Shortly after the Institute of Medicine released its report on the estimated 98,000 hospital deaths caused each year by medical errors, the finger pointing began: Physicians blamed managed care, which assigned the blame to doctors and health systems, which turned the blame back onto their accusers.
"There's certainly the 'It's everyone's fault but our own,"' says Lee Sacks, M.D., executive vice president and chief medical officer of Advocate Health Care, an Oak Brook, Ill.-based system.
No one could argue this approach has led to any improvements. So earlier this fall, Minneapolis-based UnitedHealthcare organized a forum to try to stop assigning blame and start assessing the best way to improve patient safety. At the table were representatives from United, the AMA, the Leapfrog Group and Advocate.
The panel participants didn't reach any conclusions, nor did they develop any concrete solutions. It was, they hoped, the first in a series of cooperative meetings to improve patient safety.
"If we have any chance for improvement, it has to be in a climate where we--all of us who are in healthcare--are working together," says Reed Tuckson, M.D., senior vice president of consumer health and medical care advancement at UnitedHealth Group, the parent company of UnitedHealthcare. "We're working to accomplish a goal that's free of animosity, finger pointing and blame. Once you start putting blame in different parts of the system, then what happens is people logically will retreat. They will not be cooperating in common solutions."
That's the one area in which the participants agreed. "Everyone should be practical," Sacks says. "It's not as simple as snapping your fingers and saying we're going to make a safe environment."
If those in the business of healthcare can't address the problems and develop a way to measure quality, then businesses are going to do it for them, says Larry Boress, executive director of the Chicago Business Group on Health, a member of the Leapfrog Group.
"Patient safety as a concept is the window through which we should be able to drive all quality information," Boress says. "I think, ultimately, accountability is really where employers, purchasers, consumers, physicians and the hospital community need to step up . . . People can relate to the idea that they may not come out of the hospital alive."
The Leapfrog Group, which was launched in response to the 1999 IOM report, is a consortium of more than 80 Fortune 500 companies and other employers. Group members provide healthcare benefits to more than 26 million Americans and spend more than $45 billion on healthcare each year.
"Employers are beginning to grade health plans and will soon start evaluating hospitals and physicians on quality criteria," Boress says. "There's a lot more to it than the hours they are open and the languages they speak."
If managed care continues to loosen its referral requirements, there will have to be information to allow employers and patients to know which providers are better and the standards by which they are being judged, he says.
"Health plans are rating drugs on three tiers. Now you're going to have hospitals on tiered benefits plans," Boress says. "You'll have doctors on tiers. Doctors or hospitals who meet certain satisfaction criteria, maybe those people will be on the top tier. Those that don't meet those levels will be on the lower tiers."
Initially, people will be driven to the higher-tiered--meaning higher-quality--providers because co-payments will be lower, he says. But as the public and employers become more educated, they're going to be choosing those providers because they're better, Boress argues.
All doctors have a medical degree, he says. "Some of them are at the bottom of their class."
Tuckson of UnitedHealthcare says physicians need to be able to evaluate their work without being penalized.
"As our healthcare system becomes more complex, as technology becomes more complicated, physicians deserve a support network that facilitates implementation of safe decisions they and their patients make together," he says.
About a year before the IOM report, Advocate started looking at ways to improve patient safety, Sacks says. Groups focused on four areas: medication safety, hospital infections, delays in misdiagnosis and labor and delivery safety.
Two of the eight hospitals in the system use robots to fill medication orders, Sacks says. The pilot program thus far has proven to be more accurate and more timely than having people fill those orders, he says.
Next year, the system plans to pilot another program that allows nurses to scan a barcode on patients' ID bracelets. The barcode will allow nurses to check for proper use of medication and record it for charting.
System officials also have adopted low-tech solutions, including segregating medications that are easy to confuse.
"I don't claim that we've invented any of these," Sacks says. "These have been piloted and written about before. The challenge has been to adopt them, train your staff. The changes are insignificant compared to patient safety."