Transparency and Accountability

 

Where We Stand on Health Care Transparency and Accountability

Washington Advocates for Patient Safety promotes practices, policies, and regulations that bring positive changes towards health care transparency and accountability, which are important aspects of patient centered care.  We strongly support public reporting because it aids transparency, promotes more informed patient choice, helps improve quality, lowers the cost of care, and makes healthcare providers accountable.  Public reporting also provides a strong motivation for hospitals to improve.

 

1. Public Reporting on Hospital-Acquired Infections

In 2007, the Washington State Legislature passed a law RCW 43.70.056, which requires acute care hospitals to report certain healthcare-associated infections to the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN). As a result, hospitals are now required to report central line-associated bloodstream infections and ventilator-associated pneumonia. The Washington State Department of Health publicly reports hospital infection rates through its Healthcare Associated Infections website. The reporting of surgical site infections to NHSN is expected to begin by 2013. In the meantime, hospitals are reporting surgical site infection rates to the Washington State Hospital Association.

This year, House Bill HB 1471, Updating and aligning with federal requirements hospital health care-associated infection rate reporting, was introduced in the state legislature which would eliminate reporting on infections associated with hip and knee replacements and heart surgeries. Together with Consumers Union, we worked with legislators to successfully amend the bill to restore the public reporting on these three critical procedures. The final bill passed both the House and Senate unanimously.  We believe that public reporting on these particular surgeries is critically important because consumers need this information to make an informed decision when deciding where to have these popular procures done. Public reporting is also essential in preventing HAI, improving healthcare quality, and cutting medical costs.

However per House Bill HB 1471, public reporting on hip and knee replacements and heart surgery infections will be discontinued in 2017 unless CMS (Centers for Medicare & Medicaid Services) changes their requirements on reporting or unless the state legislator passes another bill to continue the reporting.

2.  Public Reporting on Hospital-Acquired Events

 Washington State law 70.56 RCW requires healthcare facilities to report to the Washington State Department of Health (DOH) whenever an adverse event is confirmed. The department manages aggregate data on adverse events and posts quarterly reports on this website, providing hospital specific information.

Despite the law, many adverse medical events go unreported under the current reporting systems. A 2012 OIG report (OEI-06-09-00092, 2012) found that hospitals report only one percent of these events. Further, most of the events that states require hospitals to report failed to be reported because they were not identified by hospitals’ internal incident reporting systems.

To make the matter worse, there is no enforcement of the reporting requirements in Washington State. The DOH does not analyze adverse event reporting data and does not report to the Governor and the legislature annually, as required by the law RCW 70.56.040.  As a result, most medical errors are not reported in this state, as described in a 2010 article by the Seattle PI, Despite law medical errors likely go unreported  Further, the article highlighted the fact that having a finite list of events that are “reportable” interfered with full accountability and “make it easy for hospitals to rule that an error isn’t a ‘reportable error.’”

Studies show that at least 2,200 adverse events should be reported annually in WashingtonState (http://www.seattlepi.com/local/article/Lawmaker-State-s-medical-error-reporting-needs-891911.php#ixzz2J7a7s100).  Yet, in the six years of reporting (2006-2012), only about 1242 adverse events total have been reported by Washington’s 76 hospitals. According to Washington State Hospital Association, there were 552,000 hospital admissions in 2011. But only 251 adverse events were submitted to the DOH in that year.  This reporting rate is even less than the reported one percent of events identified by the OIG.

To reduce medical errors and the resulting harm and to improve patient safety, the state must improve our adverse event reporting system. This can save more lives while significantly reducing medical care costs, estimated at $45 billion for hospital care due to hospital-acquired infections alone (Scott, 2009).

 

3.  Public Inputs Can Help Improve Accuracy of Hospital Reporting

According to a 2008 HHS OIG report (OEI-06-07-00471), 16 of 27 states with mandatory error reporting programs investigate hospital compliance by comparing medical-error reports from hospitals with other data such as patient complaints and medical malpractice settlements. Three states conduct onsite audits.

