10 years, 5 Voices, 1 Challenge

Cover Story
10 years, 5 Voices, 1 Challenge
By Howard Larkin

To Err Is Human jump-started a movement to improve patient safety. How far have we come? Where do we go from here?


A decade ago, the prestigious Institute of Medicine shocked the nation by highlighting studies suggesting that medical errors kill up to 98,000 patients in American hospitals every year. To address the problem, the 1999 report To Err Is Human: Building a Safer Health System made recommendations in four areas: create leadership, research, tools and protocols to enhance knowledge of safety issues; identify and learn from errors by creating nationwide mandatory and voluntary error reporting systems; raise safety standards through actions by oversight organizations, professional groups and health care purchasers; and implement safety systems in health care organizations to enhance safe practice at the delivery level. Hospitals & Health Networks asked five prominent health care leaders representing a variety of stakeholders, from providers to payers to patients, to assess the report's impact up to now and where patient safety efforts should focus next.

Consistently advancing quality requires transparency, clarity of purpose.
James B. Conway, senior vice president, Institute for Healthcare Improvement. Shortly after Boston Globe reporter Betsy Lehman died from a medical error at Boston's Dana-Farber Cancer Institute in 1994, Conway took over as chief operating officer and led an institutionwide effort to improve care quality and patient safety. He also took part in the first national meeting on patient safety that led to the formation of the National Patient Safety Foundation in 1996.

A lot of work was done leading up to the IOM report. By 1999, Dana-Farber and other organizations began to learn what the unique properties of organizations were that enabled them to achieve dramatically higher levels of quality and safety. No one from Dana-Farber was on the IOM report committee, but what we learned was a fundamental part of the report.

I think most people did not anticipate the extraordinary press coverage the report received. President Clinton embraced it and kicked off an effort to address the problem with the Quality Interagency Coordination Task Force. The effort to evaluate and respond to the IOM report findings across all federal agencies was led by Health & Human Services Secretary Donna Shalala. We were pleasantly surprised.

But the question remains: Are we safer? The answer is, "Yes in many places more of the time." It is very hard to say if we are safer nationally. Some organizations have made extraordinary progress while others are just starting the journey.

One thing we have learned is it is hard to have safety where you don't have transparency. As IHI looks at hospitals and communities where there is the greatest improvement, one thing we consistently find is data, accountability to data and transparency.

We have really struggled with transparency. Data inputs and outputs vary dramatically by state. Most of what is collected is reported in aggregate, if at all. It is not possible to assess the performance of individual institutions. The emphasis is more on protecting organizations than protecting patients.

In Massachusetts, we had two systems: a confidential report to the state used for informing and learning and a public report of aggregate data. This year we started public reports by institution showing what their events were, why they happened and what the organization has done to keep them from happening again.

We were able to close the information circle in Massachusetts because of health system reform. We now have business and consumer representatives on the state quality and cost council that sets health policy. When you ask them if you need to report incidents by organization they say sure, why not? When you change who is sitting at the table you get different
outcomes.

The question for national reform is: Are we going to reshape the health care system or just tinker with payment mechanisms?

I frankly believe we have had too much "democracy" and not enough clarity of purpose. We have to decide to create a system that safely and reliably provides high quality care 100 percent of the time, set a date to achieve it and hold ourselves to it. It's complicated but it is absolutely doable. But we have to decide to do it.


--------------------------------------------------------------------------------

Hospitals have adopted and continue to build a culture of quality.
Rich Umbdenstock, president and CEO, American Hospital Association. In 1999 Umbdenstock was CEO of Providence Health & Services, then a nine-hospital system serving eastern Washington state and Montana. He joined the AHA board in November 1999, about the time the IOM report was released.

Everyone wants to see care improved locally and nationally. There is a lot of difference of opinion on how to do it and the obstacles. But there is no opposition to the consensus that improvement is needed. The IOM report created a sense of momentum that we didn't have before.

Significant progress has been made. Fundamentally what changed is the willingness to recognize the challenge and not argue about the numbers, but appreciate that care must be safe for each patient. This has led to palpable changes in the culture of organizations. Mistakes are no longer seen as inevitable, but as something that can be actively worked on and prevented.

