Oregon Patient Safety Commission Board of Directors Meeting Minutes December 12, 2018 12:30 p.m. 3:30 p.m. Legacy Meridian Park s Community Health Education Center, Tualatin, OR Attendees Members Present Members on the Phone Members Absent OPSC Staff Guests Agenda Items Welcome and Introductions Approve Minutes Board Officer Powers Gayle Evans (Vice-Chair), Linda Kirschbaum, Leah Mitchell (Treasurer), Melinda Muller (Chair), Kecia Norling, Dana Selover, Doug Shumaker, Suzanne Washington, Natasha Tobias-White Amy Baker (phone), Nancy Lee (phone), Regina Rose (phone) Hester Carr, Judy Marvin Suzanne Hoffman (Interim Executive Director), Valerie Harmon, Beth Kaye Richard Lane, Bob Dannenhoffer (phone) This meeting of the Oregon Patient Safety Commission (OPSC) Board of Directors was called to order by Melinda Muller at 12:35 p.m. Board members and OPSC staff introduced themselves. Melinda Muller directed Board members to the minutes that needed to be approved (October 9, 2018 and October 26, 2018). Suzanne Washington noted that she did attend the October 9, 2018 meeting. Gayle Evans made a motion to approve all the minutes, with the update to the October 9, 2018 minutes to include Suzanne Washington. Leah Mitchell seconded the motion. The minutes were approved unanimously Suzanne Hoffman: At the last meeting, the Board discussed the potential to delegate certain administrative tasks to the Executive Committee of the Board. This could include such tasks as approving the Executive Director recruitment plan. The Executive Committee has been voting on investment of funds, per the current bylaws. OPSC sought guidance to from the Department of Justice (DOJ) on what changes would be needed, if any, to the Board Bylaws to allow for the Board to delegate certain tasks to the Executive Committee. After review, the DOJ determined that the Executive Committee already had the power to vote on the Board s behalf on some of the administrative tasks specifically asked about, such as to approve the Executive Director recruitment plan. The DOJ also recommended more explicit language be added to the Bylaws for approval of investment of funds by the Executive Committee on the Board s behalf. Additionally, the DOJ recommended that if there are specific tasks the Board wishes to delegate to the Executive Committee, those tasks be reviewed by the
DOJ on a case-by-cases basis to determine if any changes to the Bylaws are necessary. Action item: OPSC staff will bring a draft of the proposed Bylaw updates to the next Board meeting for review. The draft will also include the updates to Board officer terms, as discuss in the October 9, 2018 Board meeting. System Development Update Task Force on Resolution of Adverse Healthcare Incidents: Overview and Update Valerie Harmon: At the last Board meeting, Suzanne Hoffman lead a discussion on the short-term (one-to-two year) and long-term (three-to-five year) plan for the Patient Safety Reporting Program (PSRP). OPSC staff have begun work on the short-term plan and would report progress to the Board on an ongoing basis. System development work for both the PSRP online system and the Early Discussion and Resolution (EDR) online system was being evaluated and prioritized to ensure alignment with the focus areas outlined in the short-term plan. Those focus areas include: Compliance with statutory requirements and maximize flexibilities Continue system improvements to make reporting as easy as possible using participant and staff feedback while maintaining program integrity Pursue time saving improvements for staff in order to strategically focus for highest value Increasing output of educational/informational materials Communication strategy for program clarity/awareness Since July 2018, the system development work that was prioritized and completed, along with the goals of that work based on the short-term plan include: Improved password change process (EDR, PSRP) Goal(s): Improve user experience*, improve staff efficiency Updated search filtering (EDR) Goal(s): Improve user experience, improve staff efficiency Modernized account management (EDR) Goal(s): Improve user experience Updated contact log to better align with OPSC staff workflow (EDR) Goal(s): Improve staff efficiency Streamlined OPSC staff ability to track Request for Conversation data (EDR) Goal(s): Improve staff efficiency Simplified account reactivation process (PSRP) Goal(s): Improve user experience*, improve staff efficiency Added feature to include attachments with a report (PSRP) Goal(s): Improve user experience* * In response to user feedback OPSC staff will continue to bring updates to the Board related to progress on system development work. Richard Lane, one of the Co-chairs of the Task Force on Resolution of Adverse Healthcare Incidents ( Task Force ), provided and overview of the history of how the Early Discussion and Resolution (EDR) program and how the Task Force came to be. In 2011, then Governor Kitzhaber was focusing on healthcare transformation, and one of the specific areas of focus was medical liability issues. Some of this work resulted in Senate Bill (SB) 483, which created both the EDR Page 2 of 5
