History & Start Up Principles
The Patient Safety Commission is a semi-independent state agency created by the Legislature in 2003 to reduce the risk of adverse events in Oregon and to encourage a culture of patient safety. The Commission consists of a 17-member board of directors appointed by the Governor and confirmed by the Senate. The board represents a cross-section of diverse health care interests in the state. Day-to-day operations are guided by the Commission’s Executive Director and a small staff, who are charged with managing multiple patient safety programs including a state-wide adverse event reporting program, collaborative quality improvement initiatives, and evidence-based prevention efforts for the state’s hospitals, nursing homes, ambulatory surgery centers, community pharmacies and renal dialysis facilities.
The Commission’s adverse event reporting program was intentionally designed to be voluntary; facilities may choose whether they wish to report adverse events. If they do, those reports are, by statute, confidential and non-discoverable. By combining voluntary reporting with protected information, the Commission creates the “safe table” needed to examine, understand and correct root causes of medical mistakes.
Major contributors to the Commission’s initial funding drive in 2004-2005 included Asante Health System, Blue Cross Blue Shield of Oregon; Kaiser Permanente; Legacy Health System; Lifewise Health Plan of Oregon; Mid-Valley IPA; Northwest Physicians Mutual; ODS; Oregon Health Care Association; OHSU; Oregon Medical Association; Oregon Trial Lawyers Association; PeaceHealth; Providence Health System; Salem Hospital and Tuality Healthcare.
The first board of directors for the Commission included : Nancy Chi, Sandra Douma, Andreas Goldner, David Hartwig, Judith Hibbard, Grant Higginson, Bruce Johnson, Susan King, Gloria Larson, Roy Magnusson, Lewis McCoy, George Miller, Glenn Rodriguez, David Widen, and Maureen Wright. Jim Dameron served as Administrator from 2005 through 2010; the current Executive Director is Bethany Walmsley.
The Commission receives no state funding, but is funded by yearly fees assessed of all Oregon healthcare facilities noted above. These fees have been set by administrative rule process with participation and input from the groups involved. Although the Commission’s adverse event reporting program is voluntary, yearly fees are mandatory; this allows the costs of patient safety activities to be shared equitably, and removes a potential barrier to participation in the reporting program.
- The Commission has a sense of urgency about reducing harm to patients and improving quality of care in Oregon. The status quo is not acceptable.
- The Commission represents an independent voice for patient safety. It will create a safe, nonpunitive, and confidential haven for the collection and use of patient safety information where all representatives and users of the health care system can come together to work on shared goals.
- The Commission aims to change the climate of patient safety in Oregon. Such change will require a long-term, sustained effort.
- The Commission believes the patient and the patient’s experience represent “true north” in healthcare. It believes that consumers should have an important role in reducing errors. As such, the Commission will engage consumers fully in patient safety efforts.
- The Commission believes in the ideas of a “just culture.” As such it will attempt to balance individual accountability with the need for non-punitive approaches and system improvements. A primary focus of the Commission will to reduce errors by addressing systems-related issues. To the extent that individual negligence or misconduct occurs, such activity will be handled independently by existing regulatory agencies.
- The Commission will maintain a high level of accountability—to the public, to the Legislature, to participating reporting entities, to the health care community.
- The Commission will work in close collaboration with consumers, policy makers and leaders of the health care delivery system in Oregon in order to gain their active support for the goals of the Commission and to identify, share, and implement best practices.
- The Commission acknowledges its current status as a small, semi-voluntary, and newly created organization. It needs to build credibility and forge an independent, lasting identity. Therefore it resolves to:
- Find its appropriate and unique niche among all the other organizations involved in patient safety efforts.
- Keep a narrow initial focus in its patient safety efforts.
- Create, nurture and sustain powerful public-private partnerships and coalitions.
- Have a clear, compelling and sensible vision that it communicates to all Oregonians: simply, consistently, repeatedly, effectively.
- Balance long term goals with short term visible results (wins).
- The Commission will strive to minimize the burden on reporting entities and to complement data systems that already exist.
- The Commission recognizes that securing startup and over-time funding is of critical importance to its work. To the extent possible such costs will be defrayed over a large base of funders. The Commission expects both public (at a minimum via in-kind contributions) and private financial participation (donations, in-kind, participant fees).
- The creation of a patient safety reporting program represents the key initial aspect of the Commission’s work; however, it does not represent the only aspect. Over time, the Commission will explore other patient safety projects, including the dissemination of best practices and the support of quality improvement initiatives.