Today I attended the Missouri 2014 Joint Regulatory Patient Safety Conference in Columbia with our Well Being Program Administrator, Rebecca Mowen. It was sponsored by the four regulatory boards housed under the Missouri Department of Insurance and Professional Registration. These boards are the Missouri Dental Board, the Missouri Board of Nursing, the Missouri Board of Pharmacy, and the Missouri Board of Registration for the Healing Arts (medicine). The conference was the first time these entities had worked together in this manner.
The objective of the conference was to increase dialogue on the need for greater patient safety measures. This begins with communication and coordination of care across all possible caregivers associated with a patient from diagnosis to aftercare. The concept of a Just Culture was put forth where the focus is on proactive learning from errors and correcting systems rather than punishing offenders. Presentations were given by Becky Miller, executive director of the Center for Patient Safety Center, Steve Calloway, RPh and pharmacy board member, Drs. Les Hall and Erica Otis from MU School of Medicine, Dr Sue Scott, Manager of Patient Safety and Risk Management at MU Healthcare, and Jim Wieberg, director of MAOPS Physician Health Program.
There was also a roundtable report from the four regulatory boards describing the scope and degree of patient safety issues they see in a year. They all gave examples of complaints and discipline as a means of showing how far reaching the patient safety issues can range. Brian Barnett represented the MDB and said they are obligated to investigate all of the approximate 400 complaints each year. Here’s how he broke down the classification and quantity of top complaints.
· Quality of Care - 96
· CE Violation - 32
· Advertising Violation – 30
· Malpractice Report – 28
· Fee Dispute – 25
· 10 other categories had less than 20 cases
Mr. Barnett broke down the types of discipline into these categories and the number times each was used last year
· Probation (up to 5 years) – 10
· Suspension (up to 3 years) – 7
· Censure – 2
· Revocation – 2
Finally Mr. Barnett mentioned that the current hot topics that were hard to regulate centered around sedation and infection control.
There were no significant next steps announced at the conference other than to continue to work to improve collaborative communication and care coordination. The conference was filmed and will be made available for viewing and additional use. The MDA attended to keep abreast of the discussion. There was good content on provider burnout and second victim phenomenen that is of value to the Well Being Program.
My takeaway? Healthcare is complex and opportunities for unintended blunders are everywhere. Be careful and communicate!