By Samantha Collier, MD, MBA

"...We're living longer than any
generation in history. Yet we can still improve. And we can do more."
-President George W. Bush
June 2002

Most Americans believe that good quality healthcare is a right, not a privilege. Increasingly, American consumers are demanding the information about quality that is necessary to ensure that they receive high-quality care.

HealthGrades, Inc., conducts ongoing research to educate consumers and empower them to get the best care. We believe that patient safety is the foundation of hospital quality. In the pursuit of information and knowledge that could be used to improve patient safety, HealthGrades published a report, Patient Safety in American Hospitals, in July 2004.

The purpose of this report was to identify the incident rates, associated mortality, and costs of selected medical in-hospital errors and injuries among Medicare beneficiaries across all U.S. hospitals and also to identify the best-performing hospitals. Using 16 of the 20 Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) (excluding the four obstetric PSIs) and AHRQ's Version 2.1, Revision 1 PSI software, HealthGrades identified 1.14 million adverse events associated with Medicare hospitalizations from 2000 through 2002. Applying previous research by Zhan and Miller (2003), who were the first to identify length of stay, charges, and mortality attributable to 18 of the 20 AHRQ PSIs using case-matched controls, HealthGrades estimated that these incidents were associated with $2.85 billion of excess Medicare cost and at least 25,000 excess Medicare deaths over the three years studied.

HealthGrades identified that better-performing hospitals (93rd percentile) had lower PSI incident rates and lower associated mortality and cost compared to 10th percentile performers.

Previous reports (MedPAC's Report to Congress and AHRQ's National Healthcare Disparities Report and National Healthcare Quality Report) have identified similar rates among the Medicare population. These earlier reports found that Medicare incident rates are consistently higher and increasing across most PSIs as compared to non-Medicare patients, even after accounting for age, co-morbids, and other confounding factors.

Similar to the release of the then-controversial Institute of Medicine (IOM) report To Err Is Human in 1999, HealthGrades received unprecedented feedback from all healthcare stakeholders. This feedback underscored the importance and visibility of the patient safety agenda subsequent to 1999. Despite the urgency created by the IOM report, the 50% reduction in medical errors requested by the IOM's follow-up report The Quality Chasm has not been achieved. As stated previously, the MedPAC and AHRQ reports found that rates were increasing across most PSIs among Medicare beneficiaries; the reason is not yet known. Each year that passes without even modest changes is estimated to affect hundreds of thousands of patients and their families and cost the U.S. hundreds of millions of dollars.

Recognizing that zero defects is most likely impossible in healthcare, we concluded that reducing the rate of four common PSIs (decubitus ulcer, post-op DVT/PE, post-op sepsis, post-op respiratory failure) by just 20% would save the Medicare system almost $380 million dollars and potentially prevent approximately 3,000 Medicare deaths annually.

Whose Problem Is It?
Despite widespread and accepted knowledge about antimicrobial resistance in the hospital, a study published by Giblin et al. in Archives of Internal Medicine (2004) concluded that clinicians were significantly more likely to perceive that antibiotic resistance was a problem nationally than in their own institution or practice. Part of any successful improvement program, whether it be self improvement or organizational improvement, begins with the acknowledgement of the issue. Many experts within the medical community have faced the brutal fact that medical injuries are a serious epidemic confronting the healthcare system.

With the help of the media, family, and friends, consumers are increasingly aware of the potential for medical error. The National Patient Safety Foundation found that 42% of survey respondents stated they or their friend/family member had been affected by a medical error. These same respondents believe that medical errors were the result of the failures of individual providers, such as nurses and physicians. A recent study published by Cook et al. in the American Journal of Nursing (2004) found that most healthcare professionals agree with consumers that individual providers are responsible and accountable for ensuring against medical error incidents. In this study, nurses were most frequently cited as being the responsible and accountable party. Despite this extraordinary responsibility and accountability, nurses were seen as part of the clinical decision-making team only 8% of the time, emphasizing their relative lack of authority to impact care at the point of service.

There are multiple points, or opportunities, in the delivery of care to change the outcome. Even the easiest processes for eliminating medical errors are not always followed. Case in point, only 43% of physicians wash their hands or, conversely, 57% do not. An unbelievable 15% admitted to researchers that they did not know that hand washing reduces hospital-acquired infections, and an astounding 67% admitted to researchers that hand washing was a "difficult task" (Pittet et al., 2004)! Although improvements have been made, we have a long way to go to ensure that high-quality healthcare is a universal reality.

Communicating about Quality
The healthcare community of consumers, employers, payers, and providers agree that information on patient safety and medical errors cannot be ignored without significant consequences. This is a big first leap towards the safest and most effective healthcare possible.

We also need to look at how we communicate large amounts of complex information and how we interact with all of the healthcare workers who may believe they are powerless to affect change. We must tear down the all-too-long-lived autocratic and bureaucratic culture of healthcare delivery and create one that is high-performing, team-based and patient-centered. Most importantly, we must redistribute the responsibility and accountability for patient safety across all stakeholders.

References

Agency for Healthcare Research and Quality (AHRQ). (2003, July). National healthcare disparities report. Retrieved December 3, 2004, from www.qualitytools.ahrq.gov/disparitiesreport/download_report.aspx

Agency for Healthcare Research and Quality (AHRQ). (2003, December). National healthcare quality report. Retrieved December 3, 2004, from www.qualitytools.ahrq.gov/qualityreport/browse/browse.aspx

Collins, J. (2001). Good to great. New York: HarperBusiness

Cook, A. F., Hoas, H., Guttmannova, K. & Joyner, Jane C. (2004 June). An error by any other name. American Journal of Nursing 104(6), 32-43.

Giblin, T. B., Sinkowitz-Cochran, R. L., Harris, P. L., Jacobs, S., Liberatore, K., Palfreyman, M. A., Harrison, E. I., & Cardo, D. M. (2004, August 9). Clinicians' perceptions of the problem of antimicrobial resistance in health care facilities. Archives of Internal Medicine 164, 1662-1668.

MedPAC. (2004, March). Report to the Congress: Medicare payment policy. Washington, DC: Author.

Pittet, D., Simon, A., Hugonnet, S., Pessoa-Silva, C. L., Sauvan, V., & Perneger, T. V. (2004 July). Hand hygiene among physicians: Performance, beliefs, and perceptions. Annals of Internal Medicine 141, 1-8.

Zhan, C., & Miller, M. R. (2003, October). Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. Journal of the American Medical Association 290,1868-1874.

Proceedings from the Quality Colloquium at Harvard University:

• Introduction

• Partnering with Suppliers to Improve Patient Safety

• One Piece of the Patient Safety Puzzle: Advantages of the Six Sigma Approach