This Web-assisted audio teleconference consisted of three sessions broadcast via the World Wide Web and telephone September 20, 30, and October 1, 2002. The program explored the business case for patient safety, how to overcome barriers, and practical solutions to help States and health care facilities improve patient safety. The User Liaison Program of the Agency for Health Care Research and Quality (AHRQ) developed and sponsored the program.
Cindy DiBiasi: Good afternoon. Welcome to Can You Minimize Healthcare Costs by Improving Patient Safety? This is the first in a series of three Web-assisted audio conferences for State and local health policymakers sponsored by the User Liaison Program within AHRQ, the Agency for Healthcare Research and Quality at the U.S. Department of Health and Human Services.
My name is Cindy DiBiasi and I will be your moderator for today's session entitled What is the Business Case for Patient Safety? Costs and Potential Cost Savings. This is the first event of this Web-assisted audio conference series on overcoming barriers and launching practical solutions to improving patient safety.
Why focus on patient safety at a time of budget crunches? Improving patient safety is not just a quality improvement strategy. It also may be a cost containment strategy and patient safety is directly related to the immediate crisis of workforce shortages, as we will discuss on our third call. AHRQ, in its capacity as a federal agency is playing an important role in supporting research and providing policymakers with information and tools to improve patient safety. State and local policymakers also play an essential role in addressing patient safety.
The goal of this series is to provide State and local policymakers and program administrators with insights regarding the business case for patient safety. We will also talk about methods to overcome barriers to launch practical solutions to help States and healthcare facilities to improve patient safety.
Let me tell you about each of the calls in this Web-assisted audio conference series. Today's call is entitled What is the Business Case for Patient Safety? Costs and Potential Cost Savings. It will explore the human and financial cost of errors, the potential cost savings from reducing errors and the cost and benefits of disclosing errors. Panelists will discuss healthcare purchasers as drivers of patient safety improvements. We will also hear examples of barriers and successes of State purchasers in addressing this issue.
On Monday, September 30, we will discuss how States and institutions can work together to create a culture of safety, concrete actions to improve patient safety. We will hear about the issues, opportunities, and strategies to create a culture of safety within healthcare institutions.
We will also be discussing ways in which federal, State and local governments can help facilitate this effort. Panelists will share information about evidence-based practices, leadership initiatives, and collaborative relationships between States and institutions.
On Tuesday, October 1, we will look at What do Workforce Issues Have to do with Patient Safety? Here we will examine the relationship between workforce issues and patient safety and specifically the link between healthcare shortages and medical errors. The call will highlight several State approaches to addressing workforce shortages and recent research findings on this topic.
Now I think we are ready to turn to the important matter of the business case for patient safety. Let me first introduce you to today's panelists. In the studio with me, I have Jim Mortimer, the president of the Midwest Business Group on Health. Joining us remotely from Boston is Delores Mitchell, executive director of the Massachusetts Group Insurance Commission, the employee benefit agency for the State of Massachusetts. Welcome, Jim and Dolores.
Dolores Mitchell: Glad to be here.
Cindy DiBiasi: Let's begin with Jim Mortimer. The Midwest Business Group on Health is an organization of about a dozen large and small companies in the Midwest that want to get better value for their healthcare dollars. Jim, I know that you have released a report that looks at the impact of healthcare quality problems on employers.
Jim Mortimer: Thank you, Cindy. Actually, our members do work together across an eleven-State region in the Midwest and they are leaders in trying to purchase quality healthcare. The report we have done is aimed at that question. We find that our members are not typical of the business community; that most employers are really focused on the cost of healthcare.
Cindy DiBiasi: What is the cost of poor quality healthcare?
Jim Mortimer: The cost of poor quality healthcare is unacceptable. We find that if people understand that, if they know what they are spending in their benefit plans, a significant part of that goes for in fact harmful care, poor quality healthcare, that they become more interested in the quality of care and that is really the reason that we have done this work. We want to see if we can get more public organizations, States, counties, more private purchasers to see that healthcare quality is a cost problem that they can do something about.
Cindy DiBiasi: When you talk about healthcare quality problems, what type of healthcare quality problems are you talking about?
