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Patient Safety |
PERSPECTIVE
A Call To Excellence
| Abstract |
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Health care improvement affects us all and is not optional. For change to occur, consumers must demand excellence from their providers and clinicians. Patient safety is part of a broader set of health care quality issues. Championing this view will not be easy, for it means fundamental change to the myriad interrelated systems that make up U.S. health care. HHS is taking the lead on patient safety through a number of initiatives and activities.
Michael Millenson accurately portrays how high the stakes are in patient safety and how urgent the need is for change. His investigative research has shown us the extremely visible tip of the iceberg. But fully appreciating the scope, nature, and root of medical errors—a "systems" view—means understanding that the issue is as much about commission as omission; about overuse of services when harms exceed benefits, about underuse of services when such services have been shown to enhance outcomes, and about misuse of services as well. The U.S. Department of Health and Human Services (HHS) has begun several initiatives that address the silences of both deed and word Millenson describes. However, the scale of improvements required to make safety a reliable feature of health care will also require a critical mass of patients, clinicians, and providers together demanding excellence.
One way to understand the significance of the systems argument is to look more closely at errors of omission—the less visible but no less important subtleties of everyday care. If a doctor fails to provide beta-blockers to a patient after a heart attack, despite the compelling evidence that this intervention reduces mortality, questions must be raised. What in the system prevented the doctor from using, or perhaps even knowing about, this intervention?
Research that focuses on clarifying why errors occur and how to bring about changes is now an overarching priority for the Agency for Healthcare Research and Quality (AHRQ). Additionally, the Centers for Medicare and Medicaid Services’ (CMS’s) Quality Improvement Organizations (QIOs) work locally with clinicians and providers to identify these opportunities for improvement and implement the systems changes necessary to eliminate errors.
Despite the attention generated by the Institute of Medicine’s 1999 To Err Is Human, countless news stories, and Millenson’s landmark work, Demanding Medical Excellence, the public has not yet grasped the full scope and nature of the errors issue.1 A recent survey conducted by the Henry J. Kaiser Family Foundation showed that 42 percent of the public and 35 percent of physicians polled reported that they or a member of their family had experienced an error in care.2 This is encouraging because it suggests that we may be close to a "tipping point" for change. However, the results also indicate that neither patients nor clinicians fully appreciate the importance of systems to making improvements.
| Breaking The Silence |
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 Top Breaking The Silence NOTES |
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Millenson posits another type of systems issue—a systemic silence of deed and a silence of word. The former, he says, is "the repeated failure of physician and hospital leaders to respond with corrective action to studies documenting severe and preventable quality problems," and the latter is "the absence of a thorough discussion of the tragic consequences of that lack of response." HHS is helping to break both of those silences.
Breaking the silence of deed. Within ninety days of taking office in 2001, HHS secretary Tommy Thompson announced formal establishment of a new Patient Safety Task Force charged with coordinating intergovernmental activities related to collection of patient safety data. Based within HHS, the task force is now identifying the data needed by providers, states, and other parties and is developing an Internet-based system to serve as the repository.
Additionally, AHRQ, through its Evidence-Based Practice Center program, systematically reviewed the literature regarding promising interventions and identified seventy-three that are likely to improve patient safety. It also identified eleven practices considered by researchers to be highly proven to work but not performed routinely (for example, use of medications to reduce the risk of heart attacks and infections in surgical patients in hospitals and nursing homes). The report on this work provides a roadmap for health care leaders to make tangible and sustainable improvements.3 HHS is also acting upon Millenson’s observations made six years ago in Demanding Medical Excellence: "With little fanfare, a gathering revolution is transforming the everyday practice of medicine. Owing more to laptops than lab coats, this is an information revolution."4
Today, through CLIPS—Clinical Informatics to Promote Patient Safety—HHS is putting technology’s enormous potential to work addressing many of the systems issues related to medical errors. A series of research and demonstration programs, CLIPS, led by AHRQ, is part of the department’s patient safety initiative launched in 2001. (The $50 million initiative is the federal government’s largest single investment to reduce medical errors and improve patient safety.)
How does information technology (IT) help address systems issues? If the increasingly hectic pace of the health care system means that doctors are seeing more patients and having less time to keep up with the literature, then handheld wireless devices are a means of getting this information to doctors at the point of care. If the decentralized nature of health care means that a patient’s records are now scattered among physician offices and hospitals, then the aggregation of patient history into a single electronic medical record greatly increases the chance that a drug allergy discovered two years ago (and now forgotten by the patient) will not escape notice. Translating promising findings into practice through challenge grants is an AHRQ priority for 2003.
