Section 8

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Appendixes

1. Appendix One: Participants in the Conference
2. Appendix Two: Questions for Small Groups to Consider
3. Appendix Three: Proposed Federal Legislation on Medical Error Introduced in the 106th Congress

Appendix One: Participants in the Conference

E. Andrew Balas M.D., Ph.D. (participant and small group facilitator)
Weil Distinguished Professor and Director
European Union Center and Center for Health Care Quality
University of Missouri-Columbia
Columbia, MO

Paul Barach M.D., M.P.H. (participant, co-author of background material)
Assistant Professor
Department of Anesthesia and Critical Care
University of Chicago
Chicago, IL

David W. Bates M.D., M.Sc.
Chief, Division of General Medicine
Brigham & Women's Hospital
and Medical Director, Clinical and Quality Analysis
Partners HealthCare System, Inc.
Boston, MA

James B. Battles Ph.D.
Senior Service Fellow/Patient Safety
Center for Quality Measurement and Improvement
Agency for Healthcare Research and Quality
Rockville, MD

Bill Beeson M.D.
Beeson Aesthetic Surgery Institute
Carmel, IN

Dorothy Berry R.N., FASHRM
Vice President, Healthcare Information Resources
The St. Paul Companies
Denver, CO

Gary J. Bien FACMPE
Practice Administrator
Rocky Mountain Cancer Centers
Denver, CO
(now Chief Operating Officer of Presbyterian/St. Luke's Medical Center, Denver, CO)

Charles Billings M.D., M.Sc.
Research Scientist
Institute of Ergonomics
The Ohio State University
Columbus, OH

Terrance (Terry) Borman M.D.
Medical Director
Luther Midelfort
Eau Claire, WI

Helen Burstin M.D., M.P.H. (participant, small group facilitator, co-author of conference synthesis)
Director, Center for Primary Care Research
Agency for Healthcare Research and Quality
Rockville, MD

Jay Callahan Ph.D.
Director of Programs
The National Patient Safety Foundation
Chicago, IL

Rebecca Cherney
President and CEO
Central Florida Health Care Coalition
Orlando, FL

Priscilla Dasse
Senior Vice President
Risk Management Foundation of the Harvard Medical Institutions
Cambridge, MA

Suzanne DelBanco Ph.D. (participant, facilitator)
Executive Director
The Leapfrog Group
Washington, DC

John Eisenberg M.D. (provided conference opening remarks)
Director, Agency for Healthcare Research and Quality
Center for Quality Measurement and Improvement
Agency for Healthcare Research and Quality
Rockville, MD

Karen Feinstein Ph.D., President
Jewish Healthcare Foundation
Centre City Tower
Pittsburgh, PA

Cathie Furman R.N., M.H.A. (participant, co-author of background materials)
Administrative Director, Corporate Quality & Compliance
Virginia Mason Medical Center
Seattle, WA

Thomas A. Girton FACMPE
Physician Practice Manager
Good Shepherd Rehabilitation Hospital
Allentown, PA
(now CEO, Mid-Atlantic Spine Specialists, Richmond, VA)

Terry Hammons M.D. (participant, small group facilitator, co-author of conference synthesis)
Sr. Vice President, Research and Information
Medical Group Management Association
Englewood, CO

Marjie Harbrecht M.D.
Consultant, Risk Management
Copic Insurance Company
Denver, CO

Marty Hatlie J.D., President (participant, co-author of background material, co-author of conference synthesis)
Partnership for Patient Safety (p4ps)
Chicago, IL

Charles D. Hepler Ph.D.
Professor and Director
DuBow Family Center for Research in Pharmaceutical Care
University of Florida
College of Pharmacy
Gainesville, FL

Steve Jencks M.D., M.P.H.
Director of the Quality Improvement Group (QIP) and Assistant Surgeon General USPHS
Office of Clinical Standards and Quality
HCFA
Baltimore, MD

William F. Jessee M.D., CMPE (provided welcome, facilitator of large group discussion)
President and CEO
Medical Group Management Association
Englewood, CO

Gary S. Kaplan M.D. (participant, co-author and presenter of background material)
Chairman and CEO
Virginia Mason Medical Clinic
Seattle, WA

J. Paul Keenan M.D.
Associate Medical Director
Oklahoma Health Care Authority
Oklahoma City, OK

John E. Kralewski Ph.D.
Professor/Director
School of Public Health
University of Minnesota
Minneapolis, MN

Aaron Krupp (observer)
Government Affairs, MGMA
1717 Pennsylvania Ave, NW
Washington, DC

Carole Lannon M.D.
Department of Pediatrics
University of North Carolina School of Medicine
Chapel Hill, NC

David Lawrence M.D.
Chairman & CEO
Kaiser Foundation Health Plan Inc.
One Kaiser Plaza
Oakland, CA

Lucian Leape M.D. (one of two days)
Harvard School of Public Health
Boston, MA

Caryl Z. Lee R.N.
Program Manager VHA National Center for Patient Safety
VHA National Center for Patient Safety (10X)
Ann Arbor, MI

Lauren LeRoy Ph.D.
President and CEO
Grantmakers In Health
Washington, DC

Mark A. Levine M.D., FACP (participant, small group facilitator)
Aurora, CO
(now physician, Kaiser Permanente Colorado)

Kerstin Lynam M.B.A.
MGMA Center for Research
Englewood, CO

Patricia MacTaggart Senior Advisor (participant, small group facilitator)
HCFA-CHHP
Baltimore, MD