Jim Mortimer: There are three kinds of quality problems that really are errors of different types. First is overuse. This is where people are having healthcare that they really don't need. We are all familiar with overuse of antibiotics but there are more things like going into the hospital for medical treatment that can be done more safely outpatient.
Under use is where people don't get care that they should have. Tests, follow through on chronic illness care, immunization, prevention, those kinds of things typically are under used.
The third category, misuse, is what people usually think of when they think of errors. This is where there are mistakes where medications weren't the right medications or diagnosis was done incorrectly. Some people even have surgery on the wrong limb. That is an error in healthcare.
The last part of this is errors in the administrative system. We have an unbelievably complex system and it creates its own kinds of problems, sometimes creates delays that are harmful to the person. So there is a lot to learn about healthcare quality problems. We are trying to make it easy for employers to see that and consumers to understand that so they know better what to expect from healthcare.
Cindy DiBiasi: Now just looking at this list it would seem to me that misuse might be the most relevant problem in terms of patient safety. Is that the case?
Jim Mortimer: I think so. There is an example on the next slide of preventable hospital-acquired infections. This where people may have surgery and get a wound infection that was avoidable. That causes lots of deaths, but also has a cost as well. The cost of caring for that misadventure is in the billions and that is on your slide, maybe $10 billion a year in this area.
There are other kinds of problems. The joint commission tells us that the number of incidents of wrong-site surgery is increasing and medication accuracy. Studies show that as much as 7 percent of the time there is errors in getting the right dosage and giving the right medicine to the right person in a complex inpatient healthcare system. So there are lots of different kinds of costly and harmful errors.
Cindy DiBiasi: Why should purchasers particularly be concerned about this poor care and what can they do about it?
Jim Mortimer: One reason they should be concerned is because it is invisible to them now. They really need to know more about it. They need to question things. They need to know about it because it varies a lot from one town to another. The kinds of quality problems you have are not the same. We know that it increases costs. We have estimated that. It also has an impact on productivity. Part of our estimate is related to absenteeism and lowered productivity that comes from that.
A real reason purchasers should know because in fact they are responsible for the problems we have got because we continue to pay for poor quality healthcare. Unknowingly we make it financially advantageous for the healthcare system to produce poor quality so we can take the blame for that one and realize that the system really isn't going to change until the purchasers change the financial system for healthcare.
Cindy DiBiasi: But what purchasing tools do we have to reduce these medical errors?
Jim Mortimer: Well there is a simple model that we put in the report and it is a circle where we think there is some steps that any purchaser can take to get a handle on this. One is to use the data that you have within your reach to understand what problems exist in your area, prioritize those problems and bring those problems in step two to the attention of your providers. That might be a health plan, it might be an insurance company, and it might be a hospital. It depends on the community. But bring your information to them, ask them more questions and see if they don't have some answers for how those kinds of problems can be addressed.
Third step, bring the employees in on this. Get them engaged. Let them know that there are reasons that they should be asking questions. In fact, give them good questions to ask. It is very empowering.
Lastly, pay for performance. Once you figure out what better quality is, and then you can identify it and measure it with your plans and providers. Then it is time to change how you pay for healthcare and make sure that you are rewarding good quality and that you stop paying for poor quality healthcare.
Cindy DiBiasi: Jim, can you give us an example of what a purchaser, a specific purchaser is currently doing?
Jim Mortimer: Dolores will give you some more of those in a minute from Leapfrog, but we do have a number of members who are doing good things with consumers. There is a booklet called Speak Up that the Joint Commission is producing. It is available on their Web site. It gives consumers good questions to ask. Some members are using a database called the Dartmouth Atlas of Healthcare, which is available on the Internet also to spot overuse and under use problems in their own communities. We have members that are contracting with centers of excellence where it has been shown that healthcare is superior for heart disease and other conditions. Working with health plans to measure their performance, put the dollar incentives down in the deal so that if they do better on those goals, they earn more. If they don't meet those goals, they owe the purchasers money back from the health plan.
Paying for performance with physicians. There are a lot of different examples that we can show for all of these steps in that four-part model. Those are in the report in more detail for people who want to read that and do some homework.
