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July 30, 2019
Gail R. Wilensky
| Early View, Opinion
There has been a significant focus on patient safety issues over the past two decades. This began with the release of To Err is Human in late 1999,1 but has included numerous other reports indicating the substantial number of deaths and injuries due to medical errors. Despite the focus on this topic by hospital associations, medical groups, and various professional organizations, such as the ECRI Institute, a recent report indicates serious challenges remain.2
Johns Hopkins researchers recently published a study based on the latest available statistics estimating that 161,000 avoidable deaths occur each year.2 While the good news is that this number is down from the 206,000 preventable deaths estimated in the original study from 2016, 160,000 or more avoidable deaths remains a large number of people who are dying from preventable errors in the delivery of health care and it is clear that serious safety challenges persist. It is also likely that this latest estimate may only be the proverbial “tip of the iceberg” because the number is likely to be an underestimate—there are no ICD codes for human and system errors—and because the estimate ignores other medical mishaps and morbidities that do not result in deaths.
Medicare is trying to reinforce the importance of patient safety in its payment policies by reducing payments to hospitals that have demonstrated reasons for there to be concerns about the safety of patients. Between October 2018 and September 2019, 800 hospitals will have had their reimbursements reduced for patients discharged because of such concerns, with the penalties applied when hospitals submit their claims. Under the program, a hospital is given a total score based on performance according to six quality measures: Hospitals that fall in the worst-performing quartile will lose 1% of their Medicare payments for Medicare beneficiaries who were discharged in the year in which the safety concerns occurred.
According to Centers for Medicare and Medicaid Services (CMS) reports, 1,756 hospitals have been penalized at least once over the last five years and, as of this year, there are 110 hospitals that have been penalized for the fifth straight year. It is not clear how widely the penalties for patient safety are known in the communities where the hospitals are located or whether that standing has negatively affected their admission rates—especially for those institutions penalized for patient safety issues for five straight years. It is also unclear how aggressively the low-scoring hospitals may be attempting to ameliorate their relative standing in their communities. To the extent that the low-scoring hospitals also are being negatively affected by the CMS program on Hospital-Acquired Condition Reduction, in which one domain is represented by patient safety indicators, low-scoring hospitals could find themselves doubly penalized and, therefore, in a financially challenging environment.
Not surprisingly, the American Hospital Association (AHA) has pushed back about the accuracy of the scores for penalized hospitals. Their argument is that only 41% of the 748 hospitals penalized in 2017 had hospital-acquired infection rates that were statistically different from those hospitals that were not penalized. The hospitals themselves complain that the hospitals that do the best job at testing for infections appear to be among the worst in terms of the reporting infection rates.
There are many questions raised by the current program. Among the most fundamental is whether penalizing the 25% of hospitals that score the lowest is an appropriate way to designate poorly performing hospitals. It is also unclear whether penalizing them is the best or most likely way to improve their performance. Although it does not appear to be a legitimate issue at the current time, it is possible to imagine a scenario in which the 25% lowest scorers reach at least an acceptable level in absolute terms. To account for this possibility, a blend of relative measures of patient safety scores and error rates along with absolute measures of patient safety may be preferable to the one in current use. It may also be that CMS is deliberately pitting hospitals against one another and assuming that this strategy will incentivize the lowest scoring hospitals to improve their rankings. This raises the question of whether and where appropriate assistance is available to assist low-scoring hospitals. It is not clear from the program’s description whether CMS is actively attempting to assist low-scoring hospitals on strategies that would improve their performance scores, although these services are readily available in the private sector.
Another area of concern related to patient safety is health information technology (IT). Researchers from MedStar Health’s National Center for Human Factors in Healthcare and Georgetown University’s School of Medicine recently analyzed 1.7 million patient safety events involving health IT.3 The researchers categorized responses according to one of four groups: no resolution, training and education, policy, and IT-oriented solutions. What they found is troubling. Almost two-thirds of the events did not have any resolution—a very high percentage of nonresolution events. Of the one-third with resolution, slightly more than half (55%) were resolved through training and education, which has been regarded as a limited means of resolving IT events. Also contributing to patient safety issues were the silos that frequently exist between IT and the biomedical departments of a hospital. Bridging this gap can improve patient safety as well as improve the functioning among departments.
In addition, problems with how medical devices are networked can lead to delays in treatments or even misdiagnoses according to a study that was done by ECRI.4 Examples cited in the report include lab results sent to patient records without lab values being included and incomplete information going from a ventilator to a patient monitor. The report identified a list of top ten patient safety concerns for 2019, along with strategies to address those concerns.
The focus on patient safety is an important first step to resolving these issues. However, the follow-through is at least as important. The more complex the delivery of care becomes and the more reliant on information systems and interconnectivity between systems and electronic devices, the more vulnerable a health care system is to problems with system accuracy and communications. As patients, which we all are at various times, we can only hope that this is the direction in which our health care system is going.
Gail R. Wilensky, PhD, is an economist and senior fellow at Project HOPE, an international health foundation. She directed the Medicare and Medicaid programs and served in the White House as a senior adviser on health and welfare issues to President Georege HW Bush. She was also the first chair of the Medicare Payment Advisory Commission. Her expertise is on strategies to reform health care, with particular emphasis on Medicare, comparative effectiveness research, and military health care. Wilensky currently serves as a trustee of the Combined Benefits Fund of the United Mine Workers of America and the National Opinion Research Center, is on the Board of Regents of the Uniformed Services University of the Health Sciences (USUHS) and the Board of Directors of the Geisinger Health System Foundation, United Health Group, Quest Diagnostics and Brainscope. She is an elected member of the Institute of Medicine, served two terms on its governing council and chaired the Healthcare Services Board. She is a former chair of the board of directors of Academy Health, a former trustee of the American Heart Association and a current or former director of numerous other non-profit organizations. She received a bachelor’s degree in psychology and a PhD in economics at the University of Michigan and has received several honorary degrees.
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