With health care, the concerns go well beyond insurance
Our nation’s healthcare system is failing and neither the preservation nor revocation of the Patient Protection and Affordable Care Act (Obamacare) will alter this. By narrowing the discussion of healthcare to political debate over revoking this legislation we are diverted from the critical issues it attempts to address and some of the potential unintended consequences of its (necessary) provisions for the improvement of patient safety and quality of care.
The possibility of being accidentally harmed or killed when receiving hospital-based care is well documented, but seldom discussed. Recent studies have estimated that hospitalized patients have between a 25 and 33 percent chance of being accidentally harmed as a function of receiving care — suffering complications that do not stem from the injuries or illnesses for which they are being treated. Since 1999 the Institute of Medicine (IOM) has published reports that detail how patients are accidentally harmed and killed, citing contributing factors such as broken care processes, poor information technologies, archaic organizational structures, and administrative processes that are not responsive to the needs of frontline care providers and patients. Underscoring the IOM reports, in 2010 the Centers for Medicare and Medicaid Services (CMS) reported that 180,000 hospitalized Medicare patients die annually as a result of being accidentally harmed during the course of their care. Respected journals, such as the New England Journal of Medicine and Health Affairs, among others, have published similarly disturbing statistics. No other industry in this country could accidentally kill this many people without arousing a vast public outcry; certainly not the airline, nuclear power, or chemical processing industries. Unlike the mass casualties associated with failures in these industries, accidental patient injuries and deaths occur one at a time and are typically perceived, subjectively, as unique events rather than a symptom of broken systems of care.
Although news media often report accidental patient injury and death as resulting from the negligence of clinicians this is, emphatically, rarely the case. It is the diligence of frontline care providers, and their efforts to overcome problematic conditions in clinical settings that keeps hospital-based care as safe as it is. If we are to learn how to improve the safety of hospital-based care, we must stop blaming individuals who are closest to an accidental injury or death — invariably frontline clinicians — and resolve the organizational and managerial problems that underlie clinical conditions that provoke failure and harm. These problems have arisen because the management of hospitals has not evolved in keeping with escalating complexity, which is driven by the continuous advance of medical technologies and treatments, and the rising number of specialized roles necessary to manage them. These technologies and treatments carry both benefit and risk, and they require highly reliable processes to mitigate risk and avert failure. Yet, hospital executives have not been educated to function as leaders of complex, high-risk systems and hospital trustees, who are ultimately responsible for the quality and safety of care, are at an even greater disadvantage as they often have no background in healthcare, much less the safety sciences. It is not surprising that strategies for system-based management of safety developed in other high-risk domains have not been successfully adapted to healthcare — despite good intentions and, in some cases, significant investment of resources. A study which examined the effects of a multi-year, state-wide effort to improve patient safety in North Carolina, for example, found virtually no lasting improvement.
In part, impetus for safety and quality improvement is dampened by favorable measures of quality and safety reported by hospitals, such as CMS ‘core measures’ of quality and the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators. Recent research has revealed these to be weak markers of quality and safety, yet hospitals still point to these data as evidence of safe, high quality care — and still receive awards on the basis of such metrics, despite their questionable merit. Publicity and marketing are trumping transparency and disclosure as hospitals attempt to compete for patients in the face of escalating cost and declining revenue. This period of poor transparency will eventually end, compelled in part by tying Medicare payments to more rigorous assessment of quality and patient safety.
CMS is implementing policy changes that will advance ‘value-driven’ payment for Medicare services. The purpose of ‘value-driven’ payment is to create a financial incentive for the improvement of quality and patient safety, while avoiding expenditure of Medicare funds for the treatment of hospital-acquired illness and injury. Although current methods for identifying hospital-acquired conditions are sub-optimal, much more sensitive measures are imminent. Recent data mining studies have demonstrated the merit of ‘risk triggers’; data markers for the identification of possible patient harm events in health records. One risk trigger study found that accidental patient harm occurs at rates 10 times higher than other methods have revealed.
Automated data mining of electronic health records is likely to be mandated by CMS in the next few years, which will illuminate (very publicly) the magnitude and severity of patient harm in U.S. hospitals. This will affect hospitals in multiple ways, including reduction in Medicare reimbursement, the risk of loss of participation in Medicare, and long overdue outcry over the degraded state of healthcare system safety. Better data and transparency are essential to improving patient safety but will not, alone, result in safer healthcare systems. Hospital executives and trustees are currently operating with inadequate measures of quality and patient safety, and often have an undue sense of comfort with the current state. The serious job of protecting the safety of patients requires committed and continuous attention to the concerns of frontline clinicians — they are the first to experience the unintended consequences of changes in resource allocation, processes, equipment acquisition and maintenance, staffing, and myriad other administrative actions that are routinely implicated in the clinical conditions that provoke accidental patient injury and death.
These are key needs and issues that we should be focused on, not the misinformation of politicians using the Patient Protection and Affordable Care Act to play “ideological chicken” with our nation’s budget.
Jeff Brown is a principal of Taylor-Brown and Associates Healthcare Consulting, LLC, in Peterborough. He has supported patient safety research initiatives throughout the U.S. for 14 years, and is currently supporting research with the U.S. Army Medical Research and Materiel Command, Army Institute of Surgical Research.