program and the Task Force. SB 483 became Oregon Laws 2013, Chapter 5, charging the Oregon Patient Safety Commission with administration of the EDR program and the Task Force with reporting to the legislature about the effects of EDR implementation and evaluating whether any improvements to the EDR process were necessary. Since implementation of EDR in 2014, the Task Force has been evaluating EDR program implementation and sharing what they learn, with support from OPSC, in annual public reports. The Task Force appreciates the connection with the OPSC Board through having a Board member, Currently Gayle Evans, serving on both the Board and the Task Force. This is a model the Task Force would like to retain going forward. The Board member who also serves as a Task Force member will be central to the working with the Task Force to incorporate EDR s legislative needs into OPSC s legislative agenda for 2021, with an emphasis on removing the 2023 EDR sunset date. Board members then had a discussion with Richard Lane and Bob Dannenhoffer, Task Force Co-chairs. The question central to the discussion was about what measures are used to determine EDR s success. The Board discussed the data currently being collected through the administration of the EDR program. They wondered how the program might be able to show progress related to medical malpractice in Oregon. It was ultimately concluded that there are too many factors that could affect medical malpractice. Oregon lacks comprehensive baseline data on the total number of serious adverse events occurring in the state, as well as the number of insurance claims asserted and medical malpractice cases filed related to these events. Additionally, it will not be possible to measure the impact of EDR on medical malpractice filings because we cannot count lawsuits prevented. Further, we will never be able to quantify the number of unintended patient harm events that were prevented because of patient safety improvements made in response to an EDR Request for Conversation. A measure of program success, and data currently being captured in the EDR program, is patient satisfaction with the EDR process. Patients typically want information about what happened, why it happened, whether it was preventable, what impact it may have on their health, and what is being done to improve care for future patients. An open conversation, initiate by the patient, is a new model that Oregon is pioneering with the EDR program. Other state s that have tried programs for open communication with patients following unanticipated harm events have all been provider-initiated only. Additionally, many of those programs were implemented in closed systems, that both employed their clinicians and were self-insured, making measurement of impacts to malpractice possible. The Board agreed that patient satisfaction was a good measure for EDR. Treasurer s Report Leah Mitchell: The annual PSRP invoices have been sent and payments are coming in. In some cases, the billing process is triggering program inquiries from facilities. Upcoming Board business related to the OPSC budget process includes: Board approval at the February 2019 Board meeting for the 2017-2019 budget amendment. The amendment is necessary to account for additional grant funding and related expenses. Board approval of the 2019-2021 biennial budget in April 2019. Page 3 of 5
Suzanne Hoffman shared that the Governor s Deputy Health Policy Advisor confirmed that the Governor s Recommended Budget includes full EDR funding for the 2019-2021 biennium, despite a substantial (50%) cut that was put forward in the Oregon Health Authority s budget reduction options. (Funding for EDR is passed through the Oregon Health Authority to OPSC.) A cut of this magnitude would cripple the EDR program, and OPSC was relieved that the Governor s Recommended Budget did not put forth this proposed cut. The final budget will be the Legislatively Adopted Budget passed by the Legislature in the 2019 session. Board Appointments and Reappointments Other Updates and Reminders Melinda Muller: We have two vacancies (seats: faculty and public healthcare purchaser) that should be filled during the Senate confirmation hearings and vote this week. We also have a new vacancy for the healthcare consumer seat, vacated by Elaine Wells last month due to time-constraints. Board members