There has been an increased recognition in the value of patient-reported outcome data in improving the quality of care. A recent study (Zhu et al., Medical Care, 2011) shows that 71.2% of patient-reported negative effects were classified as adverse events by physician reviewers. Another recent study that reviewed patient records concluded that, to detect the same adverse events as identified by patient record review, one cannot rely on the existing reporting systems within hospitals.

As shown by Weissman et al., (J. Internal Medicine, 2008), patients report many events that are not documented in the medical record; some are serious and preventable. The authors recommended that hospitals should consider monitoring patient safety by adding questions about adverse events to post-discharge interviews.  However, most hospital reporting systems do not presently accept or elicit reports from patients and their families.

The Agency for Healthcare Research and Quality (AHRQ) recognizes that patients’ unique perspectives could reveal important information that is not reported by health care providers. To realize the untapped potential patients’ reports, AHRQ has funded the development of a prototype Consumer Reporting System for Patient Safety (CRSPS) , designed to collect information from patients about medical errors that resulted in or nearly resulted in harm or injury

As a patient safety advocacy group, we support future legislation that will improve hospital reporting on adverse events in particular with the addition of patient inputs.

 

4.  Oversight and Accountability in Practice of Medicine

1). Protection from unprofessional actions of medical professionals

The United States Constitution authorizes states to establish laws and regulations to protect the public from unprofessional, improper, unlawful or incompetent practice of medicine. Every state has a medical practice act that defines the practice of medicine and delegates an authority to enforce the law to a state medical board.

In Washington State, the medical practice act is the law RCW 18.130, Regulation of health professions – Uniform Disciplinary Act

Under RCW 18.130.050(12), the law states:

“Safeguarding the public’s health and safety is the paramount responsibility of every disciplining authority. In determining what action is appropriate, the disciplining authority must consider the schedule adopted under RCW 18.130.390. Where the schedule allows flexibility in determining the appropriate sanction, the disciplining authority must first consider what sanctions are necessary to protect or compensate the public.”

Therefore, RCW 18.130 not only grants the state medical boards the authority to police medical professions in WashingtonState but mandates that these boards must protect the public’s health, safety and welfare through proper licensing and disciplining of medical professionals who commit unprofessional conduct.

2). Unprofessional Conduct

There are specific definitions on unprofessional conduct under the Washington State statue. Here are examples unprofessional conducts as described by RCW 18.130.180

  • Misrepresentation or concealment of a material fact in obtaining a license;
  • Suspension, revocation, or restriction of the individual’s license to practice any health care profession by competent authority in any state, federal, or foreign jurisdiction;
  • Incompetence, negligence, or malpractice which results in injury to a patient or which creates an unreasonable risk that a patient may be harmed;
  • Violation of any state or federal statute or administrative rule regulating the profession in question;
  • Not furnishing in writing a full and complete explanation covering the matter contained in the complaint filed with the disciplining authority;
  • Misrepresentation or fraud in any aspect of the conduct of the business or profession;
  • Engaging in a profession involving contact with the public while suffering from a contagious or infectious disease involving serious risk to public health;
  • Promotion for personal gain of any unnecessary or inefficacious drug, device, treatment, procedure, or service;
  • Conviction of any gross misdemeanor or felony relating to the practice of the person’s profession
  • Abuse of a client or patient or sexual contact with a client or patient;

Read more on detailed description of the law.

3). The Right to File Complaints

If you believe that your loved ones are harmed because of unprofessional conduct, you have every right to file a complaint with the state medical boards and to seek accountability.

Here is a link to the complaint intake on the Washington State Department of Health website: http://www.doh.wa.gov/hsqa/Complaint.htm

  • If your complaint relates to the care by a physician or a physician assistant, you should file a complaint with the Medical Quality Assurance Commission (MQAC):   http://www.doh.wa.gov/hsqa/mqac/

4). Be Informed about Your Doctors

When it comes to your health or the health of a loved one, it’s very important to choose the right doctor. You need to know if your physician is honest; if he takes adequate time to explain your diagnosis, to listen to your concerns, and to answer your questions; if he stays current with medical advances; and most importantly, if he is competent and knows what he’s doing. Other important things that you will need to take into consideration include whether the physician is board certified and whether there have been any board sanctions or medical malpractice law suits filed against the doctor. We highly recommend that you do background checks.

