Can protecting patients be made recession-proof? (Patient Safety Congress annual meeting)

As hospitals cut back, doctors and patient safety officers are exploring the business case for quality initiatives.

By Kevin B. O’Reilly — Posted July 20, 2009

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Protecting patients from harm is medicine's bedrock goal, but the resources required to do so have never come cheaply. With the recession taking its toll on the health sector, doctors and other medical professionals who have tackled problems ranging from hospital-acquired infections to patient falls find their efforts increasingly scrutinized on dollars-and-cents grounds.

Ninety percent of hospital CEOs have cut administrative expenses, staff and services amid the recession, according to a survey of more than 1,000 chief executives released in April by the American Hospital Assn. More than three-quarters said they cut capital spending and nearly half scaled back ongoing projects.

The moves come at a time when hospitals already are facing a changing payment landscape. For example, the Centers for Medicare & Medicaid Services and many private payers have cut or stopped paying for "never events," such as wrong-site surgeries.

President Obama has proposed bundling payments for hospitalization and care 30 days postdischarge, penalizing hospitals with high one-month readmission rates. The administration says the move would save $8.4 billion and give hospitals more financial incentive to reduce the 20% 30-day readmission rate among Medicare patients.

Given all that, it was no surprise to hear phrases not frequently uttered in patient-safety circles -- cost-benefit ratio, return on investment, cost effectiveness -- flutter about the 2009 Patient Safety Congress convened in May. The annual event, organized by the Boston-based National Patient Safety Foundation, brought more than 1,200 doctors, nurses, pharmacists, patient-safety officers, risk managers and hospital executives to National Harbor, Md., across the Potomac River from the nation's capital.

"Absolutely, there is increased pressure to make a business case for patient safety," said Gregg S. Meyer, MD, senior vice president for quality and safety at Massachusetts General Hospital/Massachusetts General Physicians Organization.

"We've laid enough of a groundwork that folks recognize that quality and safety aren't something you should look at on the expense side and say, 'Here's a way to close gaps by cutting these programs.' In fact, they may be the key to closing your gap, because I'm a firm believer that if we do many of these things right, the economics will work out.

"The economy, in some ways, ought to focus our lens on putting resources into quality and safety," added Dr. Meyer, who spoke at a conference session on nonpayment for never events. "You just can't afford not to do it."



He noted, as another example, that hospitals already faced "major red ink" of up to $30,000 on each instance of mediastinitis -- a rare, serious, but not always preventable heart-surgery-related chest infection -- before Medicare last year added it to the list of conditions for which the agency will no longer reimburse extra care costs.

Safety math

Many at the conference sought the nitty-gritty on how to bolster their financial arguments for quality and safety initiatives. One breakout session, called "Making the Business Case for Patient Safety," featured intricate equations for quantifying the savings that projects could yield.

At the session, Erik Stalhandske, of the Dept. of Veterans Affairs' National Center for Patient Safety, told the audience to scour the literature for the best evidence on the effectiveness of the proposed safety intervention.

"Take the conservative estimate" on the effect of a project, Stalhandske said. "Retrospectively, you can talk about how effective you were, but prospectively you have to do a little guesswork. ... Give yourself a longer time frame for the intervention to work. Underpromise and overdeliver. You'll be more likely to surprise people with the results you achieve."

Yet, many times savings just do not materialize as money in the bank, said the conference's keynote speaker, New York City Health and Hospitals Corp. CEO Alan D. Aviles.

Aviles cited the public health system's progress on a number of hospital safety metrics that it began publicly reporting voluntarily in 2005.

HHC has 11 acute-care hospitals and 80 community-based clinics. From 2005 to 2008, it cut by 65% its central-line infection rate and reduced the number of ventilator-associated pneumonia cases by 90%. Multiplying the average national cost of such infections by the number of cases reduced yielded an estimated savings of $16.3 million over four years.