are encouraged to send their ideas for candidates to fill the consumer seat and/or outreach ideas to Melinda Muller. Suzanne Hoffman shared the timeline for the next round of Senate confirmation hearings for new Board members. The hearings will take place in February 2019, and OPSC would need to have any recommendations to the Governor s office by January 7, 2019. Valerie Harmon: OPSC Board Email Account Transition Board members will be transitioning to use of OPSC email addresses to ensure that OPSC, as public agency, has access to and can maintain all records related to conducting OPSC business in accordance with Oregon s public records law. Roll-out of the new email addresses is planned for the first quarter of 2019. Information and instructions will be provided at February 2019 Board meeting Communications OPSC is working towards increasing our dissemination of educational and informational materials, as outlined in the short-term plan. One of the ways we are accomplishing this is by focusing on time-saving improvements for staff in order to strategically focus on disseminating shared learning. OPSC s goal is to do this on a monthly basis. This work also includes incrementally revitalizing our messaging to improve participant understanding of OPSC s programs. In November, some of the information OPSC disseminated included: CDC s recommendations for what healthcare professionals can do to combat the threat of antibiotic resistance. (Shared in conjunction with U.S. Antibiotic Awareness Week, November 12-18, 2018.) Patient Safety Alert: focused on staying diligent on pressure injury prevention, particularly in settings and in populations that may not be the focus of much of the pressure injury prevention work and research, such as outpatient settings during situations that put patients at increased risk for pressure injury (e.g., ED visits outpatient surgery) and in pediatric populations. The alert included strategies from facilities in Oregon. (Shared in conjunction with World Wide Pressure Injury Prevention Day, November 15, 2018.) Page 4 of 5
Suggested Agenda Items for February Board Meeting Executive Session: Executive Director Recruitment Update* Follow-up from Executive Session Adjourn In December, OPSC will be developing a structure to share resources central to the infection prevention grant work. Annual Event The time and agenda for the annual event have been confirmed (8:00 a.m. to 11:00 a.m., Friday, March 15, 2019). As recommended by the Board, we are perusing continuing medical education (CME) credit for the annual event, with a goal of increasing physician participation. Because our event is made possible through the support of sponsors, which is not typical of most CME events, the process has taken longer than anticipated. As of yesterday, we got confirmation that CME was approved for the event. We hope to have the documentation we need soon to move forward with opening registration and securing sponsorship. Board members were asked for their help securing sponsorship. Once OPSC has the information needed to start the sponsorship process, Valerie Harmon will send more information to Board members about how they can support this effort. Annual Mandatory Board Member Training Board members must complete the annual training by December 31, 2018 (then annually thereafter). New Board members confirmed in 2018 do not need to take the annual trainings in 2018. The training requirement for those members will begin in 2019. Once complete, email Valerie to confirm you ve completed both trainings. Valerie Harmon provided a list of suggested agenda items for the February 2019 Board meeting, which included: Status of New Executive Director System Development Update Approve Bylaws for Board Officer Terms and Board Officer Powers Annual Event Update OPSC Board Email Account Transition Plan Board members would like to add the following items to the agenda: 2017-2019 Budget Amendment Update Legislative updated from Dana Selover and Linda Kirschbaum The Board went into closed executive session at 2:00 p.m. and returned to regular session at 2:30 p.m. Melinda Muller: There is no follow-up from the executive session. The meeting was adjourned at 2:40 p.m. The next OPSC Board meeting will be Tuesday, February 12, 2019, at Legacy Meridian Park. The meeting schedule is available on the Board of Directors page of the Oregon Patient Safety Commission website. * The executive session is being heled pursuant to ORS 192.660(2)(a). This law allows OPSC Board members to meet in executive session to consider the employment of a public officer, employee, staff member of individual agent. No final decision will be made during the executive session. Public session will follow where resolution may be adopted. Page 5 of 5