Earlier today, Secretary of Health and Human Services Kathleen Sebelius and Medicare chief Don Berwick announced the “Partnership for Patients,” a far-reaching federal initiative designed to take a big bite out of adverse events in American hospitals. The program – which aims to decrease preventable harm in U.S. hospitals by 40 percent and preventable readmissions by 20 percent by 2013 – marks a watershed moment in the patient safety movement. Here’s the scoop, along with a bit of back story (which includes a gratifying bit part for yours truly).
Last July, I attended the American Board of Internal Medicine’s Summer Forum in Vancouver. This confab has turned into medicine’s version of Davos, drawing a who’s who in healthcare policy. One of the attendees was an old friend, Peter Lee, a San Francisco lawyer and healthcare consumer advocate who had just been asked to lead a new Office of Delivery System Reform within the U.S. Department of Health and Human Services. Peter’s charge was to figure out how to transform the delivery of healthcare in America, challenging under any circumstances but Sisyphean given that he’d be pushing the rock up a mountain chock full of landmines comprised of endless legal and political threats to the recently-passed Affordable Care Act.
Fueled by the enthusiasm of being a new guy with a crucial task, Peter took advantage of some conference downtime to convene a small group – about 20 of us – to advise him on what he should focus on in his new role. After soliciting ideas from many of the participants around the table, he turned to me. I decided not to be shy.
I suggested that the topic of patient safety remained compelling and scary, and that it might be at a tipping point – with new success stories in reducing infections and improving surgical safety, more hospitals possessing the infrastructure to improve safety, and increasing penetration of IT systems due to federal support through the meaningful use standards. I also knew that Don Berwick, Peter’s new boss, would not be content to move around some bureaucratic chess pieces, or even a few hundred million dollars. Instead, he’d be looking to do Something Big – an initiative aimed at capturing hearts and minds, a federal version of his IHI 100,000 Lives and 5 Million Lives campaigns. What better target than patient safety?
Peter was avidly jotting down notes, and so I continued. While you’re at it, I said, modernize Medicare’s calcified Conditions of Participation, syncing them with our modern understanding of safety. Ask whether the network of agencies designed to support CMS’s agenda at the local and regional level, the Quality Improvement Organizations (QIOs), was sufficiently nimble and innovative; my fear was that some of the QIOs had settled into a complacency borne of decades of steady federal funding. Make sure you’re using a mix of carrots and sticks to engage providers and systems, build in a strong measurement strategy so we know what we’ve accomplished at the end, and don’t forget to tap into caregivers’ professionalism and to support skill building. Finally, highlight a couple of compelling and challenging areas – perhaps hand hygiene and overhauling the hospital discharge process – as targets for improvement.
Peter thanked me and the group, and I didn’t hear from him again for a while. He called me a couple of months ago, bubbling with excitement. “When you were talking in Vancouver, I was listening,” he said. “We’re going to come out soon with something called the ‘National Patient Safety Initiative,’ but I prefer to think of it as the ‘Bob Wachter Patient Safety Initiative.’” Needless to say, I was both flattered and speechless, and looked forward to seeing what this was about.
The initiative, its name morphed (undoubtedly after a focus group or two) into the Partnership for Patients, is described here, and this morning’s event announcing should be posted here in a little while. Some of the key elements of the program are:
- For the first time, it establishes safety goals and programs as a private/public partnership, with early buy in from large insurers and employers. A broad tableau of leaders from provider organizations, insurers, federal agencies, businesses, and patient groups shared the stage with Sebelius and Berwick at this morning’s announcement to highlight the partnership theme.
- It provides large amounts of funding and technical assistance – nearly one billion dollars – both through the new CMS Innovation Center and elsewhere, to promote new knowledge and skill building.
- Like the 100K Lives Campaign, it seeks commitments from hospital executives and boards to tackle key safety goals.
- It provides support for collaborative networks designed to promote shared learning.
- It rewards hospitals for achieving certain milestones with both recognition and additional resources; those that do very well will be eligible to receive funding to help other hospitals improve.
It’s important to note that while the Partnership highlights a variety of programs – value-based purchasing, readmission incentives, hospital-acquired infections, and others – that, by 2015, will tie up to 9 percent of hospitals’ payments to their performance on certain quality and safety goals, all of these payment changes are in the ACA. As Joe McCannon, Berwick’s special assistant at CMS (and the man who played the David Plouffe role for the IHI campaigns), emphasized in a call with me and several safety leaders yesterday, the Partnership is about skill building; it’s the carrot accompanying the ACA’s collection of sticks. (“We want everyone to succeed,” Joe said on the call.)
With increased skin in the game on performance, the government will soon launch a program of detailed chart reviews (mirroring the strategy used in the Office of Inspector General recent report on patient safety) to identify national trends in preventable harm, and to audit numbers supplied by individual hospitals. Hospitals reporting unusually low rates of harm may be find themselves audited to prove that they are not gaming or fibbing.
What is the point of all this work? The Partnership for Patients has set its aim on a 40 percent reduction in preventable harm and a 20 percent reduction in preventable readmissions. It would be worth reading my last blog – yes, the wonky one on harm vs. preventable harm – to appreciate the subtleties here, including the challenges the administration will have to overcome to accurately identify preventable harm.
But despite these challenges, I see the decision to target preventable harm as an important advance in the government’s thinking about patient safety, measurement, and incentives. Under Medicare’s “no pay for errors” policy, for example, a hospital might have its payments cut for every injurious fall, decubitus ulcer, or deep venous thrombosis after surgery, even if they did everything right and despite the fact that virtually no studies show than more than half of these harms can be prevented, even with perfect care. This is deeply unfair.
By setting the goal as a fraction of “preventable harm” reduced (initially focused on nine conditions, including adverse drug events, healthcare-associated infections, and pressure ulcers), the feds have changed the game. As I understand it, let’s say that the literature tells us that one-in-four serious patient falls can be prevented with perfect care. If the national rate of falls is 5 falls per 1000 hospitalized patients (0.5 percent), the goal would then be to cut the rate to 0.45 percent (a 40 percent reduction of the published preventability fraction of 25 percent, adding up to a reduction by 10 percent). (Sorry, I should have warned you that there’d be math.) This strikes me as a nice balance between ambitious and realistic, and a clear advance from prior policies that assumed total preventability in the absence of evidence that this was achievable. Score one point for fairness; good for them.
The devil will be in the details, but there is a lot to like in this initiative: a national spotlight on the issues of patient safety, an ambitious but achievable improvement goal, an effort to harmonize measures across various stakeholders, a focus on skill building and learning networks, a broad-based partnership, and significant resources both to do the work and to create incentives for improvement. I’m proud to have had a tiny role in its creation.
Let’s hope this isn’t one of Don Berwick’s last acts as head of CMS (the initiative, which has Don’s fingerprints all over it, is yet another reason to lobby for his Senate confirmation as permanent chief). But if it is, his too-brief tenure will still have paid off.
Robert Wachter, MD, is widely regarded as a leading figure in the modern patient safety movement. Together with Dr. Lee Goldman, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine. His most recent book, “Understanding Patient Safety,” (McGraw-Hill, 2008) examines the factors that have contributed to what is often described as “an epidemic” facing American hospitals. His posts appear semi-regularly on THCB and on his own blog, Wachter’s World.