The “Business Case” For Patient Safety

Betsy Lehman

Twenty years ago this month, the Boston Globe disclosed that health columnist Betsy Lehman, a 39-year-old mother of two, had been killed by a drug overdose during treatment for breast cancer at Dana-Farber Cancer Center. In laying out a grim trail of preventable mistakes at a renowned institution, the Globe prompted local soul searching and a new focus on patient safety nationally.

Although I didn’t know Betsy personally, we were about the same age, had two kids about the same ages and were in the same profession. (I, too, was a health care journalist.) That’s why I was particularly disappointed by a recent conference celebrating the reopening of the Betsy Lehman Center for Patient Safety and Medical Error Reduction. It was heavy on statistics and poll results; e.g., one in four Massachusetts adults say they’ve seen an error in their own care or the care of someone close to them.

While it’s true that Boston is the epicenter of thinking, writing and speaking about patient safety, words do not always translate into deeds.

What the meeting lacked was urgency, the kind of poking and prodding of established interests that journalists are good at. In that spirit, let me suggest two demands the Lehman Center should make on behalf of patients. First, every hospital should publicly release timely, comparable and usable safety information. Second, every hospital should publicly commit to a “no preventable errors” goal and a strategy to reach it.

These two actions would save lives ­– locally, and also elsewhere as the prestigious local medical community sets a national example for others to follow.

Preventable hospital errors kill as many as 400,000 people annually. Harvard’s Dr. Lucian Leape famously contrasted the secrecy of hospital errors’ with the public nature of plane crashes. Unfortunately, accessible, consumer-friendly information about safety at individual hospitals is still elusive. Dana-Farber’s website, for example, discusses its commitment to safety — which has been extraordinary — but the hospital nonetheless prefers to tell rather than show.

The list of quality measures uses technical language, provides no benchmarks and mostly has information dating back to 2013. (The federal HospitalCompare site similarly has long delays in posting data and isn’t easy to use, and state data isn’t much better.) Some other local hospitals are more forthcoming, but many resemble old-time burlesque dancers, seemingly revealing all while actually showing not much of interest.

There’s a better model. Louisville-based Norton Healthcare discloses a long list of safety and quality indicators and uses color-coding to show how those numbers relate to a desired goal. There are state and national comparisons and clear rules. Among them: “We do not decide what to make public based on how it makes us look,” and “We give equal prominence to good and bad results.” Norton has been doing this for 10 years.

The state-run Lehman Center should challenge Massachusetts hospitals to meet that candid standard by this time next year. Hospitals should also post information when they know it’s valid, rather than waiting for the feds. Every patient should be able to get the kind of information Betsy Lehman might have put in her column.

Transparency works best when it fuels accountability. Although “first, do no harm” is a professional ideal, few hospitals have adopted “zero preventable harm” as an explicit goal. Most settle for voluntary industry efforts with carefully calibrated harm reductions and multi-year timetables.

Why this is so is unclear, but one barrier is concern over the “business case” for patient safety; i.e. does improving safety help the bottom line. Though the public rarely sees this discussion, one recent medical journal article presented the return on investment (ROI) from preventing bloodstream infections in kids with cancer! The article emphasized the “low cost of implementation” and “high value” of “prevention efforts in this population.”

Doctors don’t promise to “first, do no unprofitable harm.” The Lehman Center should challenge every hospital to make zero preventable harm an explicit goal and have a plan in place to achieve it.

Every patient should be able to get the kind of information Betsy Lehman might have put in her column.

The two life-saving actions I’ve proposed require nothing more than a sustained commitment to ensuring that every patient receives care as safe as you’d want for your father or your child. I still remember the haunting letter Betsy Lehman’s mother sent to a patient safety conference some 15 years ago. Mildred Lehman wrote:

May I appeal to you to pause for a moment, if you will, in your important task. For in the wings outside your busy meeting rooms may be heard the murmurings of patients gone now due to fatal medical error, or harmed by a medical system they trusted. They are the ones absent…Among them is my young, brilliant daughter.

Patient safety must be utmost and constant, both ingrained into the system you seek to strengthen, and into caring hearts.

Surely, full transparency and working towards zero preventable harm are where caring hearts seeking true system change must start.

Michael Millenson is an author, journalist and a principal at Health Quality Advisors. 

16 replies »

  1. Eye opening stuff, thanks for the great article. With the new estimates of over 400,000 deaths per year due to medical errors it should be harder and harder to ignore this issue. Assuming this estimate is accurate, medical errors are the third leading cause of death in the US for goodness sakes. Even if you go by the original IOM estimates of 44,000-98,000 deaths per year that would be equivalent to a large jet plane crashing and killing 150 people every day. Would that not make the daily news? Healthcare providers have got to have the time to empower and engage their patients and we have to find a better way to prevent health problems in the first place.

