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History

Preliminary Activities Leading to the Creation of the Florida Patient Safety Corporation

The current focus on patient safety in the U.S. health care system is generally attributed to the 1999 publication of To Err is Human by the Institute of Medicine. Since that time, Florida has established itself as a leader among other states in prioritizing patient safety efforts. A recent report by the National Academy of State Health Policy shows that Florida has created one of the most comprehensive models for its patient safety organization.

Formal calls for the creation of a Florida patient safety organization began in 2000.  Governor Jeb Bush and the secretaries of the Agency for Health Care Administration (AHCA) and the Department of Health (DOH) recommended to the 2000 Legislature the creation of a Commission on Excellence in Health Care to analyze a broad spectrum of health care quality issues. The 2000 Legislature passed and the Governor signed CS/HB 2339 (Chapter 2000-256, Laws of Florida), the Patient Protection Act of 2000, which created the Commission.  

Co-chaired by Secretaries Ruben King-Shaw of AHCA and Robert Brooks, M.D., of DOH, the Commission included many representatives of health care agencies, associations and organizations, as well as representatives of the medical malpractice professional liability insurance industry, the health insurance industry, attorneys and legislators. The group held numerous meetings throughout the state and delivered a report to Governor Bush and the Florida Legislature on February 1, 2001. Among the commission’s recommendations was a call for the creation of a separate, freestanding Center for Patient Safety and Excellence in Health Care.
           
In August 2002, Governor Bush created the Select Task Force on Health Care Professional Liability Insurance. The task force consisted of five current and former Florida university presidents and was chaired by John Hitt, Ph.D., President of the University of Central Florida. The Task Force’s mission was to address the impact of skyrocketing liability insurance premiums on health care in Florida and report to the Governor and Legislature with recommendations on how to improve the situation.
           
The Task Force held 10 meetings across the state of Florida over the course of five months, meeting with patients, providers and a broad array of impacted Floridians to receive public testimony and information. They also requested that interested persons provide potential solutions to the problems associated with medical malpractice. More than 100 proposed solutions were submitted. At the conclusion of the information-gathering process, the Task Force wrote a report that included more than 60 legislative recommendations, including the legislative creation of a patient safety authority and the adoption of a statewide electronic health record and physician medication-ordering system.

During the 2003 regular legislative session, shortly after the submission of the Task Force’s report, a bill passed the Florida House of Representatives that contained several of the Task Force proposals. However, resolution between the two legislative chambers proved elusive and no bill passed the Senate. A compromise was reached during the fourth special session of 2003. The Legislature passed Senate Bill 2D (Chapter 2003-416, Laws of Florida) and Governor Bush signed it the next day. This legislation included specific provisions aimed at improving patient safety, such as requiring each health care facility to have a patient safety system and plan, including a patient safety officer and committee; mandating that patients must be notified in person by the facility or licensed health care practitioner in the event of harm and requiring patient safety continuing education for licensed health care practitioners.

Studies by University-Based Patient Safety Centers

The 2003 legislation also authorized the Agency for Health Care Administration, in consultation with the Department of Health and patient safety centers in the state’s universities, to study the implementation requirements for a statewide patient safety authority. 

The legislation detailed topics to be covered in the study, including:

  1. An analysis of existing reporting systems related to patient safety and health care quality
  2. Development of strategies to communicate patient safety information to health care providers
  3. An analysis of the current status of health care electronic infrastructure and fostering its continued development
  4. Identification of best practices in patient safety
  5. Assessing and promoting a culture of patient safety at volunteering hospitals
  6. Development of curricula for student health care practitioners
  7. Development of continuing education for current health care practitioners

The legislation also authorized the Agency to fund additional patient safety initiatives during the 2003-2004 fiscal year. 

In the autumn of 2003, the Agency solicited proposals from the state’s university-based patient safety centers to complete the study on the implementation of the statewide patient safety authority. The Agency chose the University of Miami/Jackson Memorial Hospital Center for Patient Safety, under the direction of Paul Barach, M.D., to coordinate the study. The Agency also requested that the University of Miami work with other patient safety centers in Florida universities to make the study as broad-based as possible.

