GOVERNORS SPECIFIC AREAS FOR CONSIDERATION:
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
Performance of specified activities by licensed staff only
(No Specifics have been considered for recommendation by the Task Force
Assuring Qualifications and Competence of Staff for specified units
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
- 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.
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:
- type of professional license of the providers involved in the incident
- type of error
- patient sex and date of admission
- system / incident evaluation conducted
- determined root cause of the incident
- plan for correction implemented to address the root cause
- 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
- 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 Regulations 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:
- 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.
- workforce development and staffing shortages
- development of Illinois specific information on health care professionals
- exploration of reimbursement issues as potentially being involved in
patient safety issues
- 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.
- 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 States
role as purchaser of health care. Specific recommendations include:
- 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.
- Review and renegotiate the States 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
March 29, 2001 Letter from Carl Getto, M.D., Chair of the Governor's Task Force on Patient Safety,
to Governor George H. Ryan