Copyright 2014 American Medical Association. All rights reserved.

Medical News &Perspectives

Patient Safety Still Lagging
Advocates Call for National Patient Safety Monitoring Board
Bridget M. Kuehn, MSJ
H
ospitals and ambulatory care cen-
ters remain risky places for US pa-
tients despite more than a decade
of national efforts toimprovepatient safety,
according to testimony at a US Senate sub-
committeehearing, webcast onJuly17, 2014
(http://1.usa.gov/UaVr7g).
This soberingassessment comes at the
15-year anniversary of thereleaseof a semi-
nal report from the Institute of Medicine
(IOM) on patient safety (To Err Is Human:
Building a Safer Health System. Washing-
ton, DC: Institute of Medicine; 1999).
The report estimated that 98 000pa-
tients died each year as a result of medical
errors. Ashish Jha, MD, MPH, a professor
of healthpolicyandmanagement at theHar-
vard School of Public Health, testified
that evidence suggests that the IOM likely
underestimated patient harm. A more re-
cent estimate suggests the number of US
deaths as a result of medical error may top
400 000 per year, more than 1000 each
day (James JT. J Patient Saf. 2013;9[3]:122-
128).
If I walk into a hospital today, would I
besafer than15yearsago? saidJha. Thean-
swer is no.
There have been some advances. One
area where substantial progress has been
made is in reducing central lineassociated
bloodstream infections, an effort led by
Peter Pronovost, MD, PhD, senior vicepresi-
dent for patient safety and quality at Johns
Hopkins MedicineinBaltimore. Provost cre-
ated a program to reduce central line
associatedinfectionsbyempoweringnurses
to use checklists to ensure precautions are
taken. Thechecklist helpedMichiganinten-
sive care units reduce central lineassoci-
atedbloodstreaminfections by66%andal-
lowed 65% of the participating units to
eliminatetheseinfections(KuehnBM. JAMA.
2012;308[16]:1617-1618).
The program, which has been ex-
pandednationwide, is successful becauseit
counters theconventional wisdomthat cen-
tral line infections are inevitable with ro-
bust, transparent data, said Pronovost.
In testimony at the hearing, Pronovost
said that one of the biggest barriers to im-
proved patient safety is the lack of a robust
national system for tracking patient safety
data. He said the US Centers for Disease
Control and Prevention (CDC) has a good
systemfor trackinghealthcareacquiredin-
fections. That system, heargued, shouldbe
expanded to track other types of patient
harm.
The consumer advocacy organization
Consumers Union supports more CDC data
monitoring and greater data transparency,
testifiedLisaMcGiffert, director of Consum-
ersUnionsSafePatient Project. Shesaidthat
31 states and the District of Columbia re-
quire public reporting of health care
associated infections. In addition, a na-
tional patient safety monitoring board
should be created to provide regulatory
oversight of patient safetyinthemedical sys-
tem, she said.
Greater sanctions are also needed
against facilities that are failing to improve
safety, Pronovost said. He noted that sev-
eral hundred US hospitals have infection
rates 10 times higher than the national av-
erage, yet they do not face sanctions from
Medicare or any other regulatory body.
Better systems of carearealsoneeded,
several of the speakers testified. Joanne
Disch, PhD, RN, past president of theAmeri-
can Academy of Nursing, explained that a
host of factorssuch as the complexity of
hospital systems, time pressures, growing
use of technology, and financial incentives
that rewardhospitals bypayingthemtocare
for patients complicationsall contributeto
poor patient outcomes.
Hospital culturesthat discouragenurses
fromspeakingupwhenthey identify safety
issues or that fail togivenurses a sayinbed-
side staffing levels also increase the likeli-
hoodof patient harm. Nurses areoftenthe
last line of defense, Disch explained. She
Medical News &Perspectives.......p879
Patient Safety Still Lagging
IOMReport Calls for Overhaul of Graduate
Medical Education
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Despite some advances in patient safety in the
United States, such as reductions in central
line-associated bloodstreaminfections, medical
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News &Analysis
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argued that its time to shift away frombu-
reaucratic, patriarchal leadershipmodelsand
toward high-reliability organization mod-
els used in aviation and other industries.