Cindy DiBiasi: We are going to get back to you with more on this because you have brought up a lot of interesting points and I am sure people have questions.
First we are going to turn to Dolores Mitchell. She is the executive director of the Massachusetts Group Insurance Commission to hear about the commission's experiences implementing plans to improve patient safety. Dolores, can you tell me a little bit about the Leapfrog Group and why the Group Insurance Commission joined?
Dolores Mitchell: I can and I am delighted to do so. I am delighted to be here with everybody this afternoon. Purchasers for a long time have been working on trying to improve the quality of healthcare that they provide for their members. Yeah, if you are spending a king's ransom on healthcare, it is nice to know that you are getting good quality for it and I think we have long since gotten tired of just handing the money over and not asking any questions. But quality is a very elusive concept to try to get across, not only for ourselves but for our members as well.
So when the Institute of Medicine report, To Err is Human, came out in 1999 indicating that somewhere between 44,000 and 98,000 people die in United States hospitals every year from unnecessary medical errors. There was a lot of media attention for a while. But you know, it is very hard to keep attention on any one issue in the public eye these days. Not just these days but always has been a problem particularly given the number of media outlets that we have got. There was a great concern that if they didn't seize the moment nothing would happen except another report having been filed.
So a lot of very heavy duty business leaders, and I am talking about organizations as big as General Motors, General Electric, Verizon, Boeing and so on, got together as purchasers using their clout as large purchasers to try to focus and keep some attention on this issue. The point was not just to publicize it but to try to mobilize employer purchasing power. To save lives and reduce medical errors. To use incentives for breakthroughs in improvement and safety to hold health plans accountable and to work with our employees. To tell them what the facts are and help them make good medical choices. To improve their healthcare and their chances of having a successful outcome when they go to a hospital.
With the help of the Business Group on Health, the National Business Council, they got together this group and put their heads together, looked at the studies that are out there and chose three issues to concentrate on. Keeping it simple, using that old principle of focusing attention on just a limited number of goals. Those three goals were to encourage hospitals to use computers. Physicians should enter pharmacy orders into a computer to avoid the obvious opportunities and the multiple opportunities for errors in transmitting what it is that they wanted to order and have delivered to the patient. To encourage health plans and employees to go to hospitals that do a lot of certain high-risk procedures, a limited number of them. Then to encourage hospitals to staff their intensive care units with physicians who are experts in and have credentials in intensive care. Too many of them are staffed by doctors who are the attending physician, somebody's home physician, who comes in in the morning and then leaves, but the critical care units need that full-time expert kind of care. So they concentrated on those three.
But let me stop there and maybe you want to chime in with another question and tell me where you want me to head.
Cindy DiBiasi: I do, thanks. You represent one State, but Massachusetts is one of the largest purchasers of healthcare in New England. What happened when you joined Leapfrog?
Dolores Mitchell: I thought what these folks were doing really had a lot of merit and joined maybe six months after it became a public entity, after they went public in I think the late fall of 2000. I got my commission to endorse our joining. That actually was an easy vote since the Business Group on Health was paying for it. I didn't have to get any dues out of them so that made the sell a little easier. But there was a great deal of enthusiasm about it. It resonated very, very well in the local press and the State senate sent me a plaque commending me for my good work. Everything seemed to be going swimmingly.
Then lo and behold the push back began. We asked our health plans to participate by finding out just the basic data because absolutely critical to what Leapfrog does is what is called Transparency. Making sure that it is publicly available knowledge and information as to what hospitals had these kinds of facilities and which ones did not and what the volume was that each hospital did of these high-risk procedures and the like.
Somewhat to our surprise there was enormous resistance. Now a certain amount of it I can understand. Hospitals are being asked to fill out surveys and to participate in all kinds of organizations and I can understand why there might have been a certain amount of resentment or resistance. But I was personally somewhat surprised to see how much there was. I am kind of an impatient person and maybe we pushed a little too hard too fast. But we did meet with a lot of reluctance to report.
