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Patient Safety

PERSPECTIVE

Provider Responsibility And System Redesign: Two Sides Of The Same Coin

Abstract

 
Patient safety is a serious problem that health care professionals and hospitals must confront. The health care delivery system must be redesigned. Health care professionals have a moral and ethical responsibility to actively participate in the development and operation of well-designed care processes. Efforts to redesign the delivery system will be most effective if accompanied by changes in the environment that shapes care delivery. Health care leadership must also focus attention on identifying the types of environmental changes needed at different levels, and on the part of specific stakeholders, to allow model twenty-first-century community health systems to develop.

The overall response of the health professions and the hospital industry has been inadequate, given the enormous human toll that errors exact. There are certainly laudable examples of improvements in both hospital and physician office settings, but they are too few in number. Success stories often fail to take hold and spread throughout the health care sector. There are steps that hospitals and health professionals can take today to improve safety, and each one has an obligation to do so.

But it is equally clear that calling on hospitals and health professionals to "do the right thing" will not be enough. The health care sector is highly fragmented, with tens of thousands of small practice settings, hospitals, and other providers. Decision making is decentralized, and lines of accountability are blurred. To achieve the comprehensive change that Millenson calls for requires wholesale redesign of the health care system and the environment that shapes it, which includes payment, regulation, law, professional education, and information technology.

Mixed messages. Health care, which accounts for one-seventh of the U.S. economy, is riddled with conflicting incentives and messages.¹ There are few if any rewards for providers who take steps to improve safety. Payment systems generally do not differentiate by the quality of services provided or patient outcomes achieved. There is little useful information available to patients or purchasers to identify the highest-quality providers. Most states do not even require providers to report errors that result in death or serious harm to patients.² Many instances of errors that result in patient harm do not give rise to lawsuits, and many legal claims do not relate to negligent care.³

Providers’ responsibility. The health care system must be redesigned—both the care processes and the environmental forces that shape care delivery. The focus on system redesign does not let providers off the hook. Quite the contrary: It clearly recognizes that health care professionals have the moral and ethical responsibility to participate actively in the development and ongoing operation of effective systems and processes. An individual physician can no longer provide safe and effective care without certain organizational supports, including carefully designed care processes; computer-based clinical records; effective multidisciplinary teams; and computer-aided decision supports for both patients and members of the care team. Well-designed systems are so essential to the delivery of safe and effective care that all providers, from small practices to huge hospitals, must invest financially in their establishment.

Providers accustomed to functioning autonomously must also collaborate with others. Providers are compartmentalized, but patients’ needs are not. More than half of health care spending is on behalf of people with multiple chronic conditions, and as the number of chronic conditions increases, so, too, does the likelihood of seeing multiple physicians, being hospitalized, receiving home health care visits, and filling multiple prescriptions.⁴ Over the course of a serious illness, most patients will experience numerous transitions from institutional to community settings, with formal and informal support systems. All providers must recognize that they are but one link in a chain, and it is the effective interaction among the links that determines much of patients’ experiences and outcomes. It is not enough for individual providers to focus on developing well-designed care processes within their own settings; they must participate in community-wide efforts to develop organized systems of care.

Information technology. Nowhere are the system challenges clearer than in the case of information technology (IT). There is much potential to improve safety, quality, and efficiency through the wise use of IT, including computer-based patient records and decision-support systems, such as medication order entry systems.⁵ Reaping the full benefits of IT requires an infrastructure that extends beyond an individual provider site to span an entire community, even the nation. Patients, providers of all types, ancillary services vendors, and insurers must be able to exchange data and communicate in a secure environment with proper safeguards for privacy and confidentiality. Establishing such an infrastructure requires the development of data standards, laws, regulations, business practices, and technologies.⁶

