Dan Stultz, M'D',

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Texas Association of Health Plans
ConferenceWednesday, October 22, 2008

• Dan Stultz, M.D.,
• FACP, FACHE

Penny Hobbs
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To Err is Human Continuing to Err is
NotIndustry Impact and Super Human Response
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INTRODUCTION

• It has been almost a decade since the Institute
  of Medicine released its report, To Err is Human
  Building a Safer Health System, which exposed
  the shocking number of medical errors that occur
  in patient care situations. The report captured
  the attention of the media, the public and health
  care policy makers and called for immediate
  action.

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OUTLINE OF PRESENTATION

• Brief overview of IOM report
• Scope of Responses
• Burden of Reporting
• The Incentives for Physicians and Hospitals
• Fallacies in the System
• What it would take to fix it
• Wrap up and questions

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IOM REPORT

• Adverse events in 2.9 and 3.7 of
  hospitalizations led to death in 6.6 and 13.6
  of those
• Extrapolates out to 44,000 and 98,000 deaths a
  year from medical errors
• Hospital patients are only a small fraction of
  the total population at risk

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IOM REPORT

• Four recommendations
• national focus to create leadership, research,
  tools and protocols to enhance knowledge base
  about safety
• a nationwide mandatory reporting system about
  adverse events collected by states
• Encourage development of voluntary reporting
• extend peer review protections to patient
  safety and quality improvements data

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SCOPE OF RESPONSES

• Federal
• Bipartisan Congressional action
• Center for Patient Safety within AHRQ
• Patient Safety and Quality Improvement Act of
  2005 extends peer review protections
• CMS revised Condition of Participation for
  hospitals to include Quality Improvement Program
• CMS decision not to pay for certain never events
  serious and costly errors that should never
  happen

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SCOPE OF RESPONSES

• State
• Legislation or regulation mandating reporting of
  adverse events by 2005 over half the states had
  legislation
• Legislation denying payment for never events in
  Medicaid programs

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SCOPE OF RESPONSES

• Private Sector
• Quality Organizations
• Joint Commission
• Institute for Healthcare Improvement
• Institute for Safe Medication Practices
• American Health Quality Association
• URAC
• National Center for Healthcare Leadership
• National Coalition for Health Care
• National Committee for Quality Assurance
• National Quality Forum
• Employers and Consumers
• Foundations for Research

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SCOPE OF RESPONSES

• The Leapfrog Group
• Established in 1999
• Coalition of large self-insured employers
• Leverage purchasing power to drive improvements
  in healthcare quality
• Hospital Quality Safety Survey
• Computer physician order entry
• Evidence based hospital referrals
• ICU physician staffing and responsiveness
• Leapfrog Safe Practices Score

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So, how are we doing 10 years later?

• Hard to tell
• There has not been a follow-up report
• No decline in interest plenty of reports
• No definitive studies or reports
• Mixed results
• Definitely did not decrease by 50
• But definitely some decline/improvement

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SAMPLING OF RESULTS

• IHI 100,000 Lives Campaign
• Thompson Healthcare Report on Improvement in
  Hospital Inpatient Survival Rates
• Thompson Healthcare report on trends inpatient
  safety outcomes
• Indiana Hospitals 2008 Report
• Joint Commission 2008 Annual Report
• HealthGrades 5th Annual Patient Safety in
  American Hospitals Study

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THE RESPONSE FROM PROVIDERS
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Measurement Development
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Proliferation of Reporting Initiatives
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Impact on Reimbursement

• Minnesota HealthPartners policy to withhold
  payment to hospitals for NQF never events
  (January 2005)
• Leapfrog Group Position Statement on Never Events
  (November 2006)
• Medicare rules reduce DRG reimbursement for 10
  hospital-acquired conditions
• Major health plans announce plans to cut payments
  for avoidable mistakes using the NQF never
  events

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Providers Response

• AHA develops principles for partial or nonpayment
  for serious adverse events late 2007
• THA Board adopts principles and asks hospitals to
  develop internal policies (May 2008)

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THA Principles

• The error or event must be preventable.
• The error or event must be within the control of
  the hospital.
• The error or event must be the result of a
  mistake made in the hospital.
• The error or event must result in significant
  harm.
• The error or event must be clearly and precisely
  defined in advance.

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 Some Examples of Events that May Meet Principles

• Surgery performed on wrong body part.
• Surgery performed on the wrong patient.
• The wrong surgical procedure performed on a
  patient.
• Patient death or serious disability associated
  with intravascular air embolism that occurs while
  being cared for in a facility.
• An infant discharged to the wrong person.
• Artificial insemination with the wrong donor
  sperm or donor egg.

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Working with Health Plans

• Hospitals should identify and manage the events
  according to principles
• Many of the NQF events would not meet the
  principles
• Rescuing hospitals and physicians must be
  reimbursed
• Development of a uniform policy and operational
  guidelines would be helpful for hospitals and
  health plans

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The Incentives for Physicians and Hospitals
What Drives Behavior

• Positive Incentives
• Current reimbursement system rewards volume and
  intensity not preventive care or proactive
  disease management
• Negative Incentives
• Negative reinforcement is the poorest method to
  effect behavior change
• Mixed Incentives
• Physicians reimbursed on level of service
• Hospitals reimbursed on flat rate or per diem

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Fallacies In the System Unintended Consequences

• Smoking incentives
• Obesity training
• Qualitative payment never events
• Failure to consider societal benefits of
  improving health
• Incentives not to see sick people

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What It Would Take to Fix It

• Align incentives - reward physicians and
  hospitals with real money for better outcomes
• Financial penalties for serious adverse events
  financial rewards for miracles
• Financial rewards for healthy behaviors
• Reward advance directives and living wills
• Streamline administrative and reporting
  requirements
• Align quality measures based on nationally
  recognized and accepted criteria, evidence-based,
  attainable and relevant

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Invest in Quality!
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QUESTIONS ANSWERS