DJP Update 2-14-2008 Happy Valentine's Day; Regulations on Patient  Safety and Quality Improvement Act of 2005 Published; Previous Email on Safety act

Just in time for Valentine's Day are the proposed regulations for the  2005 Patient Safety and Quality Improvement Act of 2005.

Study the regulations and give comments if you see any problems.   Remember the goal of the Act is to enhance patient safety by having  confidential reporting of errors or near misses to a patient safety  organization.  Then experts study the events to see what is the problem with the  system that caused the error.  The fix for the problem is reported  back to those who sent the original report.  The lesson learned is  posted in a database so all can benefit from the system fix.  The  individuals involved in the original incident report remain  confidential.

Perhaps your calls and letters pushed the proposed regulations out  into the public arena as discussed in the DJP Update 1-8-2008.  Who  knows.  Thanks for your efforts!

Here is the notice from AHRQ mailed out on February 12, 2008:

Proposed Regulations on Patient Safety Organizations Published

Thank you for your continued interest in the Patient Safety and Quality Improvement Act of 2005.  We are pleased to announce that proposed regulations have been published in the Federal Register today by HHS’ Agency for Healthcare Research and Quality (AHRQ).

The proposed regulations describe how an entity may become a Patient Safety Organization (PSO) if it meets requirements specified in the Patient Safety Act.  Sections of the proposed regulations also explain how clinicians will be able to report patient safety events confidentially, how this data will be shared with others while remaining private, and how clinicians and other health care organizations will receive feedback on ways to improve patient safety.  AHRQ will administer rules governing the operation of PSOs, and the Office for Civil Rights (OCR) will enforce the confidentiality provisions of the Act.  Members of the public are invited to comment on the set of proposed rules within the next 60 days (including weekends and holidays), and their feedback will be used to shape the final rule. The Notice of Proposed Rulemaking (NPRM) can be viewed on the Federal eRulemaking 
Portal at: http://www.regulations.gov/fdmspublic/ContentViewer?objectId=09000064803acce8&disposition=attachment&contentType=html
.
For more information about the proposed regulation and rulemaking process, please visit AHRQ’s newly launched PSO Web site at http://www.pso.ahrq.gov/index.html
.
Comments on the proposed rule can be submitted by any of the following methods:

Federal eRulemaking Portal:
http://www.regulations.gov/fdmspublic/component/main?main=SubmitComment&o=09000064803acce8
.  Comments submitted electronically should include the agency name (AHRQ and/or OCR) and RIN 0919-AA01.

Mail / Hand Delivery / Courier:

Center for Quality Improvement and Patient SafetyAttention:

Patient Safety Act NPRM

Comments Agency for Healthcare Research and Quality
540 Gaither Road
Rockville, MD  20850

Comments must be postmarked, delivered, or submitted via the eRulemaking Portal by the last day of the comment period (April 14,  2008).  Please note that comments sent by facsimile (FAX) transmission or electronic mail will not be accepted.

Comments received through the eRulemaking Portal can be viewed online at the Web site listed above. All comments received through the eRulemaking Portal, mail, and hand delivery/courier are available for public inspection at the AHRQ Information Resources Center, which is located at 540 Gaither Road, Rockville, MD 20850.  The Information Resources Center is open from 8:30 a.m. to 5:00 p.m. Eastern Standard Time on Federal business days (Monday through Friday).

For questions related to the regulatory process and/or the PSO Web site, please contact:

Center for Quality Improvement and Patient Safety
Attention:  PSO Office
Agency for Healthcare Research and Quality
540 Gaither Road
Rockville, MD  20850

Telephone: (866) 403-3697 (toll free)
(301) 427-1111 (local)
(866) 438-7231 (toll free TTY)
(301) 427-1130 (local TTY)

Thank you again for your interest in this initiative.
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If you have any questions or problems with the subscription service, E-mail: updates@subscriptions.ahrq.gov. For other inquiries, Contact Us.

If you have questions about AHRQ's activities, please try to find the answers by checking our Home Page, where we have established links to various topical areas. Also check the News & Information section and Frequently Asked Questions. You may also Search or Browse the Web Site. These features are designed to assist you in obtaining the information you are seeking.

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EXCERPT FROM PREVIOUS DJP UPDATE:

DJP Update 1-8-2008 - DJP Update 1-8-2008 - Patient Safety and Quality Improvement Act; Louisiana news-DHH Secretary announced by Gov-Elect Jindal; Safety Meetings; Tulane; Safety; & Lagniappe

ITEM ONE: Patient Safety and Quality Improvement Act of 2005
The Patient Safety and Quality Improvement Act of 2005 (Public Law 109-41), was signed into law on July 29, 2005. We still do not have the regulations so that we can start using this important law.  This law allows confidential voluntary reporting of errors, review by experts, and feedback to those involved with recommendations of how to change the system to prevent occurrence again.  In addition, the information will be on a de-identified database for all to use so they also can benefit from the "lessons learned."

My sources tell me that the proposed regulations finally have left the Agency for Healthcare Research and Quality (AHRQ) and are now in the Office of Management and Budget (OMB).

For background information about the OMB, see:
http://www.whitehouse.gov/omb/
http://en.wikipedia.org/wiki/Office_of_Management_and_Budget
http://www.gpoaccess.gov/cfr/index.html

In July of 2008, it will be three years since this law was signed!  I am reminded of Cicero's lament that I stated in my 2003 AMA Inaugural Address:

"In a debate over liberty in another time and place, the Roman Cicero asked: 'How long must we tolerate these abuses?' That question echoes down through the ages and resonates with us today."  I spoke of the broken medical liability system.  You may argue about the use of the word "abuses" but I believe we can agree that this is an inefficient way to implement the overwhelming majority vote in Congress.  Do we just pass laws and forget about them? Why don't we have people crying out for implementation?

It is ridiculous that we have to wait this long to start using what I consider the most important patient safety advance since the American College of Surgeons developed the "Minimum Standard for Hospitals" in 1917. The requirements filled one page.  This quest for quality led to the formation of the Joint Commission of Accreditation of Hospitals (JCAH - later to become JCAHO and now called Joint Commission.) in 1951.

It was 97 years that the surgeons worked to enhance quality and safety in hospitals with the "Minimum Standard for Hospitals."

Failing to implement a law timely is not much better than defeating it.  Enough time has passed.

My recommendation is that everyone call or write their representatives and senators and Congress and ask them to move this along.  Nothing like a little heat in an election year to move an issue.
.....etc.
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Stay well,

Donald

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Donald J. Palmisano, MD, JD
Intrepid Resources / The Medical Risk Manager Company
5000 West Esplanade Ave., #432
Metairie, LA 70006
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312-560-0180 cell
DJP@intrepidresources.com
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