  2. Thanks, Alan. I’m sorry if I misunderstood .

    IOM circa 1999 on studies from the 1980s. Studies since then, particularly by AHRQ, leave us with about 100,000 preventable deaths from medical error each year (not the 44,000 to 98,000 of the IOM, nor the up-to-410,000 in other analyses). Much work to be done. Appreciate the comment.

  3. ““Avoidable” death means “preventable;” the notion that these patients would have died soon, anyway is mistaken, by the way.”

    I made a true comment at least based upon the first studies the IOM used. I gave examples of those types of deaths that were avoidable and actually occur just for informational sake. Afterwards to make sure one understood that I wasn’t negative towards the idea of making things better I wrote “Take note I am not excusing avoidable deaths rather stating that we have to target our resources carefully.” End of life has a lot of these scenarios.

  4. Some responses:

    “Avoidable” death means “preventable;” the notion that these patients would have died soon, anyway is mistaken, by the way.

    “Business case for patient safety” is not used by the health care industry in the compassionate way that Paul O’Neill did. In 1998, I was approached by the Pittsburgh Regional Healthcare Initiative because of my book to work with them on safety. Together, we chose zero preventable ADEs and infections (and not all ADE or infections are) well before even the CDC was talking like that. Paul at Alcoa chose safety as a way to remake the culture; he did not analyze the productivity gains/losses of safety. By way of contrast, hospitals (typically thought more compassionate than steel mills) are looking at the ROI of not hurting sick people.

    Proofreading suggestions: Thanks. Error wasn’t in the original, I’ll get it corrected.

    Finally, while it would be nice to think that patient safety is so pervasive a concern that it has created a whole new set of problems, as one commenter suggests, I’ve seen no evidence of that at all. It’s the same old problem, as I said in a Health Affairs blog post over 4 years ago: invisibility, inertia and income.

  5. I’ll repeat here what I said on the original Cognoscenti/WBUR post:

    “Every time I hear the phrase ‘the business case for [something foundational in healthcare]’ I have the urge to grab my 5 iron and tee up on something with it. As the occupants of the ivory towers – the healthcare system administrators – fiddle around with business case questions, people are dying. On their watch. While they try to figure out how to make money off of human pain and suffering.

    Patient engagement, patient safety, patient-centered care – all of these will remain unicorns as long as the first thought of those running the show is figuring out the business case for them. Secrecy is the enemy of trust. If healthcare really wants to transform itself, it’ll embrace transparency, and invite people/patients in to help accelerate that transformation. However, since it’s clear that they’re most interested in preserving revenue streams – in the US, particularly – I hold out little hope that the Tower People will actually work to effect change.

    We’re gon’ have to storm the barricades, and start a little revolution.”

  6. “hundreds of thousands of avoidable deaths”

    Joe, avoidable deaths are not necessarily deaths that we can prevent or may want to prevent.

    Example: a person dying of metastatic lung cancer in severe pain whose certain death is a mere week or so away. He is given morphine and then more morphine all with the desire to permit the patient to die without the suffering pain. If he dies from respiratory arrest that is considered an avoidable death and there are loads of those. Another example, post operatively a patient is moved from the post op care unit or ICU to the floor after remaining the set standard number of days which are deemed safe. On the floor the patient dies due to a post surgical problem that might have been detected in the more equipped post surgical or ICU. This is a rare occasion. That is an avoidable death, but does that mean that we should add several more days to the ICU for all patients? The cost would be huge.

    Take note I am not excusing avoidable deaths rather stating that we have to target our resources carefully.

  7. “What is the business case for not killing people?”

    Since medical care is now run as a business by business men, that will be the constant question from here on out. Appalling.

  8. The sentences “While it’s true…” and “Every patient…” appear twice each.

  9. It is maddening, Michael. What should we call the situation in which there are millions of medical mistakes every year, hundreds of thousands of avoidable deaths, a deep literature and well of experience on how to prevent such mistakes — and healthcare organizations fail to get serious about it, fail to set an explicit goal of zero preventable harm, not years in the future but right now, because they don’t see a “business case” for it?

    What is the business case for not killing people? To ask the question is to realize instantly the moral idiocy of it.

  10. the problem is that patient safety has been turned into a product and a slogan, which created an entirely new set of problems similar to those facing other cause-based organizations