Patient Safety is Not Enough

1
Patient Safety is Not Enough

• Steven H. Woolf, MD, MPH
• Department of Family Practice, Preventive
  Medicine and Community Health
• Virginia Commonwealth University

2
Centrality of Patient Safety

• Elemental to the Hippocratic oath
• In 1999 To Err is Human claimed that
  44,000-98,000 Americans die each year from
  medical errors
• Galvanized patient safety programs, research, and
  coalitions

3
The Potential Downside to the Focus on Patient
Safety

• Patient safety at the expense of what else?
• Suppose failure to provide preventive care claims
  100 times as many lives as lapses in patient
  safety
• Resourcestime, human energy, and moneyfor
  making healthcare better are not unlimited
• Importance of proportionality

4
Clues to Opportunity Costs

• AHRQ budget (FY 2004)
• 60 for patient safety
• 15 cut in non-patient safety grants
• American Medical News
• patient safety or medical errors 8867 hits
• uninsured and racial disparities 567 hits
• Capitol Hill
• 20 bills on patient safety

5
Notion of Proportionality

• Unless attention and resources are allocated to
  safety and to other areas of quality improvement
  in proportion to their relative impact on the
  health of patients, an excess of patients may die
  or suffer morbidity
• For every patient harmed by lapses in patient
  safety, more will suffer or die from deficient
  health care services and flawed delivery systems,
  problems that a perfect safety record will not
  take away

6
Which Matters More?

• Overdose of warfarin
• versus
• Receiving no warfarin or suboptimal long-term
  anticoagulation

• Providers
• Practices
• Hospitals
• Health systems
• Patient safety committees, task forces, and
  commissions

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The Definition of Patient Safety

• The metastasis of patient safety as an umbrella
  term
• Freedom from injury (IOM, 1999)
• additive risk
• vs.
• failing to reduce an extant risk

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Failing to Reduce Extant Risks

• Inadequate use of ß-blockers after myocardial
  infarction ? 4,300-17,000 deaths per year
• Deficiencies in other cardiac regimens
• Deficiencies in care of cancer, stroke, diabetes,
  asthma, etc.
• Gaps in preventive care ? 700,000 deaths per year
• Tobacco use alone 400,000 deaths per year

11
Getting the Balance Wrong Can Cost Lives

• Example Computerized drug order entry in the
  face of inadequate control of hypertension and
  hyperlipidemia
• The false dichotomy
• Reminder systems
• Improved work conditions

12
Taking the Systems Orientation to Heart

• Compared to system solutions to improve safety
  and reduce medical errors, system solutions to
  close the breach between what is and what should
  be done in health care are different, larger in
  scale, more challenging, more likely to save
  lives and improve health, and thus more urgent

13
Crossing the Quality Chasm

• Aims for system improvement
• Safe
• Effective
• Patient-centered
• Timely
• Efficient
• Equitable

14
Bold System Changes Needed for

• Lack of access to care
• Delayed access to diagnoses, treatment, and
  information
• Hasty encounters
• Poor access to offsite medical records or to
  colleagues treating the same patient
• Absence of decision aids, reminders,
  evidence-based guidelines

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The power of information technology
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Bold System Changes Needed for

• Information, motivation, reminders, and
  logistical aid for implementation barriers
• Supplying aid precisely when and where it is
  needed
• Infrastructure within systems with the right
  design, information connectivity, and integrated
  resources to optimize communication, timing,
  quality, and comprehensiveness of care

17
Years of potential life lost before age 75 (per
100,000 population)
Source Health, United States, 2002
18
Adults under age 65 without health care coverage
(millions)
Source Health, United States, 2002
19
Delays in getting appointments

• Percentage of people waiting more than 7 days
• 1997 22
• 2001 28

Source Center for Studying Health System Change
20
Pneumococcal vaccination of adults age 65 and
older
Source Health, United States, 2002
21
Whole-body scanning
22
Women Over 40 Having Had Mammogram in Past 2
Years ()
Source Health, United States, 2002.
23
A Neglected Crisis

• In its absence one finds patients and providers
  in struggle with the system care disrupted and
  fragmented by inefficiency, confusion, and delay
  and physicians frustrated by impediments to their
  efforts to give patients time, attention,
  empathy, and information.

