Despite progress on patient safety, still a long way across the chasm
To say the road to improving patient safety in U.S. hospitals is far from finished and filled with potholes is an understatement.
That’s despite major ongoing efforts by policymakers and healthcare providers to make improvements—from financial penalties to the sharing of best practices—and protect patients from hospital-acquired conditions and medical errors.
There is agreement that significant progress has been made on some fronts, notably in reducing central-line bloodstream infections and early elective deliveries. But problems remain in many areas, due to a wide range of unproven interventions and inadequate performance metrics. Some clinical leaders doubt hospital safety is much better than it was 15 years ago when the Institute of Medicine issued a landmark report that helped launch the patient-safety movement.
Last week, the Agency for Healthcare Research and Quality reported significant advances. It estimated that approximately 1.3 million fewer patients were harmed in U.S. hospitals between 2010 and 2013. That represents a cumulative 17% reduction, preventing about 50,000 deaths. The estimated 34,530 deaths avoided in 2013 were nearly 10 times more than in 2011, suggesting rapid progress. The estimated three-year cost saving from harm reductions was nearly $12 billion. HHS is expected to publish data this month on hospital-acquired conditions in individual hospitals.
The AHRQ report was based on medical records collected by the CMS as part of Medicare’s quality-improvement process, as well as surgical-site infection data from the Centers for Disease Control and Prevention’s National Healthcare Safety Network, and adverse obstetric events from AHRQ’s Patient Safety Indicators. The review included samples of between 18,000 and 33,000 medical records each year.
The IOM first called attention to the nation’s “epidemic of medical errors” with its 1999 report, To Err is Human, which estimated that as many as 98,000 patients die in U.S. hospitals each year because of preventable events. Healthcare was a decade or more behind other highrisk industries in providing basic safety, according to the report.
Healthcare leaders responded by establishing safety-improvement programs. Those efforts were accelerated by the 2010 Patient Protection and Affordable Care Act, which introduced financial penalties for poor quality performance, and launched the Partnership for Patients, a federally funded public-private learning collaborative to enhance safety.
Despite some reports of success, safety experts say improvements have been limited. “It is quite early to take a victory lap,” said Dr. Ashish Jha, a health policy professor at the Harvard School of Public Health. “I don’t know if care is safer. It might be, but we have a long way to go.”
Officials from the AHRQ, CMS and American Hospital Association, who presented the report last week, said improvements have come from widespread efforts to reduce adverse drug events, hospitalacquired infections and other errors over the three-year period, particularly through the Partnership for Patients. When it started in April 2011, the partnership aimed to reduce hospital-acquired conditions by 40% and preventable all-cause 30-day readmissions by 20% in 2013 using data from 2010 as a baseline.
CMS Deputy Administrator Dr. Patrick Conway said the report demonstrated “an unprecedented decline in patient harm in this country.” Significant change has come from pay-for-performance incentives, greater public reporting of quality data and the sharing of best practices, said Richard Kronick, director of the AHRQ. The AHRQ report acknowledged, however, that the rate of hospital-acquired conditions among patients in the U.S. “is still too high.”
Dr. Donald Berwick, founder and senior fellow at the Institute for Healthcare Improvement and a former CMS administrator, agreed that there has been substantial progress. Hospitals have taken safety-improvement steps seriously. “We should feel proud of what’s happened,” said Berwick, who helped establish the Partnership for Patients and was one of the authors of the 1999 IOM report.
But other prominent quality experts say that because of unreliable performance measurements and the inability to consistently provide outcome comparisons, hospitalized U.S. patients may not be much safer than they were 15 years ago. Although it’s widely agreed that hospitals are improving, there’s debate about how much progress the country has made in “crossing the quality chasm,” the title of the IOM’s follow-up patient-safety report in 2001.
While the AHRQ report offers encouraging signs, many patient-safety issues—such as misdiagnoses, overdiagnoses and unnecessary procedures and tests—are not included in existing measurements, said Dr. Hardeep
“There are major gaps. We must be absolutely clear that we are nowhere near where we need to get to.” Dr. Donald Berwick Founder and senior fellow at the Institute for Healthcare Improvement
Singh, a patient-safety researcher at the Michael E. DeBakey Veterans Affairs Medical Center in Houston.
“Those types of problems are often very complex and hard to measure,” he said. “What gets measured gets focused on. But when there are so many things that are harming patients that are not covered by the metrics, then the reality is a bit more sobering.”
The validity of measures assessing many hospitalacquired conditions remains unknown, said Dr. Peter Pronovost, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine. So it’s unclear if the evidence based on these measures is accurate.
The biggest improvements shown in the AHRQ report were for central line-associated bloodstream infections. There was a 49% reduction in CLABSI from the 2010 baseline to 2013. By comparison, there was an 18% reduction in postoperative venous thromboembolisms, a 19% reduction in surgical-site infections and a 28% reduction in catheter-associated urinary-tract infections.
Even before the partnership began, there were checklists for CLABSI, as well as clinical recommendations from professional societies and funding appropriated to reduce those infections. “All of this together creates an urgency and focus that isn’t as simple for some of the other measures,” said Dr. Don Goldmann, IHI’s chief medical and science officer. “There are ways to improve in the other areas, but it’s just not all lined up quite as well.”
Still, some experts say the partnership has been key in advancing improvement efforts. It features more than 3,700 participating hospitals organized in 26 Hospital Engagement Networks sharing evidence-based practices and submitting monthly performance data to the CMS Innovation Center, which oversees the initiative.
Most experts say reliable measurement continues to be a problem. For CLABSI, several studies demonstrated that basic interventions—including hand hygiene, use of an insertion checklist and removal of unnecessary catheters— produced more than a 60% reduction in infection rates. But quality metrics experts say the lack of well-defined studies make it is difficult to know whether interventions to reduce other infections produce the intended impact. Administrative data used to track those infections are subject to variation and changes in coding practices, experts argue.
These critics also say the proliferation of new quality measures may be causing measurement fatigue and unintended consequences. “For every instance in which performance initiatives improved care, there were cases in which our good intentions for measurement simply enraged colleagues or inspired expenditures that produced no care improvements,” several quality and safety leaders wrote in a Dec. 4 perspective article in the New England Journal of Medicine.
They cited the CMS’ quality measure for communityacquired pneumonia, which assesses whether providers administered the first dose of antibiotics to patients within six hours of presentation. “There was too much clinical variability for the measure to help physicians focus on exactly the right course of action,” the authors wrote. Hospitals dedicated time and resources to collecting data on a measure that did not prove beneficial.
These examples only represent challenges related to measuring and improving quality and safety inside hospitals. Increasingly, quality leaders are focusing on improving consistency in quality throughout the continuum of care, from primary care to ambulatory to post-acute care.
During last week’s presentation, the CMS’ Conway said much will depend on building a culture of safety and high reliability in healthcare organizations. Those that succeed in delivering consistent safety results will be the ones that have embedded safety processes in their culture, which Conway acknowledged is no easy feat. “The ultimate goal is to eliminate all preventable harm,” he said. “But obviously, in complex systems, that’s a challenging goal.”
Despite disagreement about how much progress hospitals have made on safety, Berwick said there’s nothing wrong with celebrating successes as they emerge. Still, he said, “There are major gaps. We must be absolutely clear that we are nowhere near where we need to get to.”