To save the life of a child, a zoo sacrifices a prized, endangered gorilla. In exchange for one nearsighted Israeli soldier captured in Gaza, Israel released 1,000 Palestinian prisoners. (This example from the Middle East may not be surprising. In Judaism, it is commanded that “to save a life is as if one saved the world.”) And there are other examples of extreme bravery to save one life. That’s how much societies value the life of each human being.
So how, then, do we explain our national acceptance of approximately 251,000 preventable deaths each year from medical error (according to a recent BMJ study)?
We can watch Saving Private Ryan and cheer the heroics of our armed forces as they rescue the remaining son of a family who suffered horrendous battlefield casualties during World War II.
But there is less sustained effort to do something about the hundreds of thousands of people who entrust their lives to medical facilities and suffer or die—not from their illness, accident, or surgery—but because someone did not observe sanitary precautions, or was careless in stocking the crash cart, marking a surgical site, delivering the right medications, or using a safety checklist. Somehow, we accept excuses about this tremendous casualty toll.
The nation is unforgiving when the National Aeronautics and Space Administration (NASA) loses one of its astronauts—a reflection of our national commitment to preserving life.
But we can’t accept or process the extent of death by medical error, so we challenge the validity of the data. If 150,000 Americans die each year, or 440,000, does it matter?
Estimates at the “low” end still represent an unconscionable loss of life. We nurture inconsistency. We respect claims that hospital-acquired infections are inevitable, and that superbugs will always defeat us, but then demand that we wage war on the Ebola and Zika viruses.
Sometimes we place the blame on the patient—he or she should demand that health care workers wash their hands—in other words, demand that they do the right thing. We accept excuses from hospitals that perform complex procedures if they have high rates of medical errors because “their patients are sicker”; however, their resources to enforce safety are greater.
Why don’t we stop excusing this terrible national tragedy and move with the alacrity of a SWAT team storming a burning building? Here are some measures that would work.
Demand Local Health System Leadership
Hospital and nursing home boards, management, and frontline supervisors should commit to dramatic reductions, within a year, in one or two of the nine leading causes of death: adverse drug events, catheter-associated urinary tract infections, central-line blood stream infections, patient falls in health care facilities, obstetric adverse events, pressure ulcers, surgical site infections, preventable blood clots, or ventilator-associated pneumonia.
The Centers for Medicare and Medicaid Services (CMS) is making this easy, with value-based payment initiatives that penalize providers for high rates of medical errors. So, act with alacrity! Enter a new era of transparency, by tracking progress month by month, unit by unit, and sharing best practices. Make reporting errors safe for employees, solve problems by getting to the root cause (forget workarounds), and reward high-performing staff members and unit directors. Use patient safety checklists and tools and technology to speed improvements.
Do this every year until there are dramatic reductions in all nine of the leading causes of death. Management at the highest level must continuously walk around and observe. It sends a clear message: this institution is deadly serious.
Commercial payers—like their Medicare counterpart—should favor provider organizations that are successful through their payment reform and shared savings programs. The amount of reimbursement should relate to sustained improvements.
We know that rapid, dramatic progress is possible. One of the Jewish Healthcare Foundation’s (JHF’s) supporting organizations, the Pittsburgh Regional Health Initiative (PRHI), recruited more than thirty hospitals in southwestern Pennsylvania and partnered with the Centers for Disease Control and Prevention (CDC) to systematically attack central-line associated bloodstream infections. Together, these institutions reduced central-line infections among intensive care unit patients by 68 percent. The PRHI also guided the VA Pittsburgh Healthcare System in developing a methicillin-resistant Staphylococcus aureus (MRSA) prevention protocol and interventions that led to an 85 percent reduction in MRSA infections in a postsurgical unit (see page 14). The MRSA prevention protocol became standard practice across the national Veterans Health Administration system. None of this happens without committed leadership.
Recognize and Reward Improvement Efforts
The people being needlessly harmed in our health care institutions are our neighbors, friends, and family. But those trying to deliver safe, high-quality health care are also our neighbors, friends, and family. We need to appreciate and support their efforts. We at the JHF are fortunate to have committed partners in Milton and Sheila Fine, whose Fine Foundation sponsors the Fine Awards for Teamwork Excellence in Health Care. Since 2008, Fine Award winners, representing the full spectrum of care settings, have demonstrated measurable, long-term improvement and have moved the quality bar within their organizations; achieved support from top administrators; and developed plans to sustain and spread their work. It’s a model that should be replicated elsewhere.
Step Up Education and Training
Change happens at the point of care, where the people with “boots on the ground” connect with patients. If clinicians don’t know how to solve problems rapidly in the course of their work, achieve high performance, and track progress, change won’t happen. Doctors and nurses must lead the charge, so the role of education and ongoing training and coaching in safety science and quality engineering techniques should be given high priority in health professions schools. They aren’t. And, by the way, add a dose of systems theory (which portrays the health care system as a complex entity consisting of many multidisciplinary, interdependent parts) and organizational behavior (covering topics such as introducing change, overcoming resistance to change, and building effective teams) as well.
Young professionals represent an untapped reservoir for building a network of mutually supportive change agents and reform activists. The JHF proudly provides online safety training to current practitioners and both funds and runs a series of multidisciplinary graduate student fellowships in patient safety and systems redesign. By late 2016, there will be more than 800 fellowship alumni.
Act on the Data
The Pennsylvania Department of Health publishes data on quality in skilled nursing facilities in the state, the Pennsylvania Healthcare Cost Containment Council (PHC4) publishes data on hospital-acquired infections (HAIs), and the Pennsylvania Patient Safety Authority provides data on medical errors in acute care settings, outpatient surgery settings, and long-term care settings. The data are available by facility.
Local health departments should more aggressively inform the public about the comparative data on medical error rates among local institutions. Insurance companies should provide their subscribers with useful comparisons in real time. Patients want comparative data on hip, knee, or cardiac surgeries precisely when they have to decide on a surgical team and site.
Media outlets must publicize outcomes data. Many already do so. The public needs to know which facilities are the safest and to call on the executive and governing boards of local hospitals and nursing facilities to accelerate the pace of progress.
Learn from the Past
We can learn from past successes. From anti-coagulation efforts to reduce clots, to universal precautions adherence to protect workers treating patients with AIDS, to vaccinations to prevent pneumonia, to fetal heart monitoring for better birth outcomes, to better life-support interventions for trauma victims, widespread and diligent applications of best practices have catalyzed movements to successfully fix major problems.
Take Ownership of the Problem
Death through medical error is a local problem, and it will have to be fixed at the point of care. Payment reforms can provide incentives and penalties; local workers must respond. It’s time for all insurers to tier payments to favor the safest providers, and to provide clear, actionable data on comparative safety records to employers. Employers must pass this information on to employees if the public at large is to “choose wisely” in selecting providers and treatments. Health professions schools must provide sufficient education on safety science and quality engineering. Health systems have to develop an adequate problem-solving infrastructure and reward units and employees having excellent safety records. Clinicians must observe best practices diligently, every time.
There must be no excuse for further error. The media and our public health and civic leaders must give this issue the attention that it deserves.
We don’t yet possess all of the answers necessary to eradicate heart disease and cancer—the first and second leading causes of death in the United States—but we know how to eliminate medical errors. We just haven’t shown the conviction and courage to do it. Until then, we’re falling short of truly valuing every human life.
