In all the talk about repealing and replacing the Affordable Care Act (ACA), not enough has been said about what the act did to improve patient safety and healthcare quality.
In a system long driven by volume, the ACA introduced value-based payment programs that seek instead to reward providers based on the quality of the care they deliver. In other words, the intent was to give providers a strong incentive to focus on delivering better, more effective care rather than just more care. There is little argument that such a shift in focus is important.
The Safety Side of Quality: Preventing Medical Harm
The ACA’s focus on improving the quality of care has been multifaceted. Under guidance of the Centers for Medicare & Medicaid Services (CMS), the ACA allowed for creation of a public-private partnership known as the Partnership for Patients, which focuses on reducing preventable hospital-acquired conditions (HACs). Between 2010 and 2015, the Partnership’s efforts resulted in an estimated 21 percent decline in HACs such as adverse drug events, catheter-associated urinary tract infections, and pressure ulcers.
How big is the problem of preventable medical harm? Unlike other high-risk industries, health care lacks a national, centralized repository for safety lapses and adverse events. We must rely on researchers to make educated estimates. Recent estimates range from 250,000 deaths to 440,000 deaths per year from preventable medical harm in hospitals. At the higher end, the number would represent one of the leading causes of death in the United States, after heart disease and cancer.
Moreover, those numbers do not include harm in which the patient survives but is left with lasting disability or, at least, in need of additional medical care. In a recent report on HAC rates, the Agency for Healthcare Research and Quality (AHRQ) estimates that in 2015, there were 115 HACs per 1,000 hospital discharges. Yet far more health care in the United States occurs outside of hospitals—in primary care offices, ambulatory surgical centers, and long-term care facilities and rehabilitation centers, for example. The risk of harm from delayed or wrong diagnoses, missed test results, and other lapses in these settings is substantial.
Unless we take stronger steps to address the toll that preventable medical harm takes on patients and families, we will not achieve the level of safety and quality of care that all citizens expect and deserve.
A Bipartisan Concern
One thing Democrats and Republicans can surely agree on is the fact that, as President Trump observed earlier this year, health care is “unbelievably complex.” Yet even if we cannot agree on how to reform health insurance, we should be able to agree on the steps needed to advance the safety of the healthcare system. Ensuring patient safety should be a bipartisan issue.
To raise awareness of this issue and to advocate for a bipartisan approach to address it, the National Patient Safety Foundation (NPSF) recently issued a Call to Action based on the premise that addressing preventable medical harm within a public-health framework has the potential to reduce the numbers of patients who experience harm when something goes wrong.
We have seen the public-health approach work—for example, in reducing healthcare-associated infections (HAIs). In 2008, the Federal Steering Committee for the Prevention of Health Care-Associated Infections united efforts of three federal executive departments: the Department of Health and Human Services (HHS), the Department of Labor, and the Department of Veterans Affairs. The steering committee’s efforts led to the creation of the National Action Plan to Prevent Healthcare-Associated Infections, which has helped to coordinate and guide efforts of stakeholders across the country. Since the action plan’s inception, we have seen continual declines in HAIs, including a 50 percent reduction in central-line-associated bloodstream infections.
An Action Plan for Patient Safety
We need similar national oversight, and a similar national action plan, for patient safety overall. The fact is that healthcare organizations have been working largely in isolation on piecemeal, reactive approaches to safety.
Within HHS, the AHRQ-led Patient Safety Organization (PSO) program has allowed for more transparency and collaboration that enables organizations to share challenges and best practices, but their reach doesn’t allow for the spread necessary to achieve nationwide progress. A national action plan, with clearly defined goals and measures, would be a great step forward to coordinate efforts across all groups working on patient safety, such as healthcare leaders, industry, insurers, patients and families, policymakers, researchers, safety organizations, and private foundations.
Some of the work outlined in the NPSF’s Call to Action is already being done in various forms and settings. For example, the framework calls for informing, educating, and empowering the community. Many organizations are utilizing shared-decision-making tools with patients, removing limits on family visiting hours, and involving patients in care redesign. Rising levels of physician and nurse burnout also are bringing greater attention to workforce safety and the need for efforts and initiatives to restore joy and meaning to the work of clinicians. As organizations and individuals work to address these issues, they would benefit from national oversight and the ability to share their results and triumphs more easily.
The commitment to public health at the federal level may be uncertain in today’s climate, but much can be done through public-private partnerships and collaborations. Since the release of the Call to Action, the NPSF has merged with the Institute for Healthcare Improvement, with the goal of focusing and energizing the drive for safer care. The ultimate goal is to inspire provider organizations across the nation to join together in a mighty chorus for patient safety that is committed to building a collaborative framework for addressing this national concern.
Tejal K. Gandhi, MD, MPH, CPPS, is chief clinical and safety officer at the Institute for Healthcare Improvement, Cambridge, Mass., and formerly president and CEO of the National Patient Safety Foundation, Boston.
