In the 21 years since the National Academy of Medicine published To Err is Human, significant efforts have been made to improve safety and reduce variability in health outcomes in the United States. Yet an estimated 1.2 million people are harmed by medical errors in U.S. hospitals every year. We outline the steps necessary to change this below.
Even in regions known for high-quality care (such as Boston and Metropolitan New York), there is a five times greater chance of dying from an acute myocardial infarction (heart attack), depending on the hospital one chooses. In the United States, patients are on average twice as likely to die in the worst performing hospitals. This includes a 2.3-fold difference in heart attack mortality. There are even bigger differences in safety. The top 10% of hospitals are 10 times safer than the bottom 10%. Patients are 18 times more likely to have a bloodstream infection from a central venous catheter when treated in underperforming hospitals.
Existing processes such as Joint Commission Surveys, surprising assessments by the Centers for Medicare & Medicaid Services (CMS), internal improvement processes, and retrospective public reporting of safety by government and public entities have not worked to reduce the variation.
Why do these risks and variations persist?
Variation is partly due to the time it takes to conduct evidence-based drug research. Research suggests this can take up to 17 years. Hospitals that incorporate evidence-based medicine more quickly perform better. Unfortunately, few have embraced the strategies of the best hospitals. Since there is no central accountability system, hospital leaders do not have to ensure that clinical practice is based on the most current evidence.
Economic and emotional factors can also get in the way of safety if hospital leaders allow it. When one of us (John Toussaint) was CEO of a major health system, heart surgeries were performed in two hospitals, neither of which met case volumes to achieve the highest quality of care. (It is well known that the number of heart surgeries is directly correlated with the results.) The health system administration decided to consolidate the programs and have the same surgeons perform all the surgeries in one hospital. The cardiac surgeons and other physicians working at the hospital that would lose the procedures complained that the hospital’s reputation would be tarnished and negatively impact their individual practices. Health system leaders consolidated the program anyway, and death rates plummeted.
During the Covid-19 pandemic, we’ve seen cases of surgical staff resisting universal Covid-19 screening for outpatient surgery patients, fearing it would lead to delays (and deferred reimbursements) if testing revealed asymptomatic cases. This while patients who did have the virus would have intimate contact with healthcare providers and other patients during procedures and aftercare.
Government accreditation requires that legal structures are in place to ensure quality and patient safety. For example, the regulations oblige hospitals to set up a quality committee of the board. But safety is something for which a hospital’s supervisory board is ill-equipped. While boards receive monthly or quarterly quality updates, which occasionally include analysis of the root cause of safety issues, board members, who are volunteers, generally lack the expertise to understand how complex hospital processes work or what to change when things go wrong. Therefore, hospital safety rests with the professional managers of the executive leadership team; their level of involvement determines performance.
Regulations also require every hospital to have a process for appointing physicians to a hospital’s medical personnel based on documented credentials from training programs and other regulatory agencies. The medical staff appoints a committee of physicians (usually the medical executive committee or the professional affairs committee) to oversee the quality of care provided by the members of the medical staff. Unfortunately, this looks a bit like the fox watching the hen house. When there are safety concerns related to an individual physician, it is difficult for committee members to make decisions that could negatively impact another physician’s practice.
Here are four measures that would remedy the safety shortcomings in US hospitals.
1. Make patient and staff safety a top priority.
Safety depends on the culture of the organization: the sum of the behavior of leaders and employees. A top-down management approach that discourages team members from discussing issues leads to poor safety outcomes. On the other hand, when front-line workers have the confidence to “stop the line” for a safety issue (e.g., report a problem during an operation) and management supports them with a robust, relentless response aimed at helping them resolve the issue. the result is a safer place for patients.
Accordingly, the board of directors and executive leaders of the hospital or health system should make safety a necessity, and the management system should support the day-to-day improvement of safety practices that drive changes in operations and strengthen a safety culture. This should include real-time sharing of the problem and solution across the system. Healthcare leaders in safety performance, such as Cleveland Clinic and Intermountain Healthcare, use robust day-to-day improvement practices directly related to surgery to improve safety.
2. Set up a national security organization.
When the airline industry regularly crashed planes in the 1970s, the US federal government stepped in to create the National Transportation Safety Board (NTSB) and encourage the creation of the CAST real-time learning system. Expert safety teams investigate each accident – an assessment that includes an assessment of safety systems and culture – then recommend measures to prevent future events. NTSB continuously updates safety standards based on new industry insights. The transportation industry has grown to respect the expert opinion of the team and implement most of the recommendations.
We believe that the creation of a National Patient Safety Board (NPSB) – something that a broad coalition of stakeholders has proposed – could serve a similar role in healthcare. The NPSB would not be a regulator; it would act as a facilitator for changing safety practices in hospitals. The standards for specific practices and improvement processes would take into account the nature of services, demographics, social determinants of health and other factors.
When a hospital reports a safety concern, a remote NPSB team would evaluate and recommend changes in the culture and practices of the affected health system. The team would be made up of highly trained healthcare safety experts. (Most outside teams from organizations like the Joint Commission, CMS, or elsewhere do not have the expertise or respect to recommend security improvements.) The NPSB should be a partner of health systems, not a regulatory enemy, and existing agencies, such as CMS, should ensure that the CEO of the relevant provider organization has his or her employees implement the recommendations.
To encourage health care providers to avoid accidents or mistakes and to improve their ability to predict potential problems, the NPSB should support the establishment of a public-private continuous learning system in which all major healthcare players participate enthusiastically. One model is the CAST system in aviation.
3. Create a national reporting mechanism.
It must be robust and support real-time reporting of incidents. Executives can take advantage of electronic health record data to identify and track security incidents. Advanced EHR systems now enable the capture and automatic upload of measurements such as expected versus actual mortality, hospital-related complications, such as infections, pressure ulcers, medication errors, misoperations and personnel injuries. And the advent of advanced information systems makes it possible for hospitals, surgery centers and clinics to see patient results in hours, even minutes.
A national database would store the information, which patients and healthcare team members could access on request. We believe that timely data would motivate teams to focus on immediate improvement of safety systems. Existing CMS initiatives only show data from months old. Such retrospective quality reporting from CMS and other organizations has not reduced the variation in clinical outcomes, but the system we described would. By identifying hospitals with poor safety records (for example, those with a death rate five times that of their peers) and by motivating teams, the system we advocate would improve safety in the vastly improve healthcare.
4. Enable EHR’s machine learning systems.
These systems, which identify high-risk conditions that can lead to accidents or errors so that healthcare providers can intervene and prevent damage, are embedded in most EHR systems, but often do not work. Executive teams should use this software to understand the extent of damage occurring in their hospital.
There is an epidemic problem of poor safety in healthcare. Without meaningful national changes it will not heal itself. As has happened in aviation, we need to move from ineffective reactive to proactive to predictive by taking the coupled steps we have suggested. We should not punish when damage occurs, but instead create systems that support improvements in safety and ultimately address, for good, the safety issues that US hospitals still face.
This post 4 actions to reduce medical errors in US hospitals was original published at “https://hbr.org/2022/04/4-actions-to-reduce-medical-errors-in-u-s-hospitals”