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January 29, 1999

Charles Billings, M.D., Ohio State University (designer of the Aviation Safety Reporting System)

June 15, 1999

Tim Cuerdon, Health Care Financing Administration
Margaret VanAmringe, Joint Commission on Accreditation of Health Care Organizations
Marge Keyes, Agency for Healthcare Research and Quality

Joint Meeting of Both Subcommittees

June 16, 1999

Kenneth Kizer, M.D., Undersecretary of Health, Veterans Health Administration

A short telephone survey was conducted between February 24 and May 5, 1999 of a number of states having error reporting systems that affect hospitals. The list of states was obtained from the Joint Commission on Accreditation of Healthcare Organizations. A nonrepresentative sample was chosen to obtain additional information on their programs, focusing mainly on the largest states. The respondent was the individual at the state health department with administrative responsibility over the reporting program. Information was collected on the definition of a reportable event, which organizations submit reports, the number of reports submitted in the most recent year available, the year the reporting program was implemented, who has access to the information reported, and what is done with the information obtained (e.g., organization follow-up on specific events, compilation of data and trending over time). All respondents were given an opportunity to review the information on their states and make any corrections or clarifications.

Finally, input was obtained through two group meetings with specific key audiences. The first meeting was a 90-minute discussion held on August 2, 1999, at the 12th Annual Conference of the National Academy for State Health Policy in Cincinnati, Ohio. This meeting was attended by 19 people, all of whom had responsibilities associated with quality-of-care issues, some related to state error reporting programs. Open discussion was held on roles that states can play in ensuring adequate oversight of quality-of-care and patient safety, and what would be helpful to the states to increase their efforts in safety oversight.

The second meeting was a one-day roundtable discussion held on Sep-



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