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Medical News & Perspectives

Patient Safety Still Lagging

Advocates Call for National Patient Safety Monitoring Board

Bridget M.Kuehn,MSJ

Hospitals and ambulatory care cen-

ters remainrisky places for US pa-tientsdespite more than a decade

of national effortsto improve patientsafety,

according to testimony at a US Senatesub-

committeehearing,webcastonJuly17,2014

(http://1.usa.gov/UaVr7g).

Thissobering assessment comesat the

15-yearanniversary of the release of a semi-

nal report from the Institute of Medicine

(IOM) on patient safety (To Err Is Human:

Building a Safer Health System. Washing-

ton, DC: Institute of Medicine; 1999).

The report estimated that 98 000pa-

tients died each year as a result of medical

errors. Ashish Jha, MD, MPH, a professor

ofhealthpolicyandmanagementattheHar-

vard School of Public Health, testified

that evidence suggests that the IOM likely

underestimated patient harm. A more re-

cent estimate suggests the number of US

deaths as a result of medical error may top

400 000 per year, more than 1000 each

day (James JT. J Patient Saf . 2013;9[3]:122-

128).

“If I walk into a hospital today, would I

besaferthan15yearsago?”saidJha.“Thean-swer is ‘no.’”

There have been some advances. One

area where substantial progress has been

made is in reducing central line–associated

bloodstream infections, an effort led by

PeterPronovost,MD, PhD, seniorvice presi-

dent for patient safetyand quality at Johns

HopkinsMedicine in Baltimore. Provost cre-

ated a program to reduce central line–

associatedinfectionsbyempoweringnurses

to use checklists to ensure precautions are

taken. Thechecklist helped Michiganinten-

sive care units reduce central line–associ-

atedbloodstreaminfectionsby66%andal-

lowed 65% of the participating units to

eliminatetheseinfections(KuehnBM. JAMA.2012;308[16]:1617-1618).

The program, which has been ex-

panded nationwide,is successful because it

counters theconventional wisdomthat cen-

tral line infections are inevitable with ro-

bust, transparent data, said Pronovost.

In testimonyat thehearing,Pronovost

said that one of the biggest barriers to im-

proved patient safetyis thelack of a robust

national system for tracking patient safety

data. He said the US Centers for Disease

Control and Prevention (CDC) has a good

systemfortrackinghealthcare–acquiredin-

fections. That system,he argued, should beexpanded to track other types of patient

harm.

The consumer advocacy organization

ConsumersUnion supports more CDC data

monitoring and greater data transparency,

testified LisaMcGiffert,director of Consum-

ersUnion’sSafePatientProject.Shesaidthat

31 states and the District of Columbia re-

quire public reporting of health care–

associated infections. In addition, a na-

tional patient safety monitoring board

should be created to provide regulatory

oversightofpatientsafetyinthemedicalsys-

tem, she said.

Greater sanctions are also needed

against facilities that are failing to improve

safety, Pronovost said. He noted that sev-

eral hundred US hospitals have infection

rates 10 times higher than the national av-

erage, yet they do not face sanctions from

Medicare or anyother regulatorybody.

Bettersystemsofcarearealsoneeded,

several of the speakers testified. Joanne

Disch,PhD,RN,pastpresidentoftheAmeri-

can Academy of Nursing, explained that ahost of factors—such as the complexity of 

hospital systems, time pressures, growing

use of technology, and financial incentives

thatrewardhospitalsbypayingthemtocare

for patients’complications—allcontributeto

poor patient outcomes.

Hospitalculturesthatdiscouragenurses

fromspeaking up whenthey identify safety

issuesorthatfailtogivenursesasayinbed-

side staffing levels also increase the likeli-

hood ofpatientharm. “Nursesare often the

last line of defense,” Disch explained. She

Medical News & Perspectives.......p879

Patient Safety Still Lagging

IOMReport Calls forOverhaul of Graduate

Medical Education

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Despite some advances in patientsafety in the

UnitedStates, such as reductionsin central

line-associated bloodstream infections, medical

errorsremain a major problem, a newreport says.

News & Analysis

 P . M a r a z z i , M D / w w w . s c i e n c e s o u r c e . c o m

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argued that it’stime to shift away from bu-

reaucratic,patriarchalleadershipmodelsand

toward “high-reliability organization” mod-

elsused in aviation andother industries.