So implementation becomes the hardest part and a lot of the push back that we got was in the form of why don't we just issue best practices and protocols? That is kind of the way we like to do business and set a standard for what ought to be. My objection to that is there are limitations on best practices and protocols because they are not self enforcing.
Maybe it is a little corny but I keep thinking that if you want to think about the earliest best practice ever known to man it is the Ten Commandments. It tells us how to lead a good life, a righteous life. But to the best of my knowledge, there is a lot of lip service paid to the Ten Commandments and sin somehow or other keeps on going. So those things which can be put into practice because somebody who is the purchaser, somebody who is the decision maker is going to see whether or not those things happen seemed to me to be the way to go. So we decided to push back to the push back. It has been a little bit of a rocky road and I hope I have a chance to tell you how it all turned out.
Cindy DiBiasi: You will, believe me, because now you really have our attention. Before we go there, tell me about some of the structural barriers that the Group Insurance Commission has faced in implementing the Leapfrog Group's recommendation?
Dolores Mitchell: Like most purchasers, we don't contract directly with health plans, excuse me, don't contract directly with hospitals but rather through health plans who in turn contract with hospitals. So there is an intermediary involved here. So we have to use those plans as the vehicle to get the kind of data that we were asking for. What I did is to put the requirement for collecting the data and making it available to us into the contracts that I signed with our HMOs. I am a great believer in showing how serious I am about getting the kind of information that I want or the performance that I want in a meaningful way. By meaningful I mean financial.
So we gave the plans three years to come up with the data and with some actual implementation activities with penalties as well as bonuses because I do believe in using both the carrot and the stick, and we penalized those who did not report on their hospitals and we have $100,000 per plan as a bonus for their moving some of their business to hospitals which meet those safety standards. That means there is over a million dollars on the table. I am kind of proud of our commission for having put that kind of money in play. There has been too little in the way of giving rewards and too much of kind of just exhorting people to do good. I think you should back up your exhortations with a little hard cash. So that is what we did. But the structural barriers really have to do with the fact that we can't deal directly with the hospital.
Cindy DiBiasi: But your barriers haven't been only structural, have they?
Dolores Mitchell: No. I think they are also economic and institutional. Timing in life is everything. This is a classic example of that. If you can have bad luck, it will happen. Early 2001 was not the best of times for most hospitals. An awful lot of them are having real financial troubles. Health plans themselves are under enormous attack as I think every body knows. Hospitals are consolidating, they are merging. They are going out of business and so on.
You could have chosen a better year to do this kind of thing but you have to deal with the cards you were dealt, so we move forward. I think we had to be mindful of and respectful of the economic barriers that the hospitals were facing.
Then we have the institutional barriers. Those I think were that the organized hospital associations have not been particularly supportive. They had criticisms of the three safety measures that were being promoted. They I think said that they were difficult or that it might be too hard for all but the most sophisticated and well-financed hospitals to meet those standards. I think looking back and maybe we again should have been a little bit more respectful of this issue, we are outsiders. We are not physicians. We are not hospital administrators and there we were saying this is how you should do your business. I think there was a certain amount of unspoken but very real resentment at outsiders interfering in their business. As I say, maybe we should have been a little more respectful of that reality and tried to figure out some ways to mitigate it.
Cindy DiBiasi: Do you sense the momentum shifting as you try to implement Leapfrog's standards?
Dolores Mitchell: If there weren't, I suspect nobody would have asked me to be on this program, frankly. I think a couple of things happened that made a difference. I don't think they are just unique to Massachusetts, I suspect that they happened elsewhere as well. We use a benefit consultant for a lot of our work and our benefit consultant acts as a kind of mediator and she got us to sit down with some selected hospital leaders and some national Leapfrog leaders to kind of thrash out the issues. For us to sit around the same table at the same time and for them to see that we were reasonably thoughtful people and that we didn't have horns. In turn we got to see that they had a point of view and that maybe we should have been a little more, a little better at reaching out to them and talking to them. But then some other things. That was a very important meeting.