Gregg Meyer M.D., M.Sc., Director
Center for Quality Measurement and Improvement
Agency for Healthcare Research and Quality
Rockville, MD

Thomas J. Moore
Center for Health Services Research and Policy
School of Public Health and Services
George Washington University Medical Center
Washington, DC

Jeffrey Mossoff CMPE
Executive Vice President
Woodhull Medical Group
Brooklyn, NY

Greg Nycz, Director of Research
Marshfield Family Health Center
Marshfield, WI

Dennis O'Leary M.D., President
Joint Commission on Accreditation of Healthcare Organizations
One Renaissance Blvd.
Oakbrook Terrace, IL

Eduardo Ortiz M.D., M.P.H.
Senior Service Fellow
Center for Primary Care Research
Agency for Healthcare Research and Quality
Rockville, MD

Larry T. Patton
Senior Advisor to the Director, AHRQ
Congressional and Public Liaison
Agency for Healthcare Research and Quality
Rockville, MD

Robert L Phillips, Jr. M.D., M.S.P.H.
Assistant Director, Robert Graham Center for Policy Studies in Family Practice and Primary Care
Washington, DC

Neill Piland Dr.P.H. (participant, co-author of background material, co-author of synthesis)
Director of Research
MGMA Center for Research
Englewood, CO

Michael Pine M.D., M.B.A.
President
Michael Pine and Associates, Inc.
Associate Professor University of Chicago
Chicago, IL

Chris Queram, CEO
The Alliance
Madison, WI

Roger Resar M.D., Change Agent
Luther Midelfort Medical Center
Eau Claire, WI

Joachim Roski Ph.D., M.P.H.
Asst. Vice-President Quality Measurement
NCQA
Washington, DC

David Rutstein M.D.
Chief Clinical Officer for the National Health Service Corps
Co-chair of the Bureau of Primary Health Care's Patient Safety Taskforce
Bureau of Primary Health Care
Health Resources and Services Administration
U.S. Department of Health and Human Services
Bethesda, MD

Charles Schauberger M.D.
Gundersen Lutheran Medical Center
La Crosse, WI

Stephen D. Small M.D. (participant, co-author of background material, co-author of synthesis)
Department of Anesthesia and Critical Care
University of Chicago Medical Center
Chicago, IL

Leif I. Solberg M.D.
Associate Medical Director for Care Improvement Research
HealthPartners Research Foundation
Minneapolis, MN

Ed Stygar, Jr.
Executive Director
American Association of Accreditation of Ambulatory Surgery Facilities
Mundelein, IL

Kay Tavill CEO (observer)
Partnership for Patient Safety (p4ps)
Chicago, IL

Allen J. Vaida Pharm.D., Executive Director
Institute for Safe Medication Practices
Huntington Valley, PA

Saul Weingart M.D., Ph.D.
Associate Physician
Division of General Medicine and Primary Care
Beth Israel Deaconess Medical Center
Boston, MA

Appendix Two: Questions for Small Groups to Consider

These questions were provided to the facilitated small groups of participants to use in their discussions.

Topic One—The Epidemiology of Ambulatory Patient Safety

1. What kinds of data are most needed? What are the best research methodologies to get that data?
2. What are the barriers to data collection in physician offices, urgent care centers, home health, and emergency medicine? How can those barriers be overcome?
3. What can we learn from claims data? From databases linking claims and other data usually found in large databases (e.g., laboratory and pharmacy)? Are there good projects underway to assemble and analyze these data for patient safety?
4. Is it desirable to do a "Harvard study" of ambulatory errors, adverse events, and their consequences? A different comprehensive study? Is this possible given the fragmentation and "loose links" in ambulatory care, and the shortcomings of documentation? Given large variability in ambulatory structure and process, will results of a large epidemiological study be (as) generalizable as a hospital based study?
5. Because of the loose links among the "parts" in ambulatory care, it's difficult to determine the full (downstream) effects of an adverse event, either clinical or economic. Can tracer studies help here?
6. What can we learn from surveys of practitioners and providers? Surveys of patients and persons? What are the strengths and limitations of these methods and sources?
7. How will definitions and typology evolve and the field best move towards a consensus to support research, databanks?
8. Data and experience of liability insurance companies and the risk management activities of providers may be the best sources available to us for ambulatory patient safety. What are the limitations of these sources? How can we make best use of them? Are there other existing sources of data and experience that can be used now? Other opportunities?
9. We look to technology to help us reduce patient risk. Are there examples of increased risk from technology (Macklis et al. 1998)? What are the other factors "around" the use of technology that help determine its benefits and shortcomings?
10. There are substantial methodological barriers to rigorous research into ambulatory patient safety. What are the other barriers—for example, fear of liability? How might those be managed? Are there effective ways to remove barriers, or to provide incentives that neutralize them? Can we achieve routine recognition and collection of information from daily practice throughout ambulatory care?
11. Should "errors of omission" ( e.g., not providing state of the art chronic disease care) be considered under the safety umbrella?
12. How will people receiving the most fragmented care (the uninsured, people with high deductibles/catastrophic insurance only, ambulatory psychiatric, resident aliens, difficult social situations) be captured by epidemiologic research?
13. Given the generally loose and highly variable processes and structures in ambulatory care, it is clear that we must focus on "systems issues" in ambulatory patient safety. But how important are issues related to clinicians' knowledge, skill, and judgment? Impaired clinicians?

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