IOM contributions. Given the complexity of change necessary to turn the health care sector around, it is easy to succumb to finger pointing and paralysis. This is one reason that the Institute of Medicine (IOM) has made a long-term commitment to addressing safety and quality concerns. The IOM is contributing to the overall "constant drumbeat" for change in ways that are consistent with its organizational mission. Through reports, summits, and meetings, the IOM is focusing attention on the changes required at different levels (national, state, community, and provider), on the part of specific stakeholders (public and private purchasers, regulators and accreditors, health professionals, provider organizations, and patients), and in various programmatic areas (liability, financing and insurance, law and regulation, and health professions education and training).⁷

Every major change needs to start some-where. We need a handful of model twenty-first-century community health systems with state-of-the art information and communications infrastructures and well-designed chronic care management programs capable of providing coordinated preventive, acute, and palliative care.⁸ These model community health systems must focus attention on population health initiatives, as well as personal health care.

We, too, believe that the health care sector will reach a "tipping point" and that important changes will occur, but we think that the health care system will reach that point more quickly by pursuing a change strategy that is multifaceted and includes public policy, market incentives, and professional practice interventions. We are acutely aware that the longer it takes to reach the tipping point, the greater the price the American public pays in lost lives and disability, as well as wasted resources.

Neither is time on the side of the provider community. The longer it takes to marshal an adequate response to the safety challenges, the more damage is done to the health professions. Since the release of the IOM report, To Err Is Human, many tragic cases have been covered in the news media. There is a growing skepticism about providers’ willingness or ability to address this problem, as evidenced by a recent editorial in a leading newspaper characterizing medical errors as a "Medical Enron" and a steady flow of medical error cartoons in leading newspapers and magazines.⁹ Public trust is an asset that no health care provider should take for granted.

Editor's Notes

 
William Richardson is president and chief executive officer of the W.K. Kellogg Foundation in Battle Creek, Michigan. He chaired the Institute of Medicine (IOM) Committee on the Quality of Health Care in America, which produced To Err Is Human and Crossing the Quality Chasm. Janet Corrigan is director of the Board on Health Care Services, IOM, and served as study director of the IOM Quality of Care in America Project.

The authors thank Ann Greiner for her helpful comments.

NOTES

Top NOTES

 

1. The one-seventh estimate is from K. Levit et al., "Trends in U.S. Health Care Spending, 2001," Health Affairs (Jan/Feb 2003): 154–164.
2. J. Rosenthal, T. Riley, and M. Booth, "Medical Errors and Adverse Events: A Report of a Fifty-State Survey" (Portland, Maine: National Academy for State Health Policy, April 2000).
3. R.R. Bovbjerg, R.H. Miller, and D.W. Shapiro, "Paths to Reducing Medical Injury: Professional Liability and Discipline versus Patient Safety—and the Need for a Third Way," Journal of Law, Medicine, and Ethics 29, no. 3–4 (2001): 369–380.[Medline]
4. Partnership for Solutions, Chronic Conditions: Making the Case for Ongoing Care (Baltimore: Johns Hopkins University, 2002).
5. D.W. Bates et al., "The Impact of Computerized Physician Order Entry on Medication Error Prevention," Journal of the American Medical Informatics Association 6, no. 4 (1999): 313–321.[Abstract/Free Full Text]
6. National Committee on Vital and Health Statistics, Uniform Data Standards for Patient Medical Record Information, 6 July 2000, ncvhs.hhs.gov/hipaa000706.pdf (9 January 2003).
7. Institute of Medicine, Leadership by Example: Coordinating Government Roles in Improving Health Care Quality (Washington: National Academies Press, 2002); IOM, Priority Areas for National Action: Transforming Health Care Quality (Washington: National Academies Press, 2003); IOM, Health Professions Education: A Bridge to Quality (Washington: National Academies Press, forthcoming); and IOM, Coverage Matters: Insurance and Health Care (Washington: National Academies Press, 2001).
8. IOM, Fostering Rapid Advances in Health Care: Learning from System Demonstrations (Washington: National Academies Press, 2002).
9. "A Medical Enron" (Unsigned editorial), Washington Post, 9 December 2002.

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