The Institute of Medicine is preparing to release a second report on healthcare quality at a time when many providers and lawmakers are still trying to digest the impact of the institute's 1999 medical-errors study.
That report, released a year ago this month, estimated that up to 98,000 Americans die every year as a result of medical errors in the nation's hospitals (Dec. 7, 1999, p. 16). The document led to a frenzy of quality-improvement initiatives in both the public and private healthcare sectors.
Sources wouldn't reveal too much about the follow-up report, which has been in the works for more than a year, but its impending release is already generating a buzz in healthcare circles. The IOM said the new report will be issued early next year.
Lucian Leape, M.D., an adjunct professor at the Harvard University School of Public Health who worked on both IOM reports, promises that the new report will be "equally radical" to its predecessor.
"We're urging people to rethink how the healthcare system is designed and what it is we do," Leape said in an interview.
Kenneth Kizer, M.D., president and chief executive officer of the National Quality Forum, has read the report and said it makes "some very poignant recommendations." The forum is a Washington-based not-for-profit membership organization whose goal is to improve quality measurement and reporting in healthcare. It's working on three patient-safety projects for HHS.
"Basically, it's about the need that healthcare has to focus on quality, which has to be an essential business strategy for the healthcare industry," Kizer said. As healthcare inflation continues to rise, no easy places to cut costs are left, he said. "You have to improve the processes of care."
Furor over errors. The first report rattled the healthcare industry and drew unwanted attention from Congress and President Clinton. Lawmakers even entertained the possibility of requiring hospitals to report the most serious errors to the government.
Despite all that, progress on solving the medical-errors crisis remains slow and focused more on the future than the present, leaving much work to be done, some say.
"I've been disappointed every year for the last five years," said Dennis O'Leary, M.D., president of the Joint Commission on Accreditation of Healthcare Organizations, referring to the group's efforts to win federal protections from liability for providers that disclose information about medical errors to the JCAHO for quality-improvement purposes.
The IOM's new report could stiffen the resolve of both Congress and healthcare executives to find solutions to the patient-safety problem.
Last year's IOM report laid out ambitious goals that have yet to be achieved:
* A 50% reduction in medical errors by 2005.
* The creation of a Center for Patient Safety within HHS' Agency for Healthcare Research and Quality.
* A mandatory error-reporting system.
* A law to keep secret the data that's collected by healthcare organizations for internal use in patient-safety efforts.
Some are not surprised that it's taking more than a year to accomplish any of those goals.
"When you stop and think about how massive this industry is--the thousands of hospitals, doctors and nurses involved--and you think about what the culture has been on dealing with these issues, it's not going to be that one report comes out and everything changes," said James Scott, president of the Washington office of Premier, a not-for-profit hospital alliance.
"Some things happened, but maybe not so many action items as we would like," O'Leary said. "I think we achieved increased awareness of the issues, a linking of hands among the key players, a dissemination of what works and a lot of brainstorming."
For example, the American Hospital Association formed a partnership with the Institute for Safe Medication Practices to raise hospitals' awareness of medication errors.
"This has been an important year for us and for hospital leaders," said Carmela Coyle, the AHA's senior vice president for policy. "We've really tried to engage in a number of activities to increase awareness, educate hospital leaders about these issues and provide a set of tools to help our members take steps to improve patient safety."
Financing research. Other groups, like the American Academy of Family Physicians, are funding their own research on medical errors in physician office settings, where most patients receive care. The AAFP expects to release its research findings by the end of the year.
Sue Dovey, who is supervising one AAFP study, said the preliminary results show that most errors are the result of poor office administration.
"It's the fault of a poor filing system, where messages aren't passed on or records are not available or the patient wasn't seen in a timely manner," Dovey said. "You might think it's minuscule, but what if the do-not-resuscitate order is in the wrong person's file?"
A number of organizations are sponsoring educational conferences on preventing medical errors.
Two months ago, for example, the Agency for Healthcare Research and Quality (AHRQ) held a National Summit on Research and Patient Safety in Washington; and the VHA, an alliance of not-for-profit hospitals, co-convened a patient-safety conference in Dallas in June along with the Medical Group Management Association and the JCAHO.
VHA also has seen a healthy demand for its year-old Clinical Advantage Program, under which alliance representatives go to hospitals to demonstrate how to improve outcomes through evidence-based medicine and standardized measurement, said VHA Executive Vice President Stuart Baker, M.D.
The JCAHO is getting ready to issue new patient-safety standards for accredited hospitals, including requiring hospitals to inform the patient and patient's family when a serious medical error has occurred.
"They're pretty significant, and there will be lots of discussion about them," said O'Leary, who hopes the JCAHO's board, dominated by hospital and physician representatives, will approve the standards by year's end. They would take effect July 1, 2001.
The AHRQ, for its part, hasn't yet given up on establishing a federal Center for Patient Safety with up to $50 million in funds for research, said Director John Eisenberg, M.D.
"It's in the (federal) budget, and hopefully that budget will get passed," said Eisenberg, who also co-chairs the Clinton administration's Quality Interagency Coordination Task Force on Patient Safety. "If it doesn't get passed, we may make the change as as executive decision, but we'd prefer Congress to take action."
Legislation on back burner. On Capitol Hill this year, reducing medical errors took a back seat to election-year politics and other healthcare issues like managed-care reform, antitrust exemptions for physicians, and providers' campaign for more Medicare and Medicaid funding.
"By the time we got into the (medical-errors) legislation, we had other bills that were further down the pike that attracted our attention, like managed-care reform," said Joseph Karpinski, spokesman for the Senate Health and Education Committee, which held four hearings on patient safety this year.
A spokeswoman for Sen. Charles Grassley (R-Iowa), who introduced Medicare and Medicaid patient-safety legislation in response to the IOM report, said the lack of a quick resolution wasn't surprising, considering that several congressional committees would have jurisdiction over various patient-safety issues.
"The debate clearly will be back next year," said a spokeswoman for Rep. Fortney "Pete" Stark (D-Calif.), the ranking Democrat on the House Ways and Means health subcommittee who introduced Medicare patient-safety legislation this year. "What form that debate takes is impossible to predict."
Lawmakers weren't the only ones distracted by other concerns. Many hospital executives have been fretting over whether Congress will pass Medicare-relief legislation this year.
"So many hospital folks were so focused on the balanced-budget act (givebacks) and their immediate fiscal issues that they were not taking a long-term view of making (patient safety) a priority," said Kizer, who until July 1999 was the VA's deputy undersecretary for health.