But before many of these technologies can be deployed systemwide, information systems must be able to communicate with one another; for this to happen, standards must be agreed upon and adopted. At this writing, HHS is poised to promote the adoption of IT standards. This will also ensure the security and confidentiality of information that is important to high-quality care.
Breaking the silence of word. HHS is also involved in a number of activities addressing the culture of secrecy that seems to surround medical errors and providing the type of information that will help patients make better decisions about care. AHRQ has created the first peer-reviewed, Web-based medical journal, AHRQ WebM&M, to foster discussion on medical errors cases in a blame-free environment.5 Health professionals submit medical errors cases to the site (anonymously, if they wish). Five cases are featured each month (one each on medicine, surgery/anesthesiology, obstetrics/gynecology, pediatrics, and psychiatry) with one expanded into an interactive learning module, offering continuing medical education credits. An essential focus for this site is the use of root-cause analysis to address the systemic causes of errors.
HHS also recently announced its participation in the Hospital Quality Information Initiative, a joint effort with the nation’s hospital leadership to provide public information on quality of care that sets the stage for public performance reports to stimulate improvements in care. The American Hospital Association, Federation of American Hospitals, and Association of American Medical Colleges each committed to the goal of having all U.S. hospitals voluntarily report outcomes on an initial ten quality measures in three disease areas (acute myocardial infarction, heart failure, and pneumonia). As part of this initiative, the CMS and AHRQ are developing a standardized patient survey (H-CAHPS) to give voice to the experiences of patients at different hospitals. The results will be publicly reported on the Medicare Web site, www.medicare.gov.
To help those who rely upon nursing home care, HHS launched the Nursing Home Quality Initiative as a pilot program in early 2002 and expanded it nationwide in November 2002. By posting quality measures on ten areas (including pain, delirium, pressure sores, and decline in activities of daily living) at its Nursing Home Compare site, www.medicare.gov/nhcompare/home.asp, the CMS is helping Medicare and Medicaid beneficiaries to get access to easy-to-understand comparative information while stimulating nursing homes to improve. In the fall of 2003 these measures will be reported in AHRQ’s National Healthcare Quality Report, an unprecedented annual report on the quality of American health care.
Better information also means better patient communication with clinicians and other providers. As Thomas Lee of Partners Healthcare System writes, the IOM’s report Crossing the Quality Chasm showed how the health care system "fails with embarrassing frequency to provide medical interventions known to benefit patients. These failures are not the fault of physicians alone; they reflect poor coordination among all parties, including patients."6 With this in mind, HHS has developed a number of publications helping patients to understand key issues related to patient safety, steps they can take to work as partners with their doctor, and how to get their questions answered.7
Clearly, the challenge ahead of us remains formidable: promoting better understanding of what errors mean and how widespread the problem is, deflecting energy away from the tendency to blame and directing it toward finding solutions, and educating patients and empowering them as full partners. The top priority for our agencies and the larger department will be to support research, information, and partnerships to ensure that all Americans receive high-quality, safe, and efficient health care.
| Editor's Notes |
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Carolyn Clancy, a physician, is director of the Agency for Healthcare Research and Quality in Rockville, Maryland. Tom Scully is administrator of the Centers for Medicare and Medicaid Services in Baltimore.
| NOTES |
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| TopBreaking The SilenceNOTES |
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- L.T. Kohn, J.M. Corrigan, and M.S. Donaldson, eds., To Err Is Human: Building a Safer Health System (Washington: National Academy Press, 1999); and M.L. Millenson, Demanding Medical Excellence: Doctors and Accountability in the Information Age (Chicago: University of Chicago Press, 1997).
- R.J. Blendon et al., "Views of Practicing Physicians and the Public on Medical Errors," New England Journal of Medicine (12 December 2002): 1933–1940,
- Agency for Healthcare Research and Quality, Making Health Care Safer: A Critical Analysis of Patient Safety Practices, Evidence Report/Technology Assessment no. 43, 20 July 2001, www.ahrq.gov/clinic/ptsafety (6 January 2003).
- Millenson, Demanding Medical Excellence, 1.
- AHRQ WebM&M: Morbidity and Mortality Rounds on the Web, www.webmm.ahrq.gov.
- T.H. Lee, "A Broader Concept of Medical Errors," New England Journal of Medicine(12 December 2002): 1966; and Institute of Medicine, Crossing the Quality Chasm: A New Health System for the Twenty-first Century (Washington: National Academy Press, 2001).
- These are all available online at www.ahrq.gov/consumer and www.medicare.gov.
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