March 2nd through the 8th were National Patient Safety Awareness Week – I don’t really know what that means either. We seem to have a lot of these kinds of days and weeks – my daughters pointed out that March 4 was National Pancake Day – with resultant implications for our family meals.
But back to patient safety and National Patient Safety Awareness Week. In recognition, I thought it would be useful to talk about one organization that is doing so much to raise our awareness of the issues of patient safety. Which organization is this? Who seems to be leading the charge, reminding us of the urgent, unfinished agenda around patient safety?
It’s an unlikely one: The Office of the Inspector General of the Department of Health and Human Services. Yes, the OIG. This oversight agency strikes fear into the hearts of bureaucrats: OIG usually goes after improper behavior of federal employees, investigates fraud, and makes sure your tax dollars are being used for the purposes Congress intended.
In 2006, Congress asked the OIG to examine how often “never events” occur and whether the Centers for Medicare and Medicaid Services (CMS) adequately denies payments for them. The OIG took this Congressional request to heart and has, at least in my mind, used it for far greater good: to begin to look at issues of patient safety far more broadly.
Taken from one lens, the OIG’s approach makes sense: the federal government spends hundreds of billions of dollars on healthcare for older and disabled Americans and Congress obviously never intended those dollars pay for harmful care. So, the OIG thinks patient safety is part of its role in oversight, and thank goodness it does.
Because in a world where patient safety gets a lot of discussion but much less action, the OIG keeps the issue on the front burner, reminding us of the human toll of inaction.
Earlier this month, the National Quality Forum released its revised list of “Serious Reportable Events in Healthcare, 2011,” with four new events added to the list. While the NQF no longer refers to this list as “Never Events,” it doesn’t really matter, since everyone else does. And this shorthand has helped make this list, which will soon mark its tenth anniversary, a dominant force in the patient safety field.
The NQF was founded in 1999 at the recommendation of Al Gore’s Presidential Advisory Commission on healthcare quality. For its founding chair, the organization selected Ken Kizer, a no-nonsense, seasoned physician-administrator who had just done a spectacular job of transforming the VA system from the subject of scathing articles and movies into a model of high-quality healthcare, a veritable star in patient safety galaxy.
Kizer’s original charge at NQF was to develop a Good Housekeeping seal-equivalent for quality measures (“NQF-endorsed measures”). But soon after he arrived, Kizer added another item to the NQF’s wish list: the creation of a list of medical errors and harm that might ultimately be the subject of a nationwide state-based reporting system. As Kizer said at the time,
This is intended to be a list of things that just should not happen in health care today. For example, operating on the wrong body part [or] a mother dying during childbirth. That’s such a rare event today that it’s generally viewed as something that just shouldn’t happen. Now, there’s probably going to be an occasion now and then when it happens and everything was done right, but it’s so infrequent that it means you have to investigate it every time it occurs. So “never” has quotes around it in this case. Now, wrong-site surgery is a different story—that should never happen. There’s no way that you should take off the right leg when you’re supposed to do the left one. So in this case, never really means never.
Unsurprisingly, the items on the list quickly became known as “Never Events.” Twenty-seven of them were announced in 2002, and the list was expanded and revised four years later. (This primer, written by my colleague Sumant Ranji for our patient safety website, AHRQ Patient Safety Network, is the best description of the list and some of its policy implications.)Continue reading…