To avoid doctors with bad track records, you can check online regarding a physician’s malpractice and license information, certifications, and ratings:

In Washington State, the DOH has an online Provider Credential Search, where the public can get some information on healthcare providers and a health facility. The site also provides copies of disciplinary actions taken since July 1998. For disciplinary records before 1998, DOH recommends that people should contact its CustomerServiceCenter at (360) 236-4700. The online data is supposedly updated daily, according to DOH.

At present, the credential search system contains no records on judgments, settlements and arbitration awards for medical malpractice claims against a healthcare provider, nor does it have any information on whether a health provider has been sanctioned in other states or has had any hospital or health care facility privilege actions. The current state search system also has no information on any criminal convictions, board certifications and practice specialties, or affiliations with health care facilities or businesses.  There is also no information on any refusal by an insurance carrier to issue medical liability insurance.

We believe all the information above should be made available to the public because consumers have the right know about the quality of their providers. Physicians with a series of malpractice suits and records of being sanctioned would get fewer patients, which is what they deserve.

Several states have passed law to make providers’ profiles more transparent to the public. For an example of such a law, please see the Michael Skolnik Medical Transparency Act (http://cdn.colorado.gov/cs/Satellite/DORA-Reg/CBON/DORA/1251633185830).  This law should be the model for WashingtonState.

5). State Regulatory Agencies — Are They Doing enough to Protect the Public?

If you are interested in this question, be sure to read an excellent 2011 report by Public Citizen, State Medical Boards fail to Discipline Doctors with Hospital Actions against Them

According to the report, between 1990 and 2009, a total of 10,672 physicians identified in the National Practitioner Data Bank (NPDB) Public Use File had one or more clinical privilege actions, such as revocation or restriction of their clinical privileges. About 45% also had one or more state licensing actions. However 5,887, or 55%, of these physicians (more than half) had no state licensing actions. This report is an analysis of violations by and the privileging actions taken against these physicians who, despite clinical privilege actions, escaped any state licensing action.

In Washington State, there are 46 doctors who were among those identified by Public Citizen in NPDB. Seven of them were not reported to the board, leaving 39 physicians for whom the Commission received reports between 2000 and 2009. The board investigated 38 but only took action against five and “is in the process of talking action against two more.”  That leaves 31 (80%) of those physicians who had hospital clinical privilege actions without any disciplinary action.

It is shown that, when hospitals discipline their own doctors, it is usually pretty darn serious and yet, MQAC decided 80% of those doctors needed no sanctions.

And the public will never find out why MQAC took no actions. As we have learned, MQAC never documents any of the decision processes or procedures. All their case discussions are made verbally behind closed door.  It is yet to be seen if this lack of transparency will be improved with the passage of HB 1493 in WashingtonState in 2011.

The Washington State DOH also publishes its own statistics on the state disciplinary actions and board performance. The public can access these reports here:

In 2005, the Seattle Times published a special report License to Harm that looked into how the disciplinary authorities have failed to sanction bad practitioners and to protect patients.   In response to the public’s concerns, Gov. Gregoire asked the State Auditor’s Office to conduct a performance review of the state licensing and disciplinary system, with goals to promote accountability and to protect patients. Read the Audit Report for details.   In 2008, the legislature enacted bill SHB 1103 to increase the regulators’ authority to remove health care practitioners who pose a risk to the public and to develop a schedule of sanction guidelines based on aggravating and mitigating circumstances.

For further information on the state disciplinary process and the self-regulation issues, go to this very informative website:

http://fightfraudamerica.com/doh_process.html

So, are you satisfied with the state regulatory boards? Do you believe they are doing their best to protect the public by sanctioning bad doctors or health care workers? Do you think these medical boards investigated your complaint properly and thoroughly? Do you think the state agency holds bad doctors accountable?

If you have answered any or all of those questions above with a “No”, you are not alone.

Please share your thoughts and stories with us at WaPatientRights@gmail.com