Minnesota Hospital Association
January 2014
Background for adverse health events reporting hospitals on disclosure
There is one key factor that limits how hospitals share information related to reported adverse health events: the peer review statute. The purpose of the state statute is to help internal quality improvement efforts, in terms of being able to learn from and discuss specific events. (More background on the peer review statutes is below.)
In terms of how the peer review statute applies, there are different applications for different audiences: a) patients involved in an event; b) “agents” of the hospital who are involved in quality improvement related to an event; and c) the general public.
Regarding public disclosure
Each hospital will want to review public disclosure with its own counsel, to determine what may be covered by disclosure limitations and whether other laws, such as HIPAA, might apply.
Given the limits the peer review protections place on disclosure, it appears that hospitals should not share information related to specific adverse health events, beyond what appears in the public report itself. This would apply to what has been gathered for the Root Cause Analysis (RCA) and Correction Action Plan (CAP).
Meanwhile, it appears that hospitals can share information about general patient safety improvements efforts. This information could address areas related to the categories for which hospitals have reported adverse health events.
For example, if a hospital has two falls that will be in the report, the hospital would not share any information from the RCAs or CAPs, or any other specifics. The hospital could, however, discuss the work it is doing generally to improve patient safety – including reducing falls. This discussion would need to be framed as general and not tied to the events in the report.
Regarding disclosure to patients and internal “agents”
The peer review statutes allow for some disclosure to patients and internal hospital “agents,” in terms of furthering quality improvement efforts. Hospitals may want to review patient and internal “agent” disclosure with their own counsel.
(Note: MDH’s non-public data classification of the AHE information it receives limits its ability to share information it receives, in terms of the RCAs/CAPs that are put in the Registry. This classification prohibits MDH from having to share specifics from the Registry to an interested reporter, for example.)
Peer Review Law Background
The state peer review statutes have specific directions on several points, which need to be followed. If they aren’t, the peer review protections may be lost. It is a misdemeanor to disclose peer review information.
o Review organization definition
§ A committee whose membership is limited to professionals, administrative staff, and consumer directors, except where otherwise provided for by state or federal law, and which is established by one or more of the following: a hospital, …… for the purposes of … participating in a standardized incident reporting system, including Internet-based applications, to share information for the purpose of identifying and analyzing trends in medical error and iatrogenic injury.
o Review organization data and information
§ Data and information acquired by a review organization, shall not be disclosed to anyone except to the extent necessary to carry out one or more of the purposes of the review organization, and shall not be subject to subpoena or discovery.
o Review organization participant data disclosure
§ No person … who is a member or employee, director, or officer of, who acts in an advisory capacity to, or who furnishes counsel or services to, a review organization shall disclose what transpired at a meeting of a review organization except to the extent necessary to carry out one or more of the purposes of a review organization.
§ Records of a review organization include Internet-based data derived from data shared for the purposes of the standardized incident reporting system and reports submitted electronically in compliance with the Adverse Health Care Event Reporting Act.
§ A review organization may release non-patient-identified aggregate trend data on medical errors and a facility may file the reports, analyses, and plans required {under the AHE Act} without violating this section or being subjected to a penalty and without compromising the protections provided under sections to the reporter of such information; to the review organization, its sponsoring organizations, and members; and to the underlying data and reports.
§ Any disclosure other than that authorized above of data and information acquired by a review committee or of what transpired at a review meeting, is a misdemeanor.
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