Sharp elbows are flying under the basket as federal agencies, private groups and lawmakers fight for position in the medical-errors game.
Up for grabs is who will have an official role when Congress decides how to deal with medical errors-not to mention who will get federal funding to carry out quality-improvement initiatives.
And one agency will score big as captain of the team that's ultimately charged with improving healthcare quality on a national level.
"The important story early on was reporting and confidentiality (of the reported information)," says one healthcare lobbyist. "But the big unknown is, who is going to be in charge of this thing?"
Since an Institute of Medicine report reignited the medical-errors debate last December, a few federal agencies have expressed interest in getting a hand on the ball. They include HHS' Agency for Healthcare Research and Quality (AHRQ), the Food and Drug Administration, HCFA and the National Institutes of Health. Also in the game are a handful of private quality-improvement groups.
Seeking to stave off a rivalry among agencies, President Clinton in December commissioned an interagency task force to review the IOM report. The task force reported back to the White House Feb. 5, describing what the agencies had the authority to do and wanted to do regarding medical errors. That report has yet to be made public.
"The agencies are not going to say anything until they (are told) what to say," says Dennis O'Leary, M.D., president of the Joint Commission on Accreditation of Healthcare Organizations, a frequent witness at congressional hearings these days. "The White House is going to be very careful about that because they have a candidate (Vice President Al Gore) in the (presidential) race."
But that hasn't stopped agencies from extolling their virtues and seeking more money from Congress to track and reduce medical errors.
An agency mentioned specifically in the IOM report is the AHRQ, formerly known as the Agency for Health Care Policy and Research. The report suggests the AHRQ could be the ideal home for the proposed National Center for Patient Safety. The center would collect and disseminate data on medical errors.
In testimony before the House Appropriations HHS subcommittee, AHRQ Administrator John Eisenberg, M.D., requested another $20 million in funding for fiscal 2001 to address medical errors.
"If errors were a disease, we would call it an epidemic and would respond by targeting resources for research and getting that research into practice," he says.
Eisenberg points out that his agency helped pay for the groundbreaking research upon which the IOM's conclusions were based. He said the AHRQ wants to do even more to collect data, share knowledge about error prevention and coordinate public-private partnerships to put that knowledge into practice.
The AHRQ isn't the only prospect mentioned by the IOM.
Janet Woodcock, M.D., director of the FDA's Center for Drug Evaluation and Research, told the Senate Health and Education Committee Feb. 1 that tracking adverse drug events is "a logical extension of our mission." She added that the agency would need more funding from Congress to carry out that goal, but she did not give a cost estimate.
AHRQ spokeswoman Karen Migdail says the agencies are not engaged in a turf war.
"There's no way one agency can do this alone," she says. "(The AHRQ is) nonregulatory, so if there's going to be a regulatory aspect to this, it's got to be someone else's job."
Agency competition is still friendly, but private-sector groups at the House Ways and Means health subcommittee hearing two weeks ago were jockeying for control of error data collection.
Among them are quality-improvement groups formerly called peer-review organizations. These independent groups are directed by physicians and contract with Medicare and Medicaid to improve outcomes in all healthcare settings.
The American Health Quality Association, which represents these organizations, told the health subcommittee that the groups' members are in an excellent position to collect and share data.
"If you're going to define medical errors as not following best practices, you don't have to do reporting, because we're already doing that," says William Golden, M.D., president of the AHQA. "Our members have confidentiality protection and have staffs that are used to working in a sensitive environment. The Joint Commission doesn't have that kind of protection right now." Golden says the JCAHO's quality-improvement efforts were "more episodic than continuous."
Rep. Bill Thomas, chairman of the health subcommittee, called Golden's testimony "a job application."
Golden's words also surprised the Joint Commission's O'Leary, who testified with Golden. "They were making a big pitch (to Congress), and I was a little blown away," O'Leary says. "(Golden) was talking about managing errors, but their scope of work (as contractors) really has nothing to do with that."
O'Leary said there's plenty of work to go around and he would like to have the same dialogue with the AHQA that the Joint Commission has with federal agencies. "To date, (quality-improvement organizations) have no knowledge of root-cause analyses (of medical errors), and we'd like to work with them on that."