After his talk, Aviles told AMNews that determining such savings can be tricky. "The business case can be a pretty complex calculation because it's a combination of fixed costs and variable costs," Aviles said. "If you reduce the number of nosocomial infections in the ICU, you may reduce the patients' length of stay, but that's a fixed cost. You're probably not going to lay off staff based on that. Unless you have patients to admit to those beds and are diverting patients, then you might be able to turn that improvement into big savings. The theoretical calculations make assumptions about essentially being able to put a new patient in every bed as soon as you reduce the length of stay."

Hopes for transparency

Aviles said hospitals need better accounting software to "disaggregate all the costs at a very granular level, particular on variable costs."

It is precisely because the financials of patient safety can be maddeningly equivocal that Aviles pushed HHC to make its performance data public. He predicted that the nation's health system will follow, whether by choice or force.

"At some point we will find ourselves in a situation where a lot of this data will be made public by the federal government," Aviles said. "When that happens, then the effect is going to be felt on the competitive position of hospitals and physicians."

Other experts predicted that Obama's readmissions pay-bundling proposal, if enacted, would spur health systems to invest more in remote-patient monitoring and work more closely with office-based physicians to keep patients out of the hospital.

In the meantime, as often as meeting speakers and attendees grasped for evidence of their work's quantifiable savings, they were just as likely to return to a constant refrain: The business case may be muddy, but preventing patient harm is a righteous endeavor.

"It's wonderful if you get a cost advantage by improving patient safety," said conference attendee Donald J. Palmisano, MD, founder and president of Metairie, La.-based medical risk-management firm Intrepid Resources and a former American Medical Association president. "But, as physicians and other professionals who deliver care to patients and administrators who oversee hospitals, it's our ethical imperative to do the very best for the patient, regardless of whether it costs more."

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Cushioning falls saves money

About 2,500 elderly patients fall in hospitals each year, according to the Centers for Medicare & Medicaid Services. The uncompensated cost to care for those patients can add up fast for hospitals. Investing in simple safety measures can cut those costs. For example, the James H. Quillen VA Medical Center in Mountain Home, Tenn., used a simple benefits-to-cost ratio to determine that for every $1 spent on prevention, the hospital got a return of $4.31.

Here is how they calculated the return per year:

They determined the savings: Five hip fractures avoided in one year x $23,000 average cost of hip repair = $115,000.

They added the cost of safety measures: $24,000 for hip pads + $2,700 for floor cushions = $26,700 a year.

Using the following formula they were able to calculate the benefits-to-cost ratio: Savings / Costs = Ratio: $115,000 / $26,700 = 4.31 benefit-to-cost ratio.

Source: "Making the Business Case for Patient Safety," Erik Stalhandske, Dept. of Veteran Affairs National Center for Patient Safety, as presented at the 2009 NPSF Patient Safety Congress, May

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10 years later, to err is still human

Preeminent patient-safety researcher Lucian Leape, MD, was hesitant to serve on the Institute of Medicine committee that a decade ago produced the landmark report, "To Err is Human: Building a Safer Health System."

"These committees tend to specialize in what I call 'shelf research,' " Dr. Leape said during a panel discussion of the report's 10th anniversary. "You know: You do a good job, the thing gets published, and then it gets put on the shelf."

That is not what happened with "To Err is Human." The report's controversial conclusion cited research estimating that as many as 98,000 Americans died each year due to preventable medical errors. Many physicians disputed the figure, and a July 25, 2001 Journal of the American Medical Association study said the estimate was six times too high (link).

The 98,000 number got days of news media saturation, resulting in a flood of calls that brought down phone systems at the National Academy of Sciences and focused the country's attention on patient safety.

So a decade later, where do things stand?

Measuring progress is difficult, panelists said, because there is no single reliable index tracking how many lives are lost due to preventable medical errors. But the IOM report's overarching message -- that systemic issues contribute to medical errors and can be tackled -- has gotten through, said James B. Conway, former chief operating officer at the Dana-Farber Cancer Institute in Massachusetts and now a senior vice president at the nonprofit Institute for Healthcare Improvement.

"In 1999, we were debating the numbers. We're no longer debating the numbers. Increasingly across the nation we're dealing with the problems," he said. "Our systems are too complex to expect merely extraordinary people to perform perfectly 100% of the time ... and we as leaders have to put in place systems that support safe practice."