Greater attention is also needed to pa-

tient safety outside of hospitals, said Tejal

Gandhi, MD, MPH, president of the Na-

tional Patient Safety Foundation and asso-

ciateprofessorofmedicineatHarvardMedi-cal School. She noted that most care is

deliveredinnonhospitalsettings,suchaspri-

mary care clinics, nursing homes, and am-

bulatory surgical centers, yet most patient

safety efforts focus on hospitals.

Better data and monitoring of patient

harmsinthesesettingsareneeded,shesaid.

Patient handoffs from one facility to an-

other can be particularly perilous. For ex-

ample, patients are often transferred to a

new facility only with their medical record

and no discussionbetween caregivers. She

said clinician-to-clinician discussions alone

can help pass on vital information.Jha noted that better integration be-

tween facilities andsmarter useof technol-

ogy can helpimprove patient safety. Forex-

ample,henotedthatcurrentlymanynursing

homes and rehabilitation facilities do not

have electronic health records, in part be-

cause federal incentives haven’t been ex-

tendedto them. This meansrecords forthe

sickest, mostcomplicated patients mustbe

faxed, he said.

Ultimately, improvingpatient safetywill

require that theUS health system realign fi-

nancial incentives, said Jha. He and other

speakers noted that a hospital chief execu-tive officer’s (CEO’s) compensation is often

not tied to quality of care.

“Until hospital CEOs are lying awake at

nightworryingaboutsafety,it’snotgoingto

happen,” he said.

IOMReport Calls for Overhaul ofGraduateMedical Education

KateO’Rourke,MA

Anew report from the Institute of 

Medicine (IOM) strongly urges Con-

gress to overhaul thefederalfinanc-

ingandgovernanceofgraduatemedicaledu-

cation(GME).Thereport,producedafteran

extensive assessment of physician resi-

dency training funding, recommends the

creation of new infrastructure for fund dis-

tribution and research into improved pay-

ment models.

Unsurprisingly, given the sweeping

changes proposed by the IOM committee,

the report has sparked criticism from vari-

ous medical groups, including the Associa-

tion of American Medical Colleges (AAMC),

the American Hospital Association (AHA),

the American Medical Association (AMA),

and various specialty organizations.

Altering thePayment System

“The short-term recommendations involve

improvingthepaymentmethodologyinways

thatwilladdresssomeexistinginequities.The

longer-term involves moving from a cost

reimbursement-basedpaymentsystemtoanoutcomes-basedpaymentsystem,”saidDebra

Weinstein,MD,vicepresidentforGMEatPart-

ners Healthcare System in Boston. She is a

memberoftheIOMCommitteeontheGover-

nanceandFinancingofGraduateMedicalEdu-

cation, which produced thereport.

Annually, the federal government pro-

vides $15billion forgraduatemedical educa-

tion,90%ofwhichcomesfromMedicareand

Medicaid. The IOM recommendations focus

onchangesforMedicare,whichprovidesthe

bulk of the money.

Currently, Medicaredistributesits funds

for residency training to teaching hospitals

through complicated formulas linked to the

volume of Medicare patients treated at a

hospital.According to theIOM, this system

is flawed because it discourages training in

community-based settings, where most

people obtain their health care. The report

alsosaysthereisastrikingabsenceoftrans-

parency and accountability for how the

funds are used.

“Frequently, the education director in

thehospitalwasthelastpersonwhohadany

idea of what happened to the money,” said

Gail Wilensky, PhD, the committee’s co-

chair andan economist andsenior fellowat

Project HOPE.

The committee concluded that Medi-

careshouldcontinuetofundGMEatthecur-

rent level but should repurposeand reposi-

tion the funding. It recommends creating a

2-part governance infrastructure for Medi-

care GME financing. A GME Policy Council,

housedintheDepartmentofHealthandHu-

man Services, would oversee policy devel-

opment and decision making. A GME Cen-

ter, housed within theCentersfor Medicare

& Medicaid Services, would function as an

operations center with the capacity to ad-

ministerpaymentreformsandmanagedem-

onstrations of new payment models.

The report recommends allocating the

Medicare GME funds to 2 distinct subsid-

iaryfunds.AGMEoperationalfundwouldfi-

nance ongoing residency training activi-

ties. A transformation fund would finance

the development of new programs, infra-

structure,performance methods, payment

A new report, produced afteran extensiveassessment of physician residency training funding, urges

Congress to overhaul the federal financing and governanceof graduate medical education.

News& Analysis

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