Pennsylvania Patient Safety Authority - Report Example

s Patient Safety implies the incorporation of policy measures and codified procedures in order to ensure that medicalerrors are reduced, which in turns implies that the risks involved with the health of individuals are countered. The act 13 of Pensylvania Patient Safety Authority under the Medical Care Availability & Reduction of Error Act is an effort to enhance not only the Patient`s Safety, but also the safety of the personnel. This Act can be read as follow; “Reforming the law on medical professional liability; providing for patient safety and reporting; establishing the Patient Safety Authority and the Patient Safety Trust Fund; abrogating regulations; providing for medical professional liability informed consent, damages, expert qualifications, limitations of actions and medical records; establishing the Inter-branch Commission on Venue; providing for medical professional liability insurance; establishing the Medical Care Availability and Reduction of Error Fund; providing for medical professional liability claims; establishing the Joint Underwriting Association; regulating medical professional liability insurance; providing for medical licensure regulation; providing for administration; imposing penalties; and making repeals.” Prior to going into technicalities, certain definitions need to be kept in the mind; In order to understand the aforementioned Act, understanding the basic concept behind the act is crucial. The Pennsylvania Patient Safety Authority under the Act 13 of 2002, also known as the Medical Care Availability and Reduction of Error Act, is more of an independent agency which was developed as a doctrine to enhance patient safety. The agency develops under an 11 member bench i.e. the Board of Directors out of which six are appointed by the governor and the other four would be appointed by the House as well as the Senate leadership. The eleventh Board of Director would be appointed by the Board Chair, i.e. the Governor. As per the current member, around three of the members are physicians, where three are attorneys, three being nurses, one pharmacist and the last one being a non-healthcare worker. The sole task of the Authority is to take efforts in order to effectively reduce and rather eliminate the inherent errors in the medical procedures after carefully and systematically identifying the problematic areas. Furthermore, significance recommendations are proposed to promote and enhance the patient safety in various hospitals, birthing centers, ambulatory and surgical facilities alongside other abortion facilities. The Act 13 of 2002 prescribes responsibilities on practitioners and those on field to immediately report ‘serious events’ and also various ‘incidents’ directly to the authorities. Furthermore, Act 52 of 2007 specifies that the nursing homes are obliged to report the healthcare related infections directly to the authorities, also to the Department of Health. The Act 52 further specifies that the hospitals are also obliged to submit the healthcare related infections via the Centers for Disease Control and Preventions (CDC) and the National Surveillance Network (NHSN) However, the authorities, specifically the Department of Health and Pennsylvania Healthcare Cost Containment Council is bound to receive these HAI`s via the CDC since they owe their allegiance of their individualistic roles of analyzing the data received. Once these reports reach the Containment Council and other relevant authorities, the data is analyzed systematically and then evaluated, and after a rigorous scrutiny of these reports certain recommendations would be received. Based on these recommendations, the healthcare practices and the conventional procedures being followed would be subject to change. Thus, in an effort to effectively reduce the severity and the number of serious events or incidents in the domain of the Pennsylvania Healthcare centre, certain institutional changes would be made based on data from the healthcare centers across the state. Thus, the role of authority may be non-regulatory and also non-punitive in most cases which distinguish it from other major agencies involved. Another significant aspect of the Act 13 is the Reporting System, i.e. the ‘Pennsylvania Patient Reporting System’ which is one of the confidential web portfolios which is specifically developed for the purpose of the analysis of the reports. In other words, the web portfolio directly receives the reports and data construed by the hospitals after which the software analyzes the reports regarding the serious events and the incidents to further give clear impressions of the situation at ground. The financial backbone of the system developed under the act is the Patient Safety Trust Fund, which is utilized by the authority and is independent of other General funds. The trust is run via money streaming in from the annual surcharge which is entailed on the licensing fees over the medical facilities which are obliged by the requirement of reporting to the authorities. However, there is a limit imposed on these funds, i.e. it may not exceed Five million Dollars per annum. Applying the broad based dimensions of the Pensylvania Patient Safety Act on the medical facility assigned for the purpose, major loopholes can be detected. The hospital is situate in the North Philadelphia with four hospital and two large physician practices which make it all the more liable to transparency