Better tracking of patient safety critical

In its report, the IOM said the U.S. should aim to cut in half the number of lives lost to preventable error each year. But a report from Consumers Union, which publishes Consumer Reports, released during the May meeting noted that the Centers for Disease Control and Prevention estimates that hospital-acquired infections alone kill 99,000 Americans annually.

"That means a million lives have been lost over the last 10 years," said panelist James Guest, Consumers Union CEO. "Institution by institution, a lot is happening. Probably most of the institutions represented here in this room pour their hearts and souls into any kind of quality activity and have made improvement, and the report was a catalyst for that. But at the national level -- on policy level -- that is where I think where we've fallen short."

The Patient Safety and Quality Improvement Act of 2005 allows for confidential, voluntary reporting of preventable patient harm such as hospital infections and medical errors. Twenty-six states now require some reporting of hospital infections, according to Consumers Union. But Guest said more is needed. Just as consumers benefit from reports comparing different cars, he said patients would gain from more comprehensive, publicly available hospital report cards.

"We strongly believe there ought to be data publicly reported by institution," he said. "Let's say Consumer Reports tested 50 cars, and some did really well and some were terrible. But what if we said, 'We're not going to tell you which is which?' "

Tracking patient-safety progress is critical to improvement, said Carolyn M. Clancy, MD, director of the Agency for Healthcare Research and Quality. Just as important, she added, is to help give health professionals the practical tools they need to protect patients from harm.

"We can't ever lose sight of the fact that we have to be focused not just on disseminating the bad news, but also saying, 'Here's what you can do to do better right now,' " Dr. Clancy said. "We have a ways to go before improvement becomes a habit rather than just anecdotes."

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Diagnostic errors: Costly, common and avoidable

Diagnosis-related cases are the most common culprit in medical liability claims, accounting for about 40% of lawsuits. They also are the most expensive, with an average payout of more than a $1 million each, according to CRICO/RMF, the medical liability insurer of Harvard Medical School and its affiliated hospitals and clinics.

Yet diagnostic errors get relatively little attention in the hospital-centric patient-safety movement, said Mark L. Graber, MD, chief of medical service at the Northport Veterans Affairs Medical Center in New York.

Diagnostic failure is "a tough problem -- it's complex because so much of it is cognitive," said Dr. Graber. "People just assume it will be hard to solve and it is better to focus on things like falls and medication errors first because they seem to be easier to tackle." And the problem is multifaceted, with system issues such as lost or delayed test results contributing to many misdiagnoses.

Yet more than a quarter of diagnostic errors are due solely to physicians' cognitive mistakes, according to a study Dr. Graber authored in the July 11, 2005, Archives of Internal Medicine (link). Doctors get diagnoses wrong 5% to 10% of the time, according to the best available estimates, he said.

The rates could be even higher, he said, because some misdiagnoses do not result in adverse outcomes and thus go undetected. Dr. Graber said that when making a first stab at a diagnosis, doctors should look for a problem that haunts people in all walks of life -- overconfidence.

"Everyone just cruises along and thinks, 'I'm fine; I don't make mistakes.' It's human nature," Dr. Graber said. "We all overestimate how good we are at making decisions. Everyone thinks they're a better-than-average driver."

These are some strategies Dr. Graber said physicians should employ to reduce the odds of diagnostic mistakes:

  • Minimize system flaws -- poor policies and processes that can result in miscommunications.
  • Strive to be an expert -- stay current on the medical evidence.
  • Generate a complete differential diagnosis -- use a checklist.
  • Learn about automatic "thinking" -- take a "diagnostic timeout" for a moment's reflection.
  • Use evidence-based medicine and diagnosis-support tools.
  • Keep an open mind; be wary; practice reflectively.
  • Set up a plan for feedback from patients to help catch diagnostic mistakes early.

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External links

2009 National Patient Safety Foundation Annual Patient Safety Congress (link)

New York City Health and Hospitals Corp.'s quality and safety performance programs (link)

"To Err is Human -- To Delay is Deadly," Consumers Union, May (link)

"Diagnostic Error in Internal Medicine," abstract, Archives of Internal Medicine, July 11, 2005 (link)

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