In January, 2009, federal regulations were implemented for the first-ever national system for medical providers to voluntarily report medical errors, near misses and other patient safety events to designated Patient Safety Organizations, PSO.  The system’s framework was developed by the Department of Health and Human Services (HHS).  The new federal law implements the Patient Safety and Quality Improvement Act of 2005 (PSQIA), signed into law by President Bush in July 2005.  The development has not included EMS on a national basis to date.

As of January 1, 2009, all Missouri hospitals are obligated under a new Medicaid regulation to report ‘never events’ to Missouri’s PSO, the Missouri Center for Patient Safety, MCPS. If hospitals want access to Medicaid money, they must have a relationship with MCPS and policies in place to provide never event data to that agency.  The Missouri Department of Health and Senior Service, DHSS, in collaboration with the Missouri Hospital Association, created the hard-and-fast state rule, but not for EMS, though it is expected that ambulance services will be under the same regulation before too long.

A new effort to include EMS agency medical error information under the wing of the Missouri Center of Patient Safety is moving along quite well.  MCPS has worked with Missouri Hospitals for some time to get at the causes of medical errors by acting as a safe haven for medical error information. For hospitals, such records are not open to lawyers and this definitely encourages improvement.  Until now, EMS agencies in Missouri have not enjoyed the same protection.

A work group has been formed within MCPS comprising about 35 EMS professionals in Missouri to manage the effort for the next three years.  The group is multi-disciplinary and geographically and organizationally diverse.  Presently, two sub-committees are being formed under the main group to address the issues of data and what is known as the just culture concept.

The data subcommittee is nearly formed and already working with Quantros, the software company under contract with MCPS.  The process for linking MCPS and hospitals for reporting never events is underway and includes crafting web based forms for EMS quality improvement personnel who would then review ambulance calls or perform clinical studies of success rates of anything from intubations to chest pain protocol.  This information will be entered into the PSO work product and become protected information.  

See Previous Article on PSO 

Medicare is moving toward a ‘Pay For Performance’ mechanism which means doctors will be responsible for proving positive patient outcomes – so that Medicare is not paying for bad performance.  Part of that result will be a requirement that all medical institutions have aggressive reporting methods between themselves and PSO’s as the means for gathering data on medical errors in order to eliminate them over time.

Were it not for the current national health care debate, legislation on the pay for performance issue would likely be further along.

EMS has not been considered under the ‘Pay For Performance’ concept yet, but several months ago when discussions took place in Washington DC about general Medicare increases, there was recognition that it would become an issue at some point.  This would also push the expectation that EMS will come under the Medicaid/Medicare obligation to have a relationship with their respective PSO’s – thus the reporting and data issues are on the front burner now.

The second subcommittee will be formed over the next three months to address the concept of just culture – an issue alien to most EMS agencies but one that is finding its place in hospitals.

The concept is based on the fact that medical errors will occur, resulting in the need for an environment where medical professionals can be comfortable enough to report the fact they made an error.  The object of an open environment, allowing for self-reporting, is sought so that medical professionals may receive the needed corrective education.  Part of this goal includes changing from a discipline response to errors, to an educational response.  

For example, once solid reporting data is consistent, a hospital or agency may see five medical errors each year related to giving D-50 when they should be giving Lasix.  With good reporting data, they will be able to study the cause for such an error and design an engineering solution.  The EMS goal is to bring the just culture concept into the industry over time.

It is likely the two subcommittees with in the MCPS group will solidify, becoming permanent in order to continually guide these issues.

See Previous Article on PSO