and thus, it must consistently report its findings to the authority. However, no such mechanism exists in the system currently functional in this healthcare facility. Yet, the surgical facilities in the center are quite massive and operational on a serious level. In other words, the hospital does have a level I trauma room, an ICU unit, Surgical Trauma Room, Obstetrics, Outpatients clinic amongst other facilities. These wide range of facilities make the hospital exposed to an extensive amounts of risks owing to which the entire personnel as well as other patients are at risk of catching infections, some of which may even be deadly and contagious if not caught at early stages. Similarly, around 70% of the patients are on Medicare and for this reason, the tax payers’ money must be made good use of, and for this reason procedures for best practices need to be developed. Furthermore, there are various kinds of risk exposures associated with the MCARE protocol, all of which must be discussed. Firstly, the protocol specifies clearly that in case of an endemic hierarchal procedure must be followed where the report must be forwarded to relevant authorities. In this context, the centre must keep an eye on the infrastructure developments, research facilities and the outbreak of any infectious diseases in the centre. This report would then be utilized by the state authorities to come up with recommendations to rectify the procedures, in the absence of such credible reports, liabilities would be imposed on the center. In case of the MEH, while developing a compliance with the MCARE prerogatives, the center would be at risk of exposing their weaknesses which are prevalent in terms of mis-coordination amongst various departments of the hospital and also the non-availability of latest research programmes alongside the lack of finances for incorporating the electronic machinery necessary for updating the data for reporting. Thus MEH is at a risk of having been imposed by the authorities to add extra finances (Risk exposure to liability issues) to meet the requirements of the MCARE act elaborated above. However, if the report isn`t forwarded in compliance with the MCARE protocol, the consequences are even worse, for instance, the Act itself states that failure to comply with section 307 and 308 would be a violation of the Act and in that case a penalty of around $1000 would be imposed on the center, alongside other implications which may be termed as a risk exposure to losses in profits. Thus, risks in both cases are present yet, in case of non-compliance, situation clearly gets worse. In another case, if the reports with reference to progress in terms of maintaining state of the art equipment and practices, negligence on the part of the center would lead towards a loss of credibility, which is yet another risk exposure. However, once the risks have been identified, it is essential to suggest mitigation measures. The mitigation technique to counter the first risk, i.e. liability issues can ironically be dealt by risk financing because upgrading the entire equipment of the MEH center in compliance to the Act, also making an accurate patients safety plan beforehand will lead towards mitigation in case of a crisis. In the case of the second situation, mitigation efforts must again be focused towards risk financing, since upgrading the system and management related procedures would demand an influx of finances which would secure the center from being effected from penalties. In the third case, to ensure credibility, risk control may prove to be a fruitful technique since effective management of the resources would lead towards a rational plan for patient safety. Thus, both risk control as well as risk financing must be undertaken by the MEH to ensure the losses are mitigated prior to causing massive damage. In order to ensure that the procedure via which the reports would be dispatched, certain measures would be taken. This involves incorporating reporting protocol into the organization. MEH must invest in equipment which must have its own database to store data. Staff members from the teams would be assigned the task of filing reports at the end of the day after collecting data from the team as well as from the official documents. The report may reach to me via electronic mail or via a platform accessible by the database. The database must be password protected with the staffers having access only to the information assigned to them, so that the responsibility to protect confidentiality lies on the staffers. Furthermore, to make the relevant parts of the data available to the State Authorities, researchers must be assigned the task to compile a monthly report, based on which a protection plan must also be attached which the MEH plans on following. The protocol over the key persons dealing with the report would be quite rigid where directors who would also be board members of MEH would handle personally over which parts of the data goes into the report, and further over how the report goes to the authorities. Generally, the sections or data which doesn’t affect the patient safety directly or indirectly, or doesn’t signify any relevant to the MCARE act would be omitted. Moreover, in order to ensure that the reporting is accurate and timely, not to mention honest, the policy guidelines must be institutionalized and cultured into MEH in such a way that every staffer must take it as a responsibility to inform the higher-ups