According to Gallup surveys, four of five Americans believe the quality of care they receive is good or excellent, and the majority think it is the best available in the world. Surveys by Roper, Harris Interactive, Kaiser Family Foundation, Harvard’s Chan School of Public Health, and others show similar findings. And the public’s view hasn’t changed in two decades despite an avalanche of report cards about its performance, a testy national debate about health reform and persistent media attention to its shortcomings and errors. But is the public’s confidence in the quality of the care we provide based on an informed view or something else? It’s an important distinction.
Two considerations are useful for context:
Measuring quality of care objectively in the U.S. system is a relatively new focus. And we’re learning we’re not as good as they think we are. Historically, the public’s view about “quality of care” has been anchored in two strong beliefs: 1-the U.S. system has the latest technologies and drugs, the world’s best trained clinicians and most modern facilities, so it must be the best and 2-the care “I receive” from my physicians and caregivers is excellent because they’re all well-trained and smart.
The History of the Problem
The European University (e.g. Italy, Germany, France, England) descended from the Church. The academic hierarchy, reflected in the regalia, has its roots in organized religion.
The American University was a phenocopy of the European University, but the liberal arts college was a unique American contribution, wherein teaching was considered a legitimate academic pursuit. Even the closest analogues in Europe (the colleges of Cambridge and Oxford) are not as purely an educational institution as the American liberal arts college.
The evolution of American medical education (adapted and updated from: Ludmerer KM. Time to Heal, Oxford University Press, Oxford, 1999) may be divided into five eras.
I. The pre-Flexnerian era (1776- 1910) was entirely proprietary in nature. Virtually anyone with the resources could start a medical school. There was no academic affiliations of medical school and no national standards.
II. The inter-war period (1910-1945) was characterized by an uneasy alliance between hospitals and universities. Four major models emerged. In the Johns Hopkins model, led by William Osler, the medical school and the hospital were married and teaching of medicine took place at the bedside. The Harvard model in which the hospitals grew up independently with only a loose alliance with the medical school, represented a hybrid between pre- and post-Flexnerian medical education.Continue reading…
This year marks the 15th anniversary of the Institute of Medicine (IOM)’s To Err is Human report, which famously declared that from 44,000 to 98,000 Americans died each year from preventable mistakes in hospitals and another one million were injured. That blunt conclusion from a prestigious medical organization shocked the public and marked the arrival of patient safety as a durable and important public policy issue.
Alas, when it comes to providing the exact date of this medical mistakes milestone, the IOM itself is confused and, in a painful piece of irony, sometimes just plain wrong. That’s unfortunate, because the date of the report’s release is an important part of the story of its continued influence.
There’s no question among those of us who’d long been involved in patient safety that the report’s immediate and powerful impact took health policy insiders by surprise.
The data the IOM relied upon, after all, came from studies that appeared years before and then vanished into the background noise of the Hundred Year War over universal health insurance. This time, however, old evidence was carefully rebottled in bright, compelling new soundbites.Continue reading…
Adverse events – when bad things happen to patients because of what we as medical professionals do – are a leading cause of suffering and death in the U.S. and globally. Indeed, as I have written before, patient safety is a major issue in American healthcare, and one that has gotten far too little attention. Tens of thousands of Americans die needlessly because of preventable infections, medication errors, surgical mishaps, and so forth. As I wrote previously, according to Office of Inspector General (OIG), when an older American walks into a hospital, he or she has about a 1 in 4 chance of suffering some sort of injury during their stay. Many of these are debilitating, life-threatening, or even fatal. Things are not much better for younger Americans.
Given the magnitude of the problem, many of us have decried the surprising lack of attention and focus on this issue from policymakers. Well, things are changing – and while some of that change is good, some of it worries me. Congress, as part of the Affordable Care Act, required Centers for Medicare and Medicaid Services (CMS) to penalize hospitals that had high rates of “HACs” – Hospital Acquired Conditions. CMS has done the best it can, putting together a combination of infections (as identified through clinical surveillance and reported to the CDC) and other complications (as identified through the Patient Safety Indicators, or PSIs). PSIs are useful – they use algorithms to identify complications coded in the billing data that hospitals send to CMS. However, there are three potential problems with PSIs: hospitals vary in how hard they look for complications, they vary in how diligently they code complications, and finally, although PSIs are risk-adjusted, their risk-adjustment is not very good — and sicker patients generally have more complications.
So, HACs are imperfect – but the bottom line is, every metric is imperfect. Are HACs particularly imperfect? Are the problems with HACs worse than with other measures? I think we have some reason to be concerned.
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.
Here’s a quiz for Patient Safety Awareness Week (and after): The number of Americans who die annually from preventable medical errors is:
A) 44,000-98,000, according to the Institute of Medicine
B) None, thanks to the Institute for Healthcare Improvement’s “100,000 Lives Campaign”
D) No one’s really counting
The correct answer is, “D,” but I confess it’s a trick question. With a slight twist in wording, the right answer could also be “C,” from an as-yet-unpublished new estimate with a unique methodology. (More below.) The main point of this quiz, however, is to explore what we actually know about the toll taken by medical mistakes and to dispel some of the confusion about the magnitude of harm.
Answer “A” refers to a figure in the oft-quoted (and often incorrectly quoted) 1999 IOM report, To Err is Human. The IOM estimate of 44,000-98,000 deaths and more than 1 million injuries each year refers only to preventable errors, and then just in hospitals. The quiz asked about all preventable harm. As the sophistication and intensity of outpatient care has increased, so, too, have the potential dangers.
For example, the Centers for Disease Control and Prevention (CDC) reported in 2011 that the majority of central-line associated bloodstream infections (CLABSIs) “are now occurring outside of ICUs, many outside of hospitals altogether, especially in outpatient dialysis clinics.” CLABSIs are both highly expensive and kill up to 25 percent of those who get them. Even in garden-variety primary care, one analysis found a harm rate of one per 35 consultations, with medication errors the most common problem. To Err is Human was silent about those types of hazards.