By David Mayer, MD, CEO of The Patient Safety Movement Foundation
Creating safe care for everyone requires a collaborative effort from patients, providers, vendors, health care leaders, federal and state legislators, plaintiffs and defense attorneys, health insurance companies, and medical societies. For too long, the healthcare system has operated in silos, addressing singular focuses to improve patient care – such as central line infections and ventilatory associated pneumonia bundles, pulse oximetry to detect and treat opioid respiratory depression. Yet, each year its estimated that there are over three million patient deaths and many millions more are harmed while receiving care. These numbers are only estimates, as there is currently no accurate method for measurement and we lack a national and global commitment to standardize metrics and there is no requirement that the frequency and severity of all medical errors, or the resulting patient outcomes, are reported to the public or even to regulators.
While single focuses have set the foundation, it is time we swing for the fences and strive for a home run to eliminate preventable medical harm. To achieve this goal, the Patient Safety Movement Foundation has called for a Patient Safety Moonshot™. Similar to other “moonshot” goals in the past – such as landing on the moon, eradicating polio or curing hepatitis C – this audacious goal requires a collaborative and comprehensive effort. One where no shortcuts can be taken.
To hit a home run, requires covering all the bases. Let’s dive into how we can get there.
FIRST BASE – IMPROVE SAFETY DATA TRANSPARENCY
Patients should be able to easily access information about providers and healthcare systems to make informed decisions about where to seek care. However, fear of litigation, blame or loss of reputation have made organizations and clinicians fearful of being transparent with patients and families about medical errors that have occurred. To overcome this obstacle, decision makers need to acknowledge the lack of transparency and its root causes, as well as seek out a solution to ensure patient safety data is available to the public.
Historically, medical errors have resulted in a “deny and defend” culture. However, organizations that have shifted the focus to system failures instead of individual blame have made it easier to identify the cause of harm and remedy the situation. In fact, the Agency for Healthcare Research and Quality (AHRQ) introduced the CANDOR (Communication and Optimal Resolution) program to help organizations address these situations and when properly implemented it has been shown to increase transparency, improve patient outcomes, lower healthcare costs and foster continuous learning. By opening the conversation and improving transparency, the healthcare systems can benefit from shared learning.
SECOND BASE – ALIGN INCENTIVES
Healthcare systems are currently paid according to the volume of hospitalizations, visits and procedures completed. This current incentive model rewards unnecessary care or overtreatment, which increases both cost of care and risk of harm. It also does not hold healthcare systems financially responsible for preventable medical harm. To get past second base, it is important that healthcare financial incentives are aligned with the goal of systemic prevention of all causes of harm in all care settings and payments are based on quality and safety-related outcomes of care.
THIRD BASE – ESTABLISH REGION-APPROPRIATE OVERSIGHT AND SHARED LEARNING
Lack of regional oversight has made it possible for physicians to move from one healthcare organization to another with little oversight. However, healthcare is an industry that needs to become highly reliable like aviation, nuclear power and the oil industry. Yet, the U.S. currently has no agency, authority or administration that independently reports, conducts reviews and shares learning on a national and regional level for the healthcare system. Creating a National Patient Safety Board, similar to the National Transportation Safety Board (NTSB), an independent investigative agency responsible for investigating civil transportation accidents, can help ensure healthcare organizations share learnings that put evidence-based safety processes and training programs in place.
We can’t hit preventable patient harm out of the park, without covering our bases. The time has come that we load the bases for a “grand slam” home run that seriously addresses the preventable medical harm crisis in this country. Every base needs to be covered before we can truly achieve this goal. Reaching zero preventable patient deaths by 2030 is no doubt an audacious goal, but it is one that is necessary. So, let’s step up to the plate and hit this home run together. To learn more about the Patient Safety Moonshot or how to get involved, please visit: https://patientsafetymovement.org/advocacy/policy-makers/patient-safety-moonshot/
About the Author: Dr. David Mayer joined the Patient Safety Movement Foundation as the CEO in 2019 bringing decades of experience in both the public and private sector. In his concurrent role as executive director of the MedStar Institute for Quality and Safety (MIQS) he is responsible for leading specific quality and safety programs in support of discovery, learning and the application of innovative methods to operational clinical challenges.
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