The Status of Patient SafetyDonald M. Berwick, MD, President and CEO

Institute for Healthcare Improvement

10th Anniversary of To Err is Human

The Commonwealth Fund and Alliance for Health Reform

March 17, 2010: Washington, DC

Topics

1. Trends, Impact, and Gaps in Patient Safety

2. Priorities for Closing the Gaps

3. Constructive Roles for the Federal Government

4. A Vision for the 20th Anniversary of To Err Is Human

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Trends since 1999• Firm documentation of widespread,

avoidable harm to patients.• Better understanding of the “safety

science.”• Better methods of detection and

measurement.• Better appreciation of a “culture of

safety.”• Breakthrough results in some

organizations.3

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0 50 100 150 200 250

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Hospital Standardised Reimbursement Ratio (HSRR 2007)

HSRR vs HSMR - Hospital Standardised Mortality Ratio vs Hospital Standardised Reimbursement Ratio (2007 Medicare Data)

Hospital Standardized Mortality vs. Hospital Reimbursement

Source: Sir Brian Jarman 2009

Institute for Healthcare Improvement Safety Campaigns

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2004-2006

2006-2008

The Campaign “Planks” -- Twelve Changes for Safety

1. Rapid Response Teams

2. Evidence-Based Care for Heart Attacks

3. Medication Reconciliation

4. Prevent Central Line Infections

5. Prevent Surgical Site Infections

6. Prevent Ventilator-Associated Pneumonias

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The Campaign “Planks” -- Twelve Changes for Safety

7.Prevent Pressure Ulcers

8.Reduce Methicillin-Resistant Staphylococcus Aureus (MRSA) Infections

9.Prevent Harm from High-Alert Medications

10.Reduce Surgical Complications (the Surgical Care Improvement Project (SCIP))

11.Evidence-Based Care for Congestive Heart Failure

12.Get Boards on Board

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Sentara Williamsburg (Virginia)Zero Ventilator Pneumonias in Five Years!

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Seton Family of Hospitals (Austin, TX)Birth Trauma Prevention

One Birth Injury in 10,000 Deliveries

Pressure Ulcer

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Error Reduction at Ascension

Preventable Error Reduction in Rate

Pressure Ulcer

Neonatal Mortality

Birth Trauma

Ventilator-Acquired Pneumonia

Falls with Serious Injury

Bloodstream Infections

95%

79%

74%

56%

54%

32%

Palmetto Hospital Mortality Rates(South Carolina)

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Does Improving Safety Save Money?

IMPROVEMENT COST SAVINGS NET

SURGICAL INFECTIONS

($110,000) $540,000 $430,000

BLOODSTREAM INFECTIONS

($22,500) $4,780,000 $4,757,500

VENTILATOR PNEUMONIAS

($1,268,500)(Reduced Revenue)

$1,166,400 ($102,100)

RAPID RESPONSE TEAMS

($390,000) ? ($390,000)

TOTAL ($1,791,000) $5,320,000 $4,695,400

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HENRY FORD HEALTH SYSTEM

Closing Gaps – What Now?

• Governance – Boards – responsible for safety

• Better measurements of safety levels

• More transparency

• Science to devise standards that work

• “National learning systems” to spread the successes – Make “the best” become “the norm”

• National stewardship – a “public health” model

• Consequences for inaction

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How Government Can Help:“Will, Ideas, and Execution”

GAP GOVERNMENT

Boards responsible for safety Map into accreditation standards

Better measurements of safety levels

Support prompt, active research on measurements of safety

More transparencyFurther develop Medicare data,

measurement, and reporting capacity

Science to devise standards that work

Support research on safety sciences and health care process designs

“National learning systems” to spread the successes

Develop public and private “extension” capacities for knowledge management

National stewardship – a “public health” model

Annual reports on quality and safety, with Congressional and Executive review

Consequences for inactionUnlink payment from volume; study “no

pay” for defects16

“20th Anniversary Report”

• Injury Rates in American Hospitals Measured and Tracked

• National and Regional “Learning Systems” Spread Good Practices

• Safety Education Routine in Health Professional Development

• Health Care Sets a Benchmark for High-Hazard Industries

• Patient Injuries Reduced by 90% from 1999• Health Worker Injuries Reduced by 90%

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The “Triple Aim”

PopulationHealth

Experienceof Care

Per CapitaCost

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How Do They Do That?High-Performing Communities in American Health Care

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$10,250 to 17,184 (55)9,500 to < 10,250 (69)8,750 to < 9,500 (64)8,000 to < 8,750 (53)6,039 to < 8,000 (65)

Not Populated

Everett, WA

Sacramento,CA

Temple, TX

Tallahassee,FL

La Crosse,WI Cedar

Rapids, IA

Sayre,PA

Portland, ME

Richmond, VA

Asheville, NC

Price Adjusted Spending

2006

Increase in Spending

1992 – 2006

Annual growthrate

All Others (232) $9,695 $3,376 3.6%

Qualifying (74) $8,212 $2,645 3.4%

Participants (10) $7,924 $2,297 3.0%

Potential Annual Savings: 12.7% - 16.2%

What Are They Doing?

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Per-Capita Spending – and Spending Growth – Are Lower.