De­spite progress on pa­tient safety, still a long way across the chasm

Modern Healthcare - - NEWS - By Sabriya Rice

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.”

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