of any fact which may make a difference regarding the report. Also, in order to encourage reporting, a rewards system has been incorporated which implies that points would be added to the service of the employees who make an effort to improve the quality of the report. In this context, the ground situation also needs to be analyzed which clearly indicates that there are separate directors, each assigned for Infection Control, Risk Management and also Quality Improvement, yet there seems to be no coherence amongst them, which puts the facility at risk in case the authority finds out about the mismanagement which implies that the hospital is clearly violating the Act 13 which may have serious consequences. The Act clearly requires the facility to constitute a committee of multiple members, each of who must be representative of a separate segment, so that they must oversee and offer surveillance over the endemics of the facility. In an absence of such a committee the directors would remain aloof of their surroundings which imply that they wouldn’t be able to coordinate over the developments in their respective departments. Thus, there is no way that they can develop an integrated and a coordinated report over the infections, which means that either they won`t be able to submit any data, or the data submitted would be incomplete and insufficient. Furthermore, there is no history which gives any evidence regarding an integration of a web portal to report data which again defies the Act which clearly asks to develop such an electronic system. Thus, the Reporting System, i.e. the ‘Pennsylvania Patient Reporting System’ which is one of the confidential web portfolios which is specifically developed for the purpose of the analysis of the reports is absent in such a case. The web portfolio is a dire need of the time for MEH which is used to directly receive the reports and data construed by the hospitals after which the software analyzes the reports regarding the serious events and the incidents to further give clear impressions of the situation at ground. Thus, MEH lacks in terms of technological infrastructure which leaves loopholes, which must be addressed in terms of policy initiatives and incorporation of the laws and procedures prevalent. The CEO must take strict notice of the lack of diligence and sheer ineptness of the management of the facility to address these issues which should rather be the priority. Thus conclusively, Pennsylvania Patient Safety Authority came into existence under the Act 13 of 2002. This Act, also known as the Medical Care Availability and Reduction of Error Act is more of an independent agency which was developed as a doctrine to enhance patient safety. The agency develops under an 11 member bench i.e. the Board of Directors out of which six are appointed by the governor and the other four would be appointed by the House as well as the Senate leadership.The sole task of the Authority is to take efforts in order to effectively reduce and rather eliminate the inherent errors in the medical procedures after carefully and systematically identifying the problematic areas. Furthermore, significance recommendations are proposed to promote and enhance the patient safety in various hospitals, birthing centers, ambulatory and surgical facilities alongside other abortion facilities. The Act 13 of 2002 prescribes responsibilities on practitioners and those on field to immediately report ‘serious events’ and also various ‘incidents’ directly to the authorities. Furthermore, Act 52 of 2007 specifies that the nursing homes are obliged to report the healthcare related infections directly to the authorities, also to the Department of Health which is expected to be incorporated into the policy paradigms in future. The Act 52 further specifies that the hospitals are also obliged to submit the healthcare related infections via the Centers for Disease Control and Preventions (CDC) and the National Surveillance Network (NHSN) However, the authorities, specifically the Department of Health and Pennsylvania Healthcare Cost Containment Council is bound to receive these HAI`s via the CDC since they owe their allegiance of their individualistic roles of analyzing the data received. Once these reports reach the Containment Council and other relevant authorities, the data is analyzed systematically and then evaluated, and after a rigorous scrutiny of these reports certain recommendations would be received. Based on these recommendations, the healthcare practices and the conventional procedures being followed would be subject to change. Thus, in an effort to effectively reduce the severity and the number of serious events or incidents in the domain of the Pennsylvania Healthcare centre, certain institutional changes would be made based on data from the healthcare centers across the state. Thus, the role of authority may be non-regulatory and also non-punitive in most cases which distinguish it from other major agencies involved.The financial backbone of the system developed under the act is the Patient Safety Trust Fund, which is utilized by the authority and is independent of other General funds. The trust is run via money streaming in from the annual surcharge which is entailed on the licensing fees over the medical facilities which are obliged by the requirement of reporting to the authorities. However, there is a limit imposed on these funds, i.e. it may not exceed Five million Dollars per annum. Read More