In the 21 years since the National Academy of Medicine published To Err is Human, there has been a significant effort to improve safety and reduce the variation in health outcomes in the United States. Still, an estimated 1.2 million are harmed each year by medical errors made in US hospitals. We outline below necessary steps to change this.
Even in geographies that have a reputation for high quality care (such as metropolitan Boston and metropolitan New York) there is a five times greater chance of death from acute myocardial infarction (heart attack), depending on the hospital one chooses. Across the United States, on average, patients are twice as likely to die in the lowest-performing hospitals. This includes a 2.3-fold difference in heart attack mortalities. There are even greater differences in safety. The top 10% of hospitals are 10 times safer than bottom 10%. Patients are 18 times more likely to suffer a bloodstream infection from a central venous catheter when treated at poor-performing hospitals.
Existing processes such as Joint Commission Surveys, surprise reviews by the Centers for Medicare & Medicaid Services (CMS), internal improvement processes, and retrospective public reporting of safety by government and public entities have not worked to reduce variation.
Why do these risks and variations persist?
Variation is partly due to the time it takes to implement evidence-based medicine research. Research suggests this can take up to 17 years. Hospitals that are quick to incorporate evidence-based medicine perform better. Unfortunately, few have embraced the strategies of the best hospitals. Since there is no central system of accountability, hospital leaders have little imperative to assure clinical practice is based on the most up-to-date evidence.
Economic and emotional factors can also hamper safety if hospital leaders allow it. When one of us (John Toussaint) was CEO of a large health system, heart surgery was performed at two hospitals, neither of which met the case volumes to achieve the highest quality of care. (It is well known that volume of heart surgeries is directly correlated to outcomes.) The health system’s administration decided to consolidate the programs and have the same surgeons do all the surgeries at one hospital. The heart surgeons and other doctors practicing at the hospital that was going to lose the procedures complained that the hospital’s reputation would be tarnished and would negatively affect their individual practices. The leaders of the health system consolidated the program anyway, and mortality rates dropped.
During the Covid-19 pandemic, we have seen instances where surgical staffs resisted universal Covid-19 screening for ambulatory surgery patients, worried it would result in delays (and deferred fees) if testing revealed asymptomatic cases. This was even though patients who did have the virus would have intimate contact with caregivers and other patients during procedures and follow-up care.
Government accreditation requires legal structures to be in place to ensure quality and patient safety. For example, regulations require hospitals to appoint a quality committee of the board. But safety is something that a hospital’s board of trustees is ill-equipped to govern. While boards receive monthly or quarterly quality updates, which occasionally include a root-cause analysis of safety concerns, board members, who are volunteers, typically do not have the expertise to understand how complex hospital processes work or what to change when something goes wrong. Therefore, hospital safety rests with the professional managers of the executive leadership team; their level of commitment determines performance.
Regulations also require that every hospital has a process to appoint doctors to a hospital medical staff based on documented credentials from training programs and other regulatory bodies. The medical staff appoints a committee of doctors (usually the medical executive committee or professional affairs committee) to oversee the quality of care delivered by the members of the medical staff. Unfortunately, this a bit like the fox watching the chicken coop. If there are safety problems related to an individual practitioner, it is difficult for committee members to make decisions that could negatively impact another doctor’s practice.
Here are four measures that would fix the deficiencies in safety at US hospitals.
1. Make patient and staff safety a top priority.
Safety is dependent on the organization’s culture — the sum of the behaviors of leaders and staff. A top-down management approach that discourages team members from speaking up about problems leads to poor safety outcomes. On the other hand, when frontline workers have the confidence to “stop the line” for a safety problem (eg, call out a problem during a surgery) and management supports them with a robust, relentless response focused on helping them solve the problem, the result is a safer place for patients.
Accordingly, the board and executive leaders of the hospital or health system must make safety imperative, and the management system should support daily improvement of safety practices that build changes into operations and reinforce a safety culture. This should include real-time system-wide sharing of the problem and solution. Health care industry leaders in safety performance such as Cleveland Clinic and Intermountain Healthcare use robust daily improvement practices directly tied to operations to improve safety.
2. Establish a national safety organization.
When the airline industry was regularly crashing planes in the 1970s, the US federal government stepped in to create the National Transportation Safety Board (NTSB) and encourage the creation of the CAST real-time learning system. Expert safety teams examine each accident — an assessment that includes a review of safety systems and culture — and then recommend measures to prevent future events. NTSB continually updates safety standards based on new learning across the industry. The transportation industry has grown to respect the expert opinion of the team and implements most recommendations.
We believe the creation of a National Patient Safety Board (NPSB) — something that a broad coalition of stakeholders has proposed — could perform a similar job in health care. The NPSB would not be a regulator; it would function as a facilitator for changing of safety practices in hospitals. Its standards for specific practices and improvement processes would take into account the nature of the services, demographics, social determinants of health, and other factors.
When a hospital reports a safety problem, an outside NPSB team would evaluate and recommend changes in the culture and practices of the health system in question. The team would consist of highly trained experts in health care safety practices. (Most third-party teams from organizations such as the Joint Commission, CMS, or expertise elsewhere, do not have the or respect to recommend safety improvements.) The NPSB should be a partner with health systems, not a regulating enemy, and existing bodies , such as CMS, should ensure that the CEO of the provider organization in question has his or her staff implement the recommendations.
To encourage care providers to prevent accidents or errors from occurring in the first place and to improve their ability to predict potential problems, the NPSB should support the creation of a public-private continuous learning system in which all the major players in health care enthusiastically participate . A model is the CAST system in aviation.
3. Create a national reporting mechanism.
It should be robust and should support real-time reporting of incidents. Leaders can take advantage of data from the electronic health records to surface and track safety incidents. Sophisticated EHR systems now allow for the capture and automatic upload of measures such as expected versus actual mortalities, hospital-acquired complications, such as infections, pressure ulcers, medication errors, wrong-sided surgeries, and staff injuries. And the advent of advanced information systems makes it possible for hospitals, surgery centers, and clinics to see patient results within hours, even minutes.
A national database would store the information, which patients and health care team members could access on demand. We believe timely data would motivate teams to focus on immediate improvement in safety systems. Existing CMS initiatives only display months-old data. Such retrospective quality reporting from CMS and other organizations has not reduced the variation in clinical outcomes, but the system we have described would. By identifying hospitals with poor safety records (eg, those with mortality rates five times their peers’) and motivating teams, the system we advocate would vastly improve safety in health care.
4. Turn on EHR’s machine-learning systems.
These systems, which signal risky conditions that could give rise to accidents or errors so caregivers can intervene and prevent harm, are embedded in most EHR systems but often are not operating. Executive teams should use this software to understand the degree of harm occurring in their hospital.
There is an epidemic problem of poor safety in health care. Without meaningful national changes, it will not cure itself. As happened in aviation, we need to go from ineffectively reactive to proactive to predictive by taking the linked steps we have proposed. We should not punish when harm occurs but instead create systems that support safety improvement and finally tackle for good the safety problems still plaging US hospitals.