24
Caring The Domain Not Measured By Quality
Indicators
25
2001 Medical Expenditure Panel Survey (AHRQ)

• 45 of adults said their health provider did not
  always listen to them carefully
• 44 said providers did not always explain things
  in a way they could understand
• 42 said providers did not always show respect
  for what they had to say
• 60 said providers usually did not spend enough
  time with them

Source http//www/meps.ahrq.gov/papers/st14/stat1
4.htm
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Kaiser Family Foundation Survey (1999)

• Only 15 of respondents said they could trust
  providers to do what is best for patients almost
  all the of the time
• 47 said the health care system treats people
  unfairly based on race or ethnic background

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Problems Reported By Primary Care Patients in
Virginia and Ohio
Source Kuzel et al.
28
Trying to Get Through

• So, I'm still getting the voice mail at 1030
  that says the office hours are 9 to 5. Please
  call back during work hours So I called again
  around 1130 and I got a busy signal. Then the
  line was busy for like an hour straight 'cause I
  kept hitting repeat dialing. So, then I finally
  got through at 100 in the afternoon, and I was
  put on hold for like 45 minutes...And I didn't
  want to hang up because it had been such a
  difficult time getting through so I'm just steady
  holding the phone.
• 36 year-old White female pharmacist technician,
  suburban Virginia

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Checking In

• You go to the window, you knock on the window
  and you stand there and you wait and there's
  someone sitting at the window. You knock again,
  no answer. When you finally do get an answer from
  this person that's sitting there at the window,
  they've got attitude. They don't use a
  professional manner...talking down to you like
  you're a nobody. Like you're taking up their
  time. Like you're not a paying customer. Like
  you're disturbing them.
  53 year-old African American
  disabled male, urban Ohio

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Waiting to Be Seen

• I sat in the waiting room, and ah, 45 minutes
  later I hadnt been called back, so I went up and
  asked what the problem was, you know, did you
  forget Im out here? And they said, no, no, we
  will be with you as soon as we can, the doctors
  just busy today so finally the nurse comes out
  and calls my name. I go back in the room, I get
  all undressed, get on a gown, and Im sitting up
  here on the table, and an hour goes by, and a
  doctor hasnt come in yet. So, at that point, I
  get up, I put my clothes back on, and I walk
  out.When I first started going there they had a
  little sign hanging up in the, in the waiting
  room that says if we have not called you in 15
  minutes please come to the desk, and you know,
  question it. The signs gone now.
• White female medical receptionist, suburban
  Virginia

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The Visit

• When I goWhen I go thereI mean its this quick
  boom, boom, boom. You know, theyve got so many
  people. Theyre running you in, theyre running
  you out. And, you know, so youve got to try to
  remember everything you need to say before your
  time is up.
• 39 year-old White female nurse, rural Virginia
• need to talk to you about the medicines you are g

32
The Visit

• I was trying to tell him that I didn't think
  that was it. I mean, I'm not a doctor or
  anything, but you kinda know what's going with
  your body...If he had just listened more to what
  I had to say.
• 24 year old African American male computer
  worker, urban Ohio

33
Disparities in Caring

• I feel like, when you go in for an appointment,
  I dont feel that who I am should have anything
  to do with me being seen by a doctor, but I have
  seen people come in that are white, and they go
  right in to their doctor, and I've seen the,
  lobby, be sittin there, and there be a whole
  bunch of black people sittin there, and they
  just be sittin there longer, and longer, and
  longer.
• 41 year-old African American female clerical
  worker, rural Virginia

34
Harms Reported by Patients
Source Kuzel et al.
35
Saving Lives By Abandoning Parochialism

• Taking a global perspective
• Identifying the most important root causes

36
Misplaced Priorities
Preventable deaths/yr
Source JAMA 19992822358-65
37
Making Healthcare Safer But Still Ineffective

• A system that does not remind physicians that a
  patient with atrial fibrillation needs warfarin,
  but its computers ensure that a safe dose is
  prescribed.

38
Impediments to a Systems Approach

• The attractions of parochialism interest in
  particular diseases or aspects of care, financial
  or political considerations, cultural factors
• Not considering the linkage between priorities
  and outcomes
• Being satisfied doing a good thing, without it
  being the best thing
• To not execute an approach that optimizes
  outcomes is an affirmative choice to put patients
  at higher risk

39
Patient Safety is Not Enough

• Safety is the center of the four circles but it
  is an uninspiring goal for healthcare
• Patients deserve far more than to not be harmed
  by their physicians
• It should not distract from the central mission
  of helping patients maintain their health and
  cope with illness
• The larger mission is caring.