With the University of Miami acting as lead contractor, a consortium of university-based patient safety centers was created. Sub-contractors represented the University of South Florida, University of Florida (Gainesville), University of Florida (Jacksonville), Florida State University, Nova Southeastern University, University of Central Florida and Florida Atlantic University. 

The study method chosen by the universities was to invite experts from across the country and around the world to come to Florida and share their most recent thinking about patient safety. In addition to representatives of many U.S. universities, attendees included experts from Australia, New Zealand, Great Britain, France and Denmark, as well as representatives of federal government agencies and other nationwide organizations, such as the American Hospital Association and the Institute of Medicine.

The university consortium held four invitational meetings in which these diverse experts joined with Floridians to review the latest information about health care patient safety.  The topics of the four meetings were:

  1. Reporting systems
  2. Curriculum development
  3. Promotion of a culture of safety
  4. Development of alternatives to medical malpractice litigation

The universities combined the findings from the invitational meetings with the results of a literature review, opinions derived from meetings with interested Floridians, surveys of health care providers and public responses to solicitations via email and Internet before recommending the creation of a patient safety authority for the state of Florida. Other primary recommendations for the proposed authority included:

  1. Piloting a voluntary near-miss reporting system
  2. Supporting a “single platform” for the implementation of electronic infrastructure in health care
  3. Organizing and distributing “best practice” information in all areas of the health care system to promote quality of care and patient safety
  4. Defining essential knowledge, skills and attitudes for patient safety and promoting new approaches to education using simulation and team training
  5. Continuing the study of alternatives to medical malpractice litigation
  6. Promoting additional patient safety research

The report was delivered to the Governor and the Legislature as required on February 1, 2004. After receiving the report, the Agency developed separate contracts with the universities to continue the work that was prioritized by the initial study. 

The Agency chose nine “implementation” projects from a group of proposals submitted by the universities.  The following table summarizes the projects and identifies the university-based patient safety center that was responsible for each.

 

Patient Safety Center

Project Title

Project Description

University of Miami

Implementation of a Florida Patient Safety Authority

Developed practical models and examples for use in organizing a patient safety authority.

University of Miami

Analysis of Florida Adverse Incident Data

Completed a preliminary analysis of reports of wrong site surgery.

University of Miami

Implementation of Electronic Patient Health Records

Compared different approaches to the use of electronic patient health records in three south Florida health systems.

Florida State University

Pilot Study of the Use of Handheld Information Devices by Physicians

Studied the use of handheld electronic physician order entry devices in a rural north Florida community.

Florida State University

Patient Safety Summit for Hospital Executives

Held a patient safety summit for Florida hospital executives in Orlando on June 25, 2004

University of Florida- Gainesville

Pilot Project for the Sharing of Closed Claims Data

Developed a model system for the use of information from closed medical malpractice claims when identifying patient safety problems and solutions.

University of Florida- Gainesville

Pilot Project for an Assessment System for Disciplined Practitioners

Developed a model system for the assessment of practitioners who are involved in a disciplinary action.

University of Florida- Jacksonville

Development of an Educational DVD for the Disclosure of Adverse Events

Produced a DVD to educate health care providers on the disclosure of adverse incidents to patients and families.

University of South Florida

Study of Alternatives to Medical Malpractice Litigation

Developed a report with practical suggestions for alternatives to medical malpractice litigation.

Final reports for all contracts were submitted to the Agency by June 30, 2004.

Florida Patient Safety Corporation Startup Activities

The 2004 Legislature followed up on the recommendations in the report with the enactment of HB 1629 (Chapter 2004-297, Laws of Florida), which established the Florida Patient Safety Corporation. 

The Agency for Health Care Administration solicited appointments for the board of directors from the stakeholder organizations specified in statute. Click here to see a complete list of the current board members.

The first meeting of the Board was held on July 29, 2004 in Orlando. At that meeting, Board members reviewed their enabling legislation and heard a presentation from the university patient safety centers on the issues and concepts of health care patient safety.

The second meeting was held in St. Petersburg and the third in Orlando. By the third meeting, AHCA staff had filed corporate papers with the Division of Corporations in the Florida Department of State.

The board established a Bylaws and Governance Committee that met twice via telephone conference call to work on draft bylaws. The board also established a Nominating Committee that met via telephone conference call to nominate board officers. At the third meeting, bylaws were approved and officers were elected.