The im­por­tance of never

In deal­ing with never events, fo­cus on harm to pa­tients, not the blame game

Modern Healthcare - - Opinions Commentary - Leah Binder

When Cap­tain Ch­es­ley “Sully” Sul­len­berger safely landed US Air­ways Flight 1549 in the Hud­son River a lit­tle over a year ago, re­ces­sion-weary Amer­i­cans re­joiced at this small sign that Amer­i­can courage and know-how could still save the day. Af­ter a fluke col­li­sion with birds shortly af­ter take­off dis­abled both en­gines, Sul­len­berger and crew coolly glided the jet to a land­ing on the river, and safely evac­u­ated all of the pas­sen­gers. Though this was surely one of the great mo­ments in air­line his­tory, it was also a “never event” — a catas­tro­phe that we hope never hap­pens and ex­pect air­lines to pre­vent at all costs.

The health­care sys­tem’s “never events” are in­ci­dents so aw­ful most peo­ple can­not hear about them with­out winc­ing: re­moval of the wrong limb in surgery, trans­fu­sion of the wrong blood type, sex­ual as­saults on pa­tients, dis­charge of in­fants to the wrong par­ent, and more, for a to­tal of 28 hor­rific events iden­ti­fied by the Na­tional Qual­ity Fo­rum as “se­ri­ous re­portable events (SREs) that should never hap­pen.” The ex­is­tence of this ghoul­ish list tells us that these in­ci­dents, un­for­tu­nately, do oc­cur some­times—just as a plane landed in the Hud­son. Nonethe­less, as a goal, “never” seems a rea­son­able as­pi­ra­tion for the fre­quency of these catas­tro­phes.

In 2006, the Leapfrog Group, rep­re­sent­ing the nation’s largest pur­chasers of health­care ben­e­fits, un­veiled prin­ci­ples for hos­pi­tals fo­cused on the NQF’s list of 28 events, and in do­ing so coined the term “never events.” Leapfrog’s never events prin­ci­ples drew on pur­chasers’ ex­pe­ri­ence with cus­tomer ser­vice norms in their var­i­ous in­dus­tries, from air­lines to au­tomak­ers to hos­pi­tal­ity. Leapfrog asks hos­pi­tals to ad­here to four sim­ple prin­ci­ples. In 2009, 68% of hos­pi­tals re­port­ing to Leapfrog adopted these four prin­ci­ples. En­cour­ag­ing as this may be, still one-third of those hos­pi­tals do not have the pol­icy in place.

Why do some hos­pi­tals ob­ject to adopt­ing a never-events pol­icy? Some tell us they worry about law­suits if they apol­o­gize to the pa­tient, even though stud­ies show apolo­gies vastly re­duce the odds of law­suits. Oth­ers are concerned that some events are flukes that may not have been pre­ventable, so why should hos­pi­tals have to bear the cost? This con­cern about pre­ventabil­ity in each and ev­ery cir­cum­stance fu­els a con­tro­versy at the Na­tional

US Air’s re­sponse matched Leapfrog’s prin­ci­ples even though the crash

wasn’t pre­ventable

Qual­ity Fo­rum to­day as the mem­ber­ship re­vis­its the def­i­ni­tion of SREs. Un­for­tu­nately, the de­bate at the NQF piv­ots around how pre­ventable the in­ci­dent is, not on how cat­a­strophic it would be for the pa­tient.

Pur­chasers tend to think it’s worth erring on the side of call­ing ev­ery egre­gious in­ci­dent a “never event,” even if on oc­ca­sion it wasn’t pre­ventable. To un­der­stand that per­spec­tive, let’s re­flect on our friend “Sully.” We know the crash wasn’t his fault and wasn’t pre­ventable, yet the air­line’s re­sponse matched Leapfrog’s four prin­ci­ples to the let­ter.

Apol­o­gize: The day af­ter the crash, US Air­ways sent a let­ter to ev­ery pas­sen­ger apol­o­giz­ing for the event. At the time, in­ves­ti­ga­tors were still in the process of de­ter­min­ing what was re­spon­si­ble for the crash, but US Air­ways did not wait for those con­clu­sions to ex­tend its apol­ogy. Air­lines have to worry about law­suits, too, but the sim­ple hu­man­ity of the apol­ogy was too im­por­tant to sac­ri­fice. This also likely re­duced, if not elim­i­nated, the num­ber of sub­se­quently filed law­suits.

Re­port the event: In­ves­ti­ga­tors were im­me­di­ately on the scene, and re­ports are made pub­lic and shared with all air­lines.

Do a root-cause anal­y­sis: Not only does the air­line do a root-cause anal­y­sis for its own use, but as per in­dus­try stan­dard, it shares those re­sults with all air­lines.

Waive fees: Along with the let­ter of apol­ogy, US Air­ways re­funded each pas­sen­ger the cost of their round-trip ticket plus $5,000 for their trou­bles. This was not re­quired by law.

The air­line waived fares and apol­o­gized de­spite the fact that all early ev­i­dence—later sub­stan­ti­ated—sug­gested this crash was not the fault of the air­line or the pi­lot. To the con­trary, the pi­lot and crew per­formed with ex­cep­tional com­pe­tence and even hero­ism.

Now imag­ine pub­lic dis­may if the air­line had not waived the fare for the ticket and worse, billed pas­sen­gers for the cost of the res­cue op­er­a­tions. Sadly, that’s not un­think­able in the health­care sys­tem, where providers have charged the pa­tient for the costs of a cat­a­strophic in­ci­dent, then charged them for re­pair­ing the dam­age.

Pur­chasers care about Leapfrog’s po­si­tion on never events be­cause it em­bod­ies the stan­dards for cus­tomer ser­vice that other in­dus­tries ad­here to, es­pe­cially in­dus­tries that en­joy ex­cep­tional lev­els of pub­lic trust. Given that peo­ple en­trust their lives to the health­care sys­tem, it seems a small price to pay that providers bear the brunt of re­spon­si­bil­ity for avert­ing the most dev­as­tat­ing er­rors.

At the time “Sully” landed the plane safely, the pub­lic had no way of know­ing for sure who or what was to blame for the crash. What im­pressed peo­ple were the ex­tra­or­di­nary ef­forts of the cap­tain, the crew and the air­line to put the pas­sen­gers first. A never-events pol­icy is a re­as­sur­ing way for health­care providers to demon­strate they put pa­tients first.

By set­ting the bar at “never,” providers ac­knowl­edge the ter­ri­ble con­se­quences pa­tients stand to suf­fer if the worst hap­pens in our fal­li­ble health­care sys­tem. That’s why pur­chasers will con­tinue to press for hos­pi­tals, health plans and NQF mem­ber­ship to take the strong­est pos­si­ble stance on never events.


Leah Binder is CEO of the Leapfrog Group, a group of large

pur­chasers of health­care ser­vices that pushes for qual­ity


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