Greater attention is also needed to pa-
tient safety outside of hospitals, said Tejal
Gandhi, MD, MPH, president of the Na-
tional Patient Safety Foundation and asso-
ciateprofessor of medicineat HarvardMedi-
cal School. She noted that most care is
deliveredinnonhospital settings, suchaspri-
mary care clinics, nursing homes, and am-
bulatory surgical centers, yet most patient
safety efforts focus on hospitals.
Better data and monitoring of patient
harms inthesesettings areneeded, shesaid.
Patient handoffs from one facility to an-
other can be particularly perilous. For ex-
ample, patients are often transferred to a
new facility only with their medical record
and no discussion between caregivers. She
said clinician-to-clinician discussions alone
can help pass on vital information.
Jha noted that better integration be-
tween facilities and smarter use of technol-
ogy canhelpimprovepatient safety. For ex-
ample, henotedthat currentlymanynursing
homes and rehabilitation facilities do not
have electronic health records, in part be-
cause federal incentives havent been ex-
tendedtothem. This means records for the
sickest, most complicatedpatients must be
faxed, he said.
Ultimately, improvingpatient safetywill
require that the US healthsystemrealignfi-
nancial incentives, said Jha. He and other
speakers noted that a hospital chief execu-
tive officers (CEOs) compensation is often
not tied to quality of care.
Until hospital CEOs are lying awake at
night worryingabout safety, its not goingto
happen, he said.
IOMReport Calls for Overhaul of Graduate Medical Education
Kate ORourke, MA
A
new report from the Institute of
Medicine(IOM) stronglyurges Con-
gress tooverhaul thefederal financ-
ingandgovernanceof graduatemedical edu-
cation(GME). Thereport, producedafter an
extensive assessment of physician resi-
dency training funding, recommends the
creation of new infrastructure for fund dis-
tribution and research into improved pay-
ment models.
Unsurprisingly, given the sweeping
changes proposed by the IOM committee,
the report has sparked criticism from vari-
ous medical groups, including the Associa-
tion of American Medical Colleges (AAMC),
the American Hospital Association (AHA),
the American Medical Association (AMA),
and various specialty organizations.
Altering the Payment System
The short-term recommendations involve
improvingthepaymentmethodologyinways
that will addresssomeexistinginequities. The
longer-term involves moving from a cost
reimbursement-basedpayment systemtoan
outcomes-basedpaymentsystem,saidDebra
Weinstein, MD, vicepresidentforGMEatPart-
ners Healthcare System in Boston. She is a
member of theIOMCommitteeontheGover-
nanceandFinancingofGraduateMedical Edu-
cation, whichproducedthe report.
Annually, the federal government pro-
vides $15billionfor graduatemedical educa-
tion, 90%of whichcomesfromMedicareand
Medicaid. The IOMrecommendations focus
onchangesfor Medicare, whichprovidesthe
bulk of the money.
Currently, Medicaredistributesitsfunds
for residency training to teaching hospitals
throughcomplicatedformulas linkedtothe
volume of Medicare patients treated at a
hospital. According to the IOM, this system
is flawed because it discourages training in
community-based settings, where most
people obtain their health care. The report
alsosays thereis astrikingabsenceof trans-
parency and accountability for how the
funds are used.
Frequently, the education director in
thehospital was thelast personwhohadany
idea of what happened to the money, said
Gail Wilensky, PhD, the committees co-
chair and an economist and senior fellowat
Project HOPE.
The committee concluded that Medi-
careshouldcontinuetofundGMEat thecur-
rent level but should repurpose and reposi-
tion the funding. It recommends creating a
2-part governance infrastructure for Medi-
care GME financing. A GME Policy Council,
housedintheDepartment of HealthandHu-
man Services, would oversee policy devel-
opment and decision making. A GME Cen-
ter, housedwithintheCenters for Medicare
& Medicaid Services, would function as an
operations center with the capacity to ad-
minister payment reformsandmanagedem-
onstrations of newpayment models.
The report recommends allocating the
Medicare GME funds to 2 distinct subsid-
iaryfunds. AGMEoperational fundwouldfi-
nance ongoing residency training activi-
ties. A transformation fund would finance
the development of new programs, infra-
structure, performance methods, payment
A newreport, produced after an extensive assessment of physician residency training funding, urges
Congress to overhaul the federal financing and governance of graduate medical education.
News &Analysis
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