar to “whistleblower” protections.
  2. workforce development and staffing shortages
  3. development of Illinois specific information on health care professionals
  4. exploration of reimbursement issues as potentially being involved in patient safety issues
  5. Consideration of the issues surrounding the automation or computerization of systems to increase patient safety. This should include consideration of what steps could be taken by the State in order to demonstrate a commitment to the recent IOM recommendation to build an information infrastructure that supports health care delivery with the goal of eliminating most handwritten clinical data by the end of the decade.
  6. Mandatory overtime for health care workers.
  • Additionally, a number of statutes impacting health care and the provision of health care need “overall” reviews, similar to the process for the Criminal Code, to determine if changes are needed to facilitate better programs and ways to deal with patient safety concerns: the licensing laws for professions and the licensing laws for institutions.
  • Initial recommendations and activities should deal with hospital setting. Further information would be needed in order to address and apply requirements to other types of health care settings.
  • Take action to emphasize patient safety issues within the State’s role as purchaser of health care. Specific recommendations include:
  1. Review and revise the Medicaid program provider contracts to emphasize clinical best practices; with particular attention to Medicaid managed care contracts, LTC contracts, physician and inpatient hospital contracts.
  2. Review and renegotiate the State’s contracts obtaining health care services for State employees to emphasize clinical best practices.
  • Encourage medical colleges, nursing schools and pharmacy schools to increase attention re: patient safety and medical error issues in their curricula.

March 29, 2001 Letter from Carl Getto, M.D., Chair of the Governor's Task Force on Patient Safety,
to Governor George H. Ryan


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