Innovations in Patient SafetyInnovations in Patient Safety

Helen Burstin, MD, MPH Helen Burstin, MD, MPH Director, Center for Primary Care, Prevention, Director, Center for Primary Care, Prevention,

and Clinical Partnershipsand Clinical Partnerships

Academy Health Academy Health June 6, 2004June 6, 2004

Bridging the Quality ChasmBridging the Quality Chasm

Where Where WeWhere Where WeWe Are Want To BeWe Are Want To Be

TRIPTRIP

ImplementationImplementation

DiffusionDiffusionAdoptionAdoption

EducationEducationHealth IT Health IT

Diffusion of knowledgeDiffusion of knowledge

69.1% (1999)69.1% (1999)19841984Cholesterol ScreeningCholesterol Screening

75.5% (2001)75.5% (2001)19821982MammographyMammography

48.1% (2000)48.1% (2000)19811981Diabetic Eye ExamDiabetic Eye Exam

53% (2000)53% (2000)19771977Pneumococcal VaccinePneumococcal Vaccine

64% (2000)64% (2000)1968 1968 Flu VaccineFlu Vaccine

Current rate of useCurrent rate of useLandmark TrialLandmark TrialClinical ProcedureClinical Procedure

Balas EA, Boren SA., Managing Clinical Knowledge for Health Care Improvement. Yearbook of Medical Informatics 2000.

RAND Study: Quality of HealthRAND Study: Quality of Health Care Often Not Optimal Care Often Not Optimal

Patients’ care often deficient, study says. Proper treatment given half the time. On average, doctors provide appropriate health care only half thetime, a landmark study of adults in 12 U.S. metropolitan areas suggests.

Medical Care Often Not Optimal Failure to Treat Patients Fully Spans Range of What Is Expected of Physicians and Nurses

Study: U.S.Doctors are not following the guidelines for ordinary illnesses

.

The American healthcare system,often touted as a cutting-edge leader in the world, suddenlyfinds itself mired in serious questions about the ability of itshospitals and doctors to deliverquality care to millions.

Medical errors corrodequality of healthcare system

To Err is HumanTo Err is HumanBuilding a Better Healthcare SystemBuilding a Better Healthcare System

1999 IOM Report1999 IOM Report Between 44,000 and 98,000 die as a result of Between 44,000 and 98,000 die as a result of

medical errors annuallymedical errors annually– Would be the 8Would be the 8thth leading cause of death leading cause of death– Ranks higher than MVAs, breast CA, AIDSRanks higher than MVAs, breast CA, AIDS

Total costs: $17-29 billionTotal costs: $17-29 billion

44,000-98,000 Lives44,000-98,000 Lives

Based on extrapolation from two studies:Based on extrapolation from two studies: Analysis of New York hospitalizations: adverse Analysis of New York hospitalizations: adverse

events occurred in 3.7% of which 27% were events occurred in 3.7% of which 27% were negligent and death occurred in 13.6% (Brennan et negligent and death occurred in 13.6% (Brennan et al, NEJM, 1991)al, NEJM, 1991)

Analysis of Utah and Colorado hospitalizations: Analysis of Utah and Colorado hospitalizations: adverse events occurred in 2.9% of which about adverse events occurred in 2.9% of which about 30% were negligent and death occurred in 6.6% 30% were negligent and death occurred in 6.6% (Thomas, Medical Care 2000)(Thomas, Medical Care 2000)

Medical Injuries During Medical Injuries During HospitalizationHospitalization

Based on 18 types of medical injuries:Based on 18 types of medical injuries: >32,000 attributable deaths occur annually >32,000 attributable deaths occur annually 2.4 million extra days of hospitalization2.4 million extra days of hospitalization $9.3 billion excess charges$9.3 billion excess charges

(Zhan, Miller; JAMA 2003)(Zhan, Miller; JAMA 2003)

HHS Reports: Quality and HHS Reports: Quality and Disparities in Health Care Disparities in Health Care

First national comprehensive efforts to measure the First national comprehensive efforts to measure the quality of health care in America and prevailing quality of health care in America and prevailing disparities in health caredisparities in health care– Presents data for clinical conditions, including cancer, Presents data for clinical conditions, including cancer,

diabetes, end-stage renal disease, heart disease, HIV and diabetes, end-stage renal disease, heart disease, HIV and AIDS, mental health, and respiratory diseaseAIDS, mental health, and respiratory disease

– Includes data on maternal and child health, nursing home and Includes data on maternal and child health, nursing home and home health care, and patient safetyhome health care, and patient safety

Reports available at: http://www.qualitytools.ahrq.govReports available at: http://www.qualitytools.ahrq.gov

National Healthcare Quality Report: National Healthcare Quality Report: Missed OpportunitiesMissed Opportunities

Only Only 20.9%20.9% of patients with diabetes receive all recommended tests of patients with diabetes receive all recommended tests 90% of adults are screened for high blood pressure – but only 90% of adults are screened for high blood pressure – but only 25%25%

are controlledare controlled Nearly Nearly 1/31/3 of adults and children with asthma do of adults and children with asthma do NOTNOT receive receive

effective Rxeffective Rx Almost Almost 20%20% of persons with a usual source of care report that they of persons with a usual source of care report that they

are are notnot asked about medications to prevent interactions asked about medications to prevent interactions

A Culture of SafetyA Culture of Safety

Non-punitive policies to address adverse Non-punitive policies to address adverse eventsevents

Organizational commitment to open Organizational commitment to open communication about errors to encourage communication about errors to encourage reporting, analysis, prevention and mitigationreporting, analysis, prevention and mitigation

Alignment between legal and clinical staffs to Alignment between legal and clinical staffs to ensure openness without compromising the ensure openness without compromising the organizationorganization

Stages of Problem RecognitionStages of Problem Recognition

““The data are wrong.”The data are wrong.” ““The data are correct but it isn’t a problem.”The data are correct but it isn’t a problem.” ““The data are right, it is a problem but it isn’t The data are right, it is a problem but it isn’t

my problem.”my problem.” ““I accept the burden of improvement.”I accept the burden of improvement.”

Innovations in Patient SafetyInnovations in Patient Safety

Panelists (i.e. the innovators):Panelists (i.e. the innovators):– Ada Sue Hinshaw Ada Sue Hinshaw – Brent JamesBrent James– Jonathan PerlinJonathan Perlin