A Pragmatists Argument for Quality and Safety: Keeping the Focus in Tough Times

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A Pragmatists Argument for Quality and
SafetyKeeping the Focus in Tough Times

• Robert M. Wachter, MD
• Professor and Associate Chairman, Department of
  MedicineUniversity of California, San Francisco
• Editor, AHRQ WebMM and PSNetAuthor, Internal
  Bleeding and Understanding Patient Safety

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Speaking of a Business Case

• UM in-state tuition 11,000/year
• UM out-of-state tuition 36,000/year
• Difference over 4 years 100,000

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Does Anybody Care to Adopt a Nice Boy?
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Lets Not Belabor the Point Quality Safety
Arent Very Good

• 44,000-98,000 yearly deaths from errors
• 54 adherence with evidence-based practice
• Clinically indefensible variations, with high
  cost often associated with poor quality

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Why Do We Have Our Quality and Safety Problems?

• a) Its really complicated
• b) Theres sooo much new information
• c) There are sooo many new drugs and devices
• d) Its hard to get different types of people to
  work together
• e) Patients are not machines they are pretty
  unique and their care is tricky to hard-wire
• f) None of the above

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The Answer is f (None of the above)

• a-e are undoubtedly true
• But the fundamental flaw was the absence of an
  incentive system
• Business, academic, marketing anything
• Played out in myriad (and self-fulfilling) ways,
  from failure to computerize, to boards/CEOs not
  recognizing depth of their problems
• Much of the past 10 years can be seen as efforts
  by stakeholders to put skin in the game viz
  patient safety and quality

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My Points for Today

• Until recently, quality and safety driven by
  ethics, not a business case
• No longer so the trends point to a increasingly
  robust business case
• There are some savings thru standardization,
  simplification, preventing re-work
• But it will cost money in the short term
• Failure to invest now will haunt you later
• No sympathy for the unfunded mandate argument
• Bonus its the right thing to do

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What Levers are Available to Promote Safety and
Quality?

• Education/Information
• Social pressure
• Media pressure
• The malpractice and legal system
• Accreditation/regulation changes
• Error reporting and transparency
• Money

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Education/Information
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Social Pressure
and many parallel local campaigns
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Media Pressure
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Malpractice System and Accountability

• Prior to IOM report, med mal was the only
  tangible motivator
• Unfortunately, promotes wrong paradigm
• Individual fault, rather than systems thinking
• New issue accountability at multiple levels
• How to balance systems thinking with need to
  assign fault, when appropriate
• Its time to get serious about this
• In 2009, hand hygiene is not a systems problem

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Accreditation/Regulations/Laws

• Accreditation
• Joint Commission NPSGs, robust inspections
• ACGME housestaff duty hour limits
• Regulations
• More vigorous state reporting systems
• Enforcement of CMS Conditions of Participation
• Laws
• Californias nurse-to-patient ratios
• MRSA screening requirements
• More coming.

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Public Reporting

• Biggest surprise of quality revolution
• Simple reporting leads to major improvements
• Pathophysiology is embarrassment, not consumerism
• Problem viz medical errors measuring safety
• CMS measures are all of quality, not safety
• Previously processes (beta blockers, aspirin, flu
  shots)
• Increasingly outcomes (risk-adjusted mortality,
  30-day readmission rates)
• At this point, measuring safety relies largely on
  provider self reports

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How Would You Interpret These Hospital Incident
Report Data?
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And How About These?
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Why Reporting Systems Are Gaining Mojo in Patient
Safety

• Key was to develop a manageable list of topics
  (NQF never events)
• 27 states now w/ mandatory reports, mostly of NQF
  list
• States have become smarter about using reports
• Key is internal change, not outside analysis
• Californias required reporting of NQF events
  (within 1 month) has transformed UCSFs Root
  Cause Analysis process

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So How About Using Money?

• (This is America, after all)

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Three Ways to Use s to Promote Safety and
Quality

• Provide funding to promote system changes that
  may lead to higher quality and safer care
• AHRQ funding for research, implementation
• 19 billion for HIT in stimulus package
• Pay more for better care
• Pay less for worse care

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Paying More for Better Care The Role of P4P
Lindenauer P et al. N Engl J Med 2007356486-96
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Rather Than P4P for Safety, How About Non-P for
Non-P?
Wachter, Foster, Dudley. Jt Comm Journal Quality
Pt Safety, 2008
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10 Conditions for Which CMS Will Now Withhold
Reimbursement

• Hospital-Acquired Infections
• Catheter-associated UTI
• Staph aureus bloodstream infections
• Certain surgical site infections
• After CABG
• After bariatric surgery

• Other Complications of Care
• Pressure ulcers
• Objects left in during surgery
• Air embolism
• Blood-type incompatibility
• Hospital injuries (inc. burns and falls)
• Extremes of glycemia
• Post-op DVTs/PE

Key issues standard definitions, POA,
preventability??
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The Dramatic Arc of the Quality and Safety
Movements

• High profile, iconic cases or compelling
  examples, data create burning platform
• Jumbo jets, 50 error rate, mediagenic error
• Need for change promoted by credible entity
• Variety of levers used social pressure,
  transparency, accreditation, differential pay
• Research, best practices emerge
• Pushback/unexpected consequences inevitable
• Ultimately, change happens and diffuses

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A Familiar Example The Back Story
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Was To Err About Healthcare Associated
Infections?
Excluding Appendices
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Julie Gerberdings thoughts on infection control
and patient safety
Precise and valid definitions of
infection-related adverse events, standardized
methods for detecting and reporting events,
confidentiality protections, appropriate rate
adjustments for institutional and case-mix
differences, evidence-based intervention
programs and skilled professionals to promote
ongoing improvements in care...
Gerberding, Ann Intern Med 2002
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Re-Branding HAIs
Branding a healthcare-associated infection a
preventable adverse event meant that failure to
adhere to the practices that could decrease the
rates of these events could be deemed medical
errors.
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The Next Transformative Event Zero is Possible
Berenholtz, Crit Care Med 2004
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From There, Things Took Off

• CLABSI becomes a NQF Never Event
• Included on no pay list, pressure for public
  reporting of CLABSI rates, NPSG requires treating
  severe HAIs as sentinel events
• IHI promotes bundles to prevent HAIs
• AHRQ, Michigan hospitals, Hopkins researchers try
  an audacious experiment
• Seminal study demonstrates that change is
  possible, measurement is feasible
• Spread not just of study, but overall model

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The Bottom Line Leaders and organizations will
be accountable for Quality and Safety

• No blame is not a moral imperative (even if it
  seems so to providers, it most definitely does
  not to patients). Rather, its a tactic to
  achieve ends for which providers and healthcare
  organizations will be held accountable.

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The Bottom-Bottom Line

• The winners, as Ian says, will be determined on
  the playing field of value quality safety
  divided by cost
• The denominator will be promoted by new payment
  methods that reward efficiency
• The numerator, which was previously assumed, will
  now require real performance
• In this new world, we should all be ready for our
  Golda Meir moments

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Dont be humble. Youre not that great
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Never let it be said that I stood between a
people and their golf