Not every organization is as far along as others. But in our own work with the Quest for Quality Prize we have found an incredible amount of positive change. The Hospital Compare data show that more hospitals follow nationally agreed upon care steps. An ever-increasing number are demonstrating 90 percent-plus compliance with 90 percent-plus patients. But we can improve on that and there are some areas where we need to start from the beginning. We are constantly seeing new challenges, such as drug-resistant bacteria and more immune-compromised patients, which require new approaches. Quality is a moving target.

Hospitals have been strong advocates of public reporting. At the national level, the AHA is one of the founding entities of the Hospital Quality Alliance. Acute care hospitals are leaders in reporting quality and patient satisfaction at the state level. About 40 states report not just quality measures, but also financial measures. We have been strong supporters of reporting sentinel events and have learned a lot from the reports and related root cause analyses. We are seeing hospitals learn from unfortunate events elsewhere and prevent them from happening locally.

One challenge is the huge number of reporting measures requested not only by Medicare and other federal agencies, but by state agencies and private-sector payers and business coalitions. The volume of requests and different measures sometimes work against improvement because they consume financial and clinical resources that could be used to improve care. We are not seeing much progress on standardizing clinical measures, though everyone agrees these measures should be individually vetted and the National Quality Forum is the group to do it.

We want reform to build on the momentum that exists. We have substantial partnerships in the NQF and HQA that we should build on rather than replace with something that excludes the work and commitment of the private sector. We want changes that enable greater integration and coordination among providers. We need to remove some legal barriers, such as the Stark law, that were set up to deal with abuses but have had the unintended consequence of keeping the system fragmented. We want to see payment reforms that reward quality and care coordination. We are very much in favor of demonstration projects and private initiatives to understand how to do this while preventing unintended adverse consequences.


--------------------------------------------------------------------------------

Experience has deepened understanding of quality issues, but overall progress is slow.
Janet Corrigan, president and CEO, National Quality Forum. As a senior board director at the Institute of Medicine, Corrigan directed the Quality of Care in America initiative that produced To Err Is Human and Crossing the Quality Chasm.

In many ways, the greatest significance of this report is the enhanced awareness of how unsafe the care environment really is. That is a necessary prerequisite for improvement. A good deal of the public today is aware that there are safety issues. It also unleashed a lot of improvement initiatives among health care professionals, hospitals and nursing homes.

Over the last decade, we have gained a deeper understanding of how complex the issues are. It is hard to change the culture of an institution. Many forces work against transparency and continuous quality improvement. It takes time and leadership and you have to stick with it.

Making significant improvements requires an overhaul of the delivery system. We can't get there without sizable investments in information technology to create a complete electronic health record and access to it. You need strong organizational support, a team with good communication, a common treatment plan, a variety of decision support tools, and a way to engage family members and caregivers as part of the team.

It will require changing the payment system. Current systems don't reward investments in safety as they should. We are just now starting to see efforts to reward safety and penalize unsafe environments by withholding payments for preventable events.

We have not made enough progress on transparency. I applaud states that have established reporting systems, but we need a nationwide system. The IOM recommended two types of reports; mandatory reports for the small fraction of events resulting in death or serious harm to patients, and voluntary reports focusing on errors that result in minor or temporary harm or near-misses. The voluntary reporting system should provide protection from legal discovery to create a learning environment in which providers would not have reservations about coming forward.

In both cases we have fallen short. Mandatory reporting is required in some states but not all. Health care is the only part of our society in which someone can die and there is no investigation. I continue to think it is critical that we have public reporting on a variety of safety measures including health care-acquired infections.

However, progress has been made, and many examples go beyond individual hospitals. In Michigan, more than 100 hospitals reduced catheter-related bloodstream infections that saved an estimated 1,500 lives and $100 million over 18 months. Everything from small rural hospitals to major academic medical centers participated. The question is why haven't we been able to take those accomplishments to scale across all 50 states?

