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Quality Improvement EffortsThe thesis of the paper by Michelle Mello and colleagues (Mar/Apr 03) seems to be this: The United States has a lousy system of driving improvements in health care quality—the medical malpractice lottery—so let’s not feed it more fuel. But is hand-wringing about potential abuses of the tort system more important than concerted efforts to improve health care quality?The phrase "quality does not happen by itself" may be corporate-speak, but in this case it applies. The Leapfrog Group is one of several growing efforts to develop measurements of health performance coupled with public reporting programs. Such endeavors will face legitimate scientific challenges and may provide potential evidence for the trial bar, whose quality improvement mechanism has more often than not produced the opposite effect in health care. But one should not use fear of malpractice to justify the profound poverty of ambition characterizing many of today’s quality improvement efforts. Further, the authors’ review of Leapfrog’s recommendations is imbalanced and does not align with the assessment of a wide variety of experts in patient safety and quality improvement. The authors cite no evidence contradicting Leapfrog’s recommendations. Also, they failed to check their facts. For example, we do not recommend "round-the-clock" intensivist coverage. Leapfrog promotes coverage at least eight hours per day, coupled with intensive care unit telemonitoring, precisely because of the shortage of intensivists that the authors cite. We also have been clear that the current iterations of our recommendations are starting points. We continue to work with the medical community to refine and develop recommendations that stress process and risk-adjusted outcome measures. Leapfrog emphasizes informing consumers. For now, we ask hospitals to report on three activities that reduce mortality and improve outcomes. Hospitals are free to report on their performance, as well as the steps they are (or are not) taking to improve. A transparent health care system would at least permit patients to assess the risks associated with their choices and help them be vigilant about the risks they may take. A troubled tort system does not negate a patient’s desire or right to make informed health care choices, or a provider’s desire or right to be rewarded for improving quality.
Leapfrog Group, Washington, D.C.
The authors respond: It is hard to imagine a more powerful substantiation of our message than Suzanne Delbanco and colleagues’ dismissal of the concerns we raised as "hand-wringing." Liability fears do not and should not trump the urgent need for initiatives—like Leapfrog’s—that hold great promise for improving patient safety. However, we in the patient safety movement have been slow to recognize that, for good or ill, the civil justice system matters. It is not enough to impugn tort litigation as antithetical to the goals of quality improvement and move on. There is growing recognition of the need to be attentive to this interrelationship, as providers’ fears about litigation continue to present the greatest barrier to progress in disclosure, reporting, and patient safety research. In referring to "round-the-clock" intensivist coverage in the ICU, we erred in suggesting that the Leapfrog standard called for on-site intensivists. However, round-the-clock coverage surely stands as the correct term for describing presence in the ICU eight hours a day, seven days a week, and availability to return more than 95 percent of ICU pages within five minutes. More importantly, we fail to see how telemonitoring options eliminate the basic tension we noted between the ICU standard and workforce realities.1 A medical malpractice crisis is unfolding in the United States today. Risk-averse providers need reassurance that patient safety reformers recognize and have made every effort to minimize the legal consequences of their efforts. We heartily endorse both Leapfrog’s efforts and comprehensive reform of the tort liability system.2 But urgently needed advances will stall if the patient safety movement proceeds without careful attention to the liability implications of its work.
Harvard School of Public Health, Boston, Massachusetts NOTES
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