ORLANDO, Fla.—Healthcare leaders are partly responsible for a failure to make "substantial, measurable, systemwide strides” to improve patient safety in the U.S., according to a report released Tuesday.
The new National Patient Safety Foundation report highlights eight areas where improvement has continued to lag in the 15 years since an eye-opening report highlighted the prevalence of healthcare-associated patient injuries.
The authors stressed that inaccurate metrics, poor coordination of care and technology hazards are pressing issues, but added that leaderships' failure to prioritize safety is among the biggest concerns.
“Safety has to fight for airtime,” said committee chair, Dr. Donald Berwick. He met up with Modern Healthcare in Orlando during the 27th annual Institute for Healthcare Improvement Forum, where the report was released. Financial pressures, new metrics and payment and policy reform have taken center stage, he said.
The Joint Commission, the nation's largest hospital accreditation group, also focused on leadership in 2014. The organization released guidance that said the C-suite struggles with creating the top-down infrastructure needed to drive an integrated safety system and that could lead to failed initiatives.
While the NPSF report said that the overall system has not become safer, it agreed that significant progress has been made on individual safety problems. Federal health officials released estimates this month that found about 2.1 million fewer patients were harmed from infections, adverse drug events and other conditions between 2010 and 2014. Progress on hospital-acquired conditions helped avert $19.8 billion in associated costs and 87,000 deaths, health officials said Dec 1.
However, that report also acknowledged that improvement doesn't transcend all categories. Patient falls and ventilator-associated pneumonia saw little improvement over the past five years, for example. This year, the Institute of Medicine also flagged diagnostic mistakes as a persistent blind spot amid efforts to boost patient safety in the U.S.
Various healthcare safety leaders have been urging for "total system improvement," spearheaded by one national regulatory agency. It's been a successful approach in other industries, such as aviation, which has the Federal Aviation Administration, and nuclear power, which has the Nuclear Regulatory Commission. They call for a similar body in healthcare.
The idea that healthcare hazards can be managed effectively through systemwide improvements “has really caught on,” Joint Commission CEO Dr. Mark Chassin told Modern Healthcare.
Approaches that help health providers expand from focusing on one-off issues, such as infections or patient satisfaction are key, said Dr. Peter Pronovost, director of the Armstrong Institute for Patient Safety at Johns Hopkins. “We need systems that integrate to eliminate all harms.”
The National Academy of Medicine also announced that it will hold a one-day symposium on Dec. 10. That session in Washington, D.C., will also focus on the nation's progress and feature the new NPSF report, called "Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err is Human." The report outlines eight recommendations.
One recommendation stresses the importance of a centralized and coordinated body to oversee patient safety and set standards for metrics. While federal organizations, public private partnerships, federal health agencies and consumer groups have all been issuing metrics to help hold healthcare accountable, the overall impact would be far greater if the efforts were coordinated, NPSF President Dr. Tejal Gandhi said in a phone call.
“More is not necessarily better,” she said. “If you have 10 different organizations giving you 20 different things to measure, it's hard to figure out what is meaningful and where to focus.”
Berwick added that “gaming the system” as highlighted in a recent Wall Street Journal analysis on 30-day readmission is perhaps one clear example of the unintended consequence of uncoordinated efforts. “In an atmosphere of fear or surveillance, human beings are tempted to try to get control of the information,” he said. “It's a vicious cycle. If there's fear in the system, data becomes a threat.”
The NPSF also made recommendations to ensure that new technology are safe and optimized to improve patient safety; offer support from bullying and burnout among the healthcare workforce; coordinate care for patients across the continuum; and ensure that patients and their families are seen as partners in their care.
