Statement from New York State Health Commissioner Richard F. Daines, M.D.

ALBANY, N.Y. (July 30, 2009) - The recent New York Daily News series focusing on incident reporting to the New York State Department of Health from the Health and Hospital Corporation's (HHC) hospitals provides an incomplete and inaccurate picture of the state's NYPORTS Hospital Adverse Event reporting system, the state's overall oversight of hospitals and the performance of HHC hospitals. Patient safety is a paramount concern of the State Health Department and all the hospitals in the state. We utilize many reporting and analytic methods to accomplish this goal. NYPORTS is only one of these tools.

The information that was the basis for the NY Daily News series was actually provided by DOH. It was collected through the Department's diverse patient safety program which, in addition to NYPORTS self reporting from hospitals, includes patient complaints, tens of thousands of medical chart reviews, inspections by outside accrediting agencies, direct Department surveys of health facilities and, when relevant, medical malpractice filings.

In every case, DOH works with the hospital to fully investigate and develop a "plan of correction" that must be approved by DOH as fully addressing any violations and assuring, to the best of the provider's ability that they will not recur.

While any poor outcome is a concern and requires action, HHC's overall record regarding patient safety and incident reporting has been consistent and reflects well on that organization. DOH has found HHC to be cooperative in this and in other efforts to improve quality and safety. DOH will continue to work with hospitals to improve their quality, safety and reporting programs.

There is no requirement for filing annual NYPORTS reports nor is there a set schedule for NYPORTS advisory committee meetings. The Department regularly convenes expert panels and workgroups that address patient health and safety issues and its staff participates with various hospital industry workgroups with similar goals. NYPORTS reports and analysis are frequently used by these bodies.

A partial listing of groups providing advice and guidance to DOH on quality of care issues includes:

The Committee for Quality of Care in Office- Based Surgery; The Emergency Department Overcrowding Workgroup; The NYS Surgical Invasive Procedure Protocol; Patient Safety Conference held in 2007; Medical Director meetings; The NYS Transplant Council; The Cardiac Advisory Committee; The Stroke Advisory Committee; The Perinatal Safety Symposium to Improve Maternal Outcomes May 2008 Symposium; The Technical Advisory Workgroup on Hospital Acquired Infections; The NYS WAIT-NYS Wise Antibiotic Team; The NYPACE-NY Patient Safety Enhancement Project initiated in 2002.

Over the last several years the Department has overseen major efforts to further protect patient safety including: accreditation of office-based surgeries to prevent adverse events due to substandard care in physician's offices; reporting cardiac surgery outcomes annually to provide patients and their doctors additional information when seeking surgery; and establishing a hospital-acquired infection reporting system requiring hospitals to report rates of infection for those infections that are most likely to lead to serious illness in patients. The Department's quality of care initiatives utilize valuable information generated from NYPORTS to further protect patient safety.

In a relatively small number of cases of particularly serious deviations from standards, the Department proceeds to enforcement actions and fines against providers. Concerned that the fines were too small, in 2008, the Department obtained legislative approval for a substantial increase in those fines from $2,000 to $10,000 per violation. To date, using the new enhanced fine system; the Department has levied fines totaling $412,000 against 5 facilities. A portion of the monies collected are used to fund additional patient safety efforts.

In conclusion, New York State has probably the most comprehensive and extensive reporting systems for hospitals and office based surgery practices in the nation. We find New York hospitals, in general, to be cooperative and open in using this system to improve care.