Patient Safety Movement Foundation founder Joe Kiani appeared today before the Senate Health, Education, Labor & Pensions Committee and laid out five steps to help eradicate preventable patient deaths.
More than 200,000 preventable patient deaths occur each year in U.S. hospitals.1,2 The Patient Safety Movement is committed to reducing these deaths to zero by 2020. The Patient Safety Movement, established through the support of the Masimo Foundation for Ethics, Innovation, and Competition in Healthcare, works with all stakeholders to address the problems and solutions of patient safety. The Foundation also convenes the action-oriented annual Patient Safety, Science & Technology summit.
Mr. Kiani’s recommendations from today’s hearing included:
1. Create a System of Transparency
Current reporting systems do not require consistent, accurate, measurable and electronic reporting on the total number and causes of preventable deaths. We cannot improve what we do not measure.
Government should take the lead to create standardized processes for hospitals to define, measure, and report hospital-acquired infections (HAI) and hospital-acquired conditions (HAC). Reporting should be electronically facilitated through the Meaningful Use program and via claim submissions. Congress should require HAI and HAC rates to be publicly reported to facilitate quality comparisons, much like the Security and Exchange Commission does for the finance industry.
2. Incentives and Disincentives
Congress should expand the current HAC Medicare policy to include a list of causes of preventable death. Congress should suspend payment for the primary health condition until it is determined whether the cause of death was preventable. If preventable, and the hospital has implemented evidence-based strategies for prevention, the hospital would receive payment for the primary condition. If the hospital had not implemented the strategy, then payments for both the primary and any secondary conditions would be denied.
Congress should also expand the current HAC Medicare policy by expanding the non-payment policy for secondary health conditions that develop after a patient is admitted to a hospital. Currently, only preventable, high-cost, high-volume conditions for which there are evidence-based precautions are eligible. Congress should eliminate the “high-cost, high-volume” limitation so that any known preventable condition is eligible for the list if there is a clinical intervention strategy to prevent it.
Additionally, if hospitals implement evidence-based practices, they should be shielded from malpractice lawsuits to the fullest extent possible, such as through an affirmative defense and limits on damages.
3. Create the “Patient Data Super Highway”
For more than a decade Congress and the Administration have devised and implemented policies to spur the use of information technology in healthcare. Seamless information technology should enable us to identify problems in real time and resolve them before they become deadly. As a result, medical professionals have begun to increasingly rely on medical technology and information systems to treat their patients. Today, however, these technologies are not always able to communicate or interoperate.
Some technology vendors, as well as some providers, pursue business practices to create “walled gardens” – strategies that block information sharing between different systems to capture market share and/or additional future revenues. The Office of the National Coordinator has identified this as a barrier to progress, as it fundamentally diminishes the value of health IT, and undermines programs to incentivize the use of technology in healthcare.
Technology solutions must be required to openly share information, particularly when their purchase is subsidized with taxpayer dollars and patients’ lives are dependent on it.
Congress should grant the Office of the National Coordinator for Health Information Technology (ONC) the authority to investigate and decertify products that pursue information-blocking practices. While respectful of patient privacy regulations under HIPAA, we shouldn’t provide incentives or reimbursement for products that do not openly share data with hospitals, patients, and all parties that can use the information to improve patient safety.
4. Safe Harbor
Today there are no incentives, only penalties, for medical technology companies to identify why a patient was harmed by their product. Hospitals are afforded protections for reporting adverse events through Patient Safety Organizations.
Congress should extend the type of legal safe harbor afforded to providers through Patient Safety Organizations to technology vendors to promote transparency, which will benefit the system overall.
5. Patient Dignity
Too often a patient’s or a family’s cry for help is ignored. Patients and their families must be partners with healthcare providers. We believe there should be a Patient Advocate at every hospital whom patients or their families can access in real time if they experience lack of empathy or problems with communication related to their care.
- Daniel R. Levinson, Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries (Department of Health and Human Services: Office of the Inspector General, November 2010).
- L. T. Kohn, J. M. Corrigan, M. Donaldson, eds., To Err Is Human: Building a Safer Health System (Washington, DC: Institute of Medicine, 1999), 1.