HHS aims to cut medical errors
WASHINGTON – Department of Health and Human Services officials have launched a new program, developed under the Affordable Care Act, aimed at eliminating medical errors on a national scale.
The program, Partners for Patients, will use data collection and health IT systems to help prevent medical errors that could potentially save up to $50 billion and help save 60,000 lives over the next three years, according to HHS Secretary Kathleen Sebelius, who spoke at an April 12 news conference.
Sorrel King, patient advocate and a mother who lost a child to medical errors, said medical errors cause the same number of deaths as a jumbo jet crashing every day, yet not enough has been done to fix the problem. "We cannot keep going at the pace we've been going," she said.
HHS will initially invest $1 billion for the program for a total medical error elimination demonstration project and a nationwide education program, according to Sebelius. Leaders of major hospitals, employers, health plans, physicians, nurses, and patient advocates have pledged commitment to the initiative, she said.
Some of the first goals will include cutting hospital-acquired infections in Medicare patients by 40 percent and readmissions by 20 percent over the next three years, Sebelius said.
Donald Berwick, MD, administrator of the Centers for Medicare & Medicaid Services (CMS), said the program is not about blaming healthcare providers for medical errors. It is about supporting them by spreading knowledge of best practices; transparency; and "very thoughtfully, respectfully" providing incentives for providers that reduce medical errors.
"The workforce is not the problem," Berwick said. "Doctors, nurses, pharmacists, managers, all want to do no harm. They try to do that everyday, in everything they possibly can. Still, millions get injured because of defects in the system, despite the heroic efforts of providers."
Berwick said HHS would not approach the program as "one size fits all," but would focus on local strategies. A top-down approach will not work, he said.
The program will initially target all forms of harm to patients but will start by asking hospitals to focus on nine types of medical errors and complications, including preventing adverse drug reactions, pressure ulcers, childbirth complications and surgical site infections, Berwick said.
Innovation center to help
The program's new innovation center will help hospitals adapt effective, evidence-based care improvements to target preventable patient injuries on a local level, developing innovative approaches to spreading and sharing strategies among public and private partners in all states, he said.
In addition, CMS will be launching a pilot within the next few months that will involve vanguard healthcare organizations striving to eliminate virtually all medical errors, Berwick said.
Achieving even the minimal goals will require: will and culture change from providers; education on best practices; and execution on a national scale, Berwick said.
"Why not bring excellence to full scale?" he asked. "We are in this together. We have to be in this together. The enemy is not each other; the enemy is harm itself."
Berwick said stakeholders across the board have stepped up to participate. "I have been working on patient safety for the better part of 20 years, and I've never seen anything like this," he said.
"Game on," Sebelius said at the close of the press conference.
Widespread support
The program is enjoying widespread support from key stakeholders.
David Cote, CEO of Honeywell and Business Roundtable member said, "We think this could be huge." He predicted there would be "howls of protest," over the need for metrics, though metrics are "an essential part of the process."
"We can't support anything that doesn't produce a quality outcome," Cote said. "It doesn't make sense."
America's Health Insurance Plans President and CEO Karen Ignagni said AHIP supports the effort. “We pledge to work together with the public sector and other stakeholders to further reduce hospital admissions and prevent hospital acquired infections,” she said.
Leaders of the Business Roundtable are urging all purchasers of employer-sponsored health coverage to use market-based incentives to promote improvements in safety and to work with other private payers, states and the federal government to measure performance on quality and safety.
Rich Umbdenstock, president and CEO of the American Hospital Association said AHA is committed to the new program. "The AHA will be an active partner with HHS in this effort and we will spotlight best practices and share them broadly with the field and link them to the assistance HHS is making available," he said.
The HHS announcement follows Rep. Paul Ryan's (R-Wis.) recent proposal to convert Medicare and Medicaid into consumer-directed health systems by replacing current programs with tax credits and vouchers. According to Ryan, his plan would encourage consumers to purchase the safest and most efficient healthcare. At the news conference Sebelius said Ryan's plan does not do enough to address quality of care.