Then a critical one was Dana Farber Hospital. It is a famous cancer hospital here in Boston. In 1996 they had a terrible medical error that occurred at that hospital that was very widely reported. I think in part because the patient who died had been a health reporter for the Boston Globe. She died of a miscalculation of a cancer drug. It was a very widely reported incident and that hospital said we are going to report. That really I think broke the ice in large measure.
We compromised. We agreed to report, to delay the reporting deadlines and to give them a chance maybe to work with their boards of directors and to convince some of the people in the hospital and they in turn agreed to report at a later date than we originally wanted. So it is sort of like negotiations in foreign policy and everything else. You have got to keep talking and people will be willing to shift their opinions and their positions just a little bit without losing sight of the major goal.
Cindy DiBiasi: Well it seems like you have learned a lot from this experience. Do you have anything you can share in terms of your experience with Leapfrog standards that you can share with other State purchasers?
Dolores Mitchell: Sure. I don't want to sound as though this is True Confessions, but I suppose in a way those lessons of diplomacy and tack and how you go about getting your goal are terribly relevant. They are probably just as relevant as the content of what you are trying to do.
I think I said earlier that patience was not my favorite virtue. I had to grit my teeth and try to have some. Quiet persistence maybe works a little better than noisy insistence. There is strength in numbers. In the Massachusetts area as Fleet Bank and Fidelity Investments and General Electric and Verizon joined with us in the Mass Business Group on Health, I think our voice got a little more convincing. Keep the message simple and focused. Don't demonize the other side, tempting though it may be. Particularly don't do it in public. Compromise on the small points. If you want to use that same phrase in the vernacular, it is don't sweat the small stuff. You can afford to give on a date by which something has to be done if that is what it is going to take to get those plans and those hospitals to report the data. I like to quote famous political figures. I suppose it is part of being in government. So here is one for you. Teddy Roosevelt said it. "Speak softly and carry a big stick."
Cindy DiBiasi: These look like good life lessons learned.
Dolores Mitchell: I guess so.
Cindy DiBiasi: We are going to come back because you have also had a couple of very interesting points and we are going to be opening the phones up for discussion and E-mail up for discussion for questions from our listening audience. We do encourage you to call.
There are three ways you can communicate your questions to us. If you are on the phone, please press "14" to indicate that you have a question. You may E-mail us your question at ulp@ahrq.gov and if you are logged on through the Internet you can click on the button marked "Q & A" on the Event Window and type your question in the field labeled "Send a Question", then just click on the "Submit" button. Please note that your sent message will not appear in the "Chat" box.
One important thing. If you prefer not to use your name when you communicate with us, that is fine but we would like to know what State you are from and the name of your department or organization. So please indicate that regardless of the way in which you transmit your questions.
Before going to questions, however, I would like to say a few words about our sponsor. The mission of AHRQ is to develop and disseminate research-based information that will help clinicians and other healthcare stakeholders make decisions to improve healthcare quality and promote efficiency in the way that healthcare is delivered. As you will be hearing during the course of these Web-assisted audio conference calls, AHRQ has sponsored some very valuable research that is directly relevant to patient safety.
AHRQ's User Liaison Program serves as a bridge between researchers and State and local policymakers. ULP not only brings research information to policymakers so that you are better informed, it brings your questions back to AHRQ researchers so that they are aware of the priorities in the State and local level. Hundreds of State and local officials participate in ULP workshops every year.
We will have audiotapes of this Web-assisted audio conference series available for purchase after all three events are completed. I will give further details about this at the end of today's show.
If you did not receive a copy of the slides presented in this series prior to the broadcast, you may request a copy by sending your E-mail message to ulp@ahrq.gov and please indicate whether you would like the slides for the entire series or for specific presentations.
Finally, an archive of these events will be available on the AHRQ ULP Web site in several weeks' time. The URL is www.ahrq.gov/news/ulpix.htm. We would appreciate your feedback about today's program and at the end of the broadcast a brief evaluation form will appear on your screen. Its easy-to-follow instructions are included on how to fill this out. Also you can E-mail your comments to the AHRQ User Liaison Program at ulp@ahrq.gov.
So again we do encourage you to write in or call in. That is even better because then we can do follow-up questions with you. But in the meantime let me ask some questions of our presenters today.