Hospitals are flummoxed by the problem of patient safety, according to a report issued by the Government Accounting Office (GAO) just in time for this week’s Patient Safety Awareness Week. Issued at the request of ranking members of the Senate Committee on Finance and Senate Committee on Health, Education, Labor and Pensions, Sen. Ron Wyden (D-Ore.) and Sen. Patty Murray (D-Wash.), respectively, the report reveals three explanations on why hospitals find it so difficult to address patient safety. I am summarizing, but I am not exaggerating:
- Hospitals can’t find the problem. Hospitals cannot identify in their own records all their errors, accidents and infections, even though they are required to report many of them to the federal government.
- Hospitals can’t figure out how to solve the problem. Despite a large body of research about how to address most safety problems, hospital leaders can’t seem to find the time to read it. Some hospitals even admit to throwing a bunch of ideas at a problem at once–surprised when it becomes nearly impossible to tease out which ones worked, and which didn’t.
- Nobody does what they are told anyway. Even when hospitals identify a problem that is hurting patients, and commit to an evidence-based solution to stop the harm, they can’t get their staff on board.
In the hour it took me to study the report, at least 20 people died of a preventable error in American hospitals. Hundreds more suffered an avoidable injury or infection that will debilitate them and devastate their families.
When tens of thousands of people are dying from preventable errors, is it too much to ask hospitals to read the latest research? It’s as if the house is burning down with people inside, and the fire department is confused about which room to attack first, and which hose to use. Worse, the chief isn’t sure the firefighters will do the job.
Admittedly, the GAO report has some significant limitations. The researchers interviewed leaders at only six hospitals, so it clearly can’t be generalized to represent the universe of 5,000 hospitals nationwide. Nor did the GAO see fit to differentiate among those six in assigning credibility to their interviews, even though some hospitals were chosen because they are high performers and some because they are low. It stands to reason the “A” student and the “C” student are not going to offer the same perspective on the worthiness of the curriculum.
Whatever the limitations, policymakers and industry leaders haven’t condemned the report as inaccurate or misleading. No one in the hospital industry has commented. In fact, the report has generated very little attention at all. That’s a big problem.
There is a startling lack of urgency from hospitals and policymakers even when so much is at stake. Why might that be? One major reason is the way hospitals get paid. Traditional fee-for-service payment means the more harm, the higher the payment. Clinicians care deeply about patients, but our financing system makes it very easy for them to treat patient harm like a second thought. The report also offered perspectives from some health plans. There, too, we find a disturbing lack of urgency. Only two of the six had any investment at all (generally modest) in supporting or incentivizing efforts to improve safety.
More than anything, that’s what the GAO report reflects: safety is a problem we aren’t devoting 100% of our manpower to solving.
Yet, the report has two surprising bright spots. First, the federal government’s Partnership for Patients program. Run by HHS, this program has helped hospitals collaborate and set goals to improve safety, and the impact has been significant. Many lives were saved. We don’t often see substantial results from patient safety initiatives, so this is a promising finding and a feather in the cap of the administration.
Second, one quite surprising and hopeful sign: the rapid pace of hospital consolidations may have the potential to improve patient safety. Hospitals that were part of larger systems put a higher priority on safety, and didn’t seem to have the same problems with data analysis and strategy. This would suggest the potential for system leaders to focus attention across hospitals on achieving safety goals–elevating safety on the priority list and minimizing some of the burden individual hospitals report in researching the data and the solutions.
Ultimately we need to tie system payments to the effectiveness of interventions. That was the original vision for Accountable Care Organizations (ACOs), and clearly we need to recommit to achieving it.