We haven't accomplished everything and improvement has been slower than we expected. But overall, the glass is more than half full.


--------------------------------------------------------------------------------

Without public reporting, there's no way to tell what progress has been made.
Lisa McGiffert, director, Safe Patient Project, Consumers Union. She is co-author of the Consumers Union report To Err is Human—To Delay is Deadly: Ten Years Later a Million Lives Lost, Billions of Dollars Wasted.

The IOM report initially produced a flurry of activity, but things died down. Legislation was introduced and some money was given to the Agency for Healthcare Research & Quality, but the impact was less significant than many of us hoped.

One problem was there was no organization to oversee implementation. The intent of the IOM report was to create such an entity, but we as a country fell short. The IOM committee did the report and dispersed. When we did our 10-year follow-up, we found it difficult to get anything new on the subject from the IOM. They referred us to people on the
committee.

There have been a lot of individual improvements in care processes. People take risks and try things and significantly reduce infections or medication errors or bed sores and report their results at conferences. As a nation we could be safer because of this. But nobody knows because we are not measuring it. There is no validated standardized data reporting.

To show how little progress has been made, the latest AHRQ report used the IOM's 1999 work as the best estimate of the magnitude of medical errors. The best information we have now comes from AHRQ's 2008 National Healthcare Quality Report. Based on paper chart reviews and billing records, it estimates that patient safety declined by 1 percent in each of the six years following the IOM report. According to this data, we are less safe than in 1999.

Even when projects involving hundreds of hospitals are undertaken, the results often are not shared with the public. The Michigan keystone project looked at measures to reduce bloodstream infections for two years and found that half of hospitals reduced their rate to zero and sustained it and half did not. But they would not publish which did and which didn't. If you only have aggregate data you can't make an informed decision.

Our belief is public reporting is a key element to bring about systemic change. As long as this harm is kept secret, we are not going to be able to end it. We have decades of experience with secret voluntary reporting and it has been ineffective in bringing about real change.

That does not mean there are not places where care is safer. There are. Individual institutions are stepping up. But progress is spotty and it depends on who is in charge. We are moving in the right direction, but not fast enough.


--------------------------------------------------------------------------------

Greater safety focus is needed to keep employer-sponsored coverage viable.
Helen Darling, president, National Business Group on Health, which provides a forum for employers to discuss and develop policy positions on health care.

Shockingly modest progress has been made given the impact of the problem, how many people were made aware of it, and how many efforts have been made to address it. From the employer community's perspective, we think more should have occurred.

We are finally starting to see some action. CMS is making "never events" unreimbursable. There are longer lists of events at the National Quality Forum. We have gone from saying "patient safety is an important thing that you should do" to tying money to it. I anticipate more progress as we see more pressure from payers and regulators. There has to be less tolerance for waste if we are going to cover 46 million people who have nothing now.

The potential savings are huge. A study in the American Journal of Medical Quality found that just improving discharge planning could reduce hospital readmissions enough to save about $400 per admission. We are talking about billions of dollars not to mention a reduction in human suffering.

A lot can be done with financial incentives. Almost everything we have in health care was developed in response to market demand. The roughly $22 billion investment in health care IT will make it possible to provide and track services in ways that were not possible before. With the new technology we will know sooner when people are being readmitted and there will be a financial consequence.

There are a lot of good examples. We recognized two this year with our first patient safety leadership awards: Henry Ford in Detroit and Memorial Hermann in Houston. They have ambitious goals on safety. They achieve them and sustain them with support from the board level on down.

But we are not going to accomplish delivery and finance reform unless we harmonize the activities of the public and private sectors. They don't have to be identical and we can still have multiple payers, but we have to harmonize how we pay hospitals and doctors to get them to collaborate. The AHA has put forward principles that we all agree on.

Our for-profit employers are in the worst economy in 70 years. Companies are eliminating or reducing 401(k) matches rather than cut health care. They can't afford to go much further. If nothing happens to slow health cost increases, companies will cease to fund it.


This article 1st appeared in the October 2009 issue of HHN Magazine.

abrir aquí:
10 years, 5 Voices, 1 Challenge