The Health Care Crisis: First We Need to Make Patients Safe - Part 2
RICHMONDWOMAN,
Volume 2, Issue 16, July 2005, pp.16 and 17.
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“Patient
safety” is “freedom from accidental injury due to medical care, or medical
errors.”
“Medical
error” is “the failure of a planned
action to be completed as intended or the use of a wrong plan to achieve an
aim…
[including] problems in practice, products, procedures, and systems.” Institute of Medicine
This is the
second of two articles about the role that patient safety plays in the current
health care crisis. Part 1, published
in the June 2005 issue of richmondWOMAN,
provided information on the scope of the patient safety issue and summarized
the current state of efforts to reduce medical errors including actions taken
in Virginia. This article explores what
should be done to make health care safer, save lives and reduce health care
costs.
Some
significant and positive changes have taken place since 1999 when the Institute
of Medicine reported in To Err is Human:
Building a Safer Health System that as many as 98,000 people die annually
as a result of medical errors. The most
important change is that no one now tries to deny that the health care system
in America has a safety problem. At the
same time, however, it is clear that this change in attitude and initial
efforts to address the underlying problems have not yet resulted in any
significant increase in patient safety or reduction in patient deaths.
As Lucian
Leape, MD and Donald Berwick, MD, reported in the May 18, 2005 issue of the Journal of the American Medical Association,
“[b]uilding a culture of safety is proving an immense task and the barriers
are formidable.” JAMA, May 18, 2005,
Vol. 293, No. 19, page 2385 . Yet, some
hospitals are proving that the goal of reducing patient deaths and injuries is
not only realistic, it is achievable.
The 100,000
Lives Campaign, launched by the Institute for Healthcare Improvement, is
showing that hospitals that focus on patient safety can prevent medical errors
and hospital transmitted diseases, such as pneumonia and blood infections. The campaign has adopted as its goals those
suggested by the Institute of Medicine:
90% reduction in infections; 50% reduction in medication errors; 90%
reduction in errors associated with high-harm medications; and 100% elimination
of the National Quality Forum’s “never” list.
Reporting on the 100,000 Lives Campaign, the Associated Press recently
reported that hospitals in Michigan and New Jersey have “virtually eliminated
ventilator-associated pneumonia and blood infections from neck and groin
catheters,” (“Hospitals Push to Curb Medical Mistakes,” Associated Press, June
2, 2005).
Achieving
these results not only saves lives, but it saves money and reduces health care
costs for everyone. According to Dr.
Thomas Rainey of the 100,000 Lives Campaign, each case of pneumonia is life
threatening and increases health care costs by at least $40,000. Infections from catheters kill 42% of the
patients infected on average. One
hospital system in New Jersey reported that it saved $2 million in direct costs
for medicines and supplies in one year by reducing patient complications well
below the state average.
What can we
do to encourage more emphasis on patient safety within Virginia hospitals and
health care institutions? In addition
to encouraging a “culture of safety,” I believe that we must take three key
steps if we are to improve patient safety in Virginia. First, we need to collect and publish data
that will allow patients and policy makers to make informed decisions about
patient safety at Virginia health care institutions. Without data, it is impossible to understand the problem or to
design a solution.
Next, we
need to use that data and implement a payment system that rewards institutions
and providers with strong safety records.
Finally, we
need to consider additional changes to our system for compensating victims of
preventable medical accidents and diseases that occur in institutional
settings.
Getting the Facts
Virginia
does not have a mandatory system for reporting all significant medical
errors. As the staff of the Joint
Commission on Health Care pointed out in 2000, Virginia’s patient level data
reporting system is inadequate to develop a comprehensive picture of medical
errors occurring in Virginia institutions.
While mandatory-reporting systems cannot cure our patient safety
problem, it is impossible to monitor patient safety and improvements in patient
safety without reliable data.
There is
great concern among doctors and hospital administrators about mandatory
reporting. A study reported in the March 16, 2005 Journal of the American
Medical Association reported that “[m]ore
than two-thirds of the doctors responding thought that a state-mandated public
reporting system would discourage error reporting and would not improve patient
safety. In contrast, the hospital executives thought that confidential
reporting would foster the desire to focus on identified problems rather than
lay blame and would lead to safer, higher quality care. “
The Centers
for Disease Control have recommended establishing public reporting systems for
one or more of the following medical errors related to hospital acquired
infections: central-line insertion practices, prophylactic antibiotics for
surgery, flu vaccination, bloodstream infections associated with a
central-line, and surgical site infections following specific surgical
procedures. The CDC released guidelines
in February 2005 to help guide states considering mandatory reporting of
hospital-acquired infections.
It is time
for Virginia to require health care institutions to report patient safety
data. Such data should be collected
confidentially but information on the experience at individual hospitals should
be aggregated and made public. Once we
know the actual dimensions of the problem in Virginia, we adopt goals and
measure our progress in solving it.
Paying for Results
The
National Quality Forum has developed a list of 30 evidence-based safe practices
ready for implementation. The Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) began requiring hospitals to implement eleven of these
practices in 2003.
It is time
to start paying for performance, and rewarding health care institutions that
save lives and money. According to
Leape and Berwick, “[t]he current reimbursement structure works against
improving safety and actually rewards less safe care in many instances.” … In most industries, defects cost money and
generate warranty claims. In health
care, perversely, under most forms of payment, health care professionals
receive a premium for a defective product; physicians and hospitals can bill
for the additional services that are needed when patients are injured by their
mistakes.” JAMA, May 18, 2005, page
2388.
In a report
to Congress on March 1 of this year, the Medicare Payment Advisory Commission
concluded, “it is time for the Medicare program to differentiate among
providers when making payments.” The
Commission called for Congress to instruct the Medicare program to design a
pay-for-performance system that rewards improvement, as well as attaining or
exceeding certain benchmarks.
It is time
for us to call on the Virginia legislature to implement a Medicaid
reimbursement system that is structured to reward institutions that implement
these safe practices. Private insurers
should follow suit.
Compensating the Injured
The Joint
Commission on Accreditation of Healthcare Organizations (JCAHO) suggests that
the current medical liability system fails patients because it does not
effectively deter negligence, offer corrective justice, or provide fair
compensation to those injured through the care process. The JCAHO has made 19
specific recommendations and identified three strategies for improving patient
safety and reducing medical liability: (1) actively pursue patient safety
initiatives that prevent medical injury; (2) promote open communication between
patients and practitioners; and (3) create a patient-centered injury compensation
system.
The
Virginia General Assembly passed legislation in 2005 designed to facilitate
open communication. It allows doctors
and hospitals to talk candidly with patients about mistakes without fear that
their words will be used against them in a lawsuit.
The
Virginia legislature should look carefully at the JCAHO’s recommendation that a
no-fault system like the workers’ compensation system be developed to
compensate patients for injuries and diseases incurred in a hospital setting. Such a system could reduce the human and
financial cost of medical errors while ensuring that patients receive timely
compensation for preventable injury or death.
Of course,
we will never get achieve the goal of a “culture of patient safety” without
leadership. Leape and Berwick report
that, to date, “few of the chief executive officers and boards of hospitals and
health-plans have made safety a true priority in their institutions or
committed substantial resources toward safety.” JAMA, May 18, 2005, page 2388.
It may well be that the only sure way to move safety up the priority
list is to link it directly to the bottom line or profit statement of these
institutions.
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