New Patient Safety Initiative Stresses Teamwork, Not Blame

April 12, 2011

April 12, 2011 — A new $1 billion federal initiative to reduce medical errors in hospitals, such as catheter-related infections, and avoid unnecessary readmissions promises to save 60,000 lives and $10 billion in Medicare spending through 2013, federal officials announced today.

Over 10 years, the Medicare savings could reach $50 billion, with billions more saved in Medicaid spending.

Dr. Donald Berwick

Achieving the ambitious goals of the new Partnership for Patients program is not a matter of telling physicians, nurses, and other clinicians to be more careful, said Donald Berwick, MD, administrator of the Centers for Medicare and Medicaid Services (CMS). Instead, the key to success is fine-tuning the system they work in.

"The workforce is not the problem," said Dr. Berwick at a news conference today. "Doctors and nurses...want to offer safe care. They learned 'do no harm' in their training. In spite of that, patients get injured because of defects in the care system.

"Blame and accusations are not the answers. Teamwork and improvement are the answers. Commercial air travel didn't get safer by exhorting pilots to please not crash. It got safer by designing planes and air travel systems that support pilots and others to succeed in a very, very complex environment. We can do that in healthcare, too."

Illustrating the system-wide challenge of attacking problems as basic as patient falls, the new federal program brings together a diverse coalition of groups such as the American Medical Association, the American Nurses Association, major hospitals, employers, health plans, unions, patient advocates, and state and federal agencies.

"Doing It Right Costs Less Than Doing It Wrong"

The Partnership for Patients has 2 specific objectives. The first objective is to decrease the number of preventable, hospital-acquired conditions by 40% by the end of 2013 compared with 2010. The second objective is to improve follow-up care after discharge from hospitals and other facilities and, as a result, reduce hospital readmissions by 20% — what officials describe as "healing without complication."

CMS will spend up to $1 billion in funds allocated under the new healthcare reform law, known as the Affordable Care Act, to reach these objectives. The new Innovation Center at CMS will invest up to $500 million in pilot projects to reduce hospital-acquired conditions and improve patient hand-offs. These experiments initially will target 9 types of medical errors and complications, including adverse drug reactions, childbirth complications, surgical site infections, and pressure ulcers.

The new Community-Based Care Transition Program at CMS will award another $500 million to community-based organizations that partner with hospitals to offer comprehensive follow-up care within 24 hours of a patient's release. "We know that if a patient's primary care physician receives their discharge papers within 24 hours, the likelihood of a hospital readmission will be reduced," said American Medical Association President Cecil Wilson, MD, at the press conference.

Kathleen Sebelius

Health and Human Services Secretary Kathleen Sebelius underscored the need for the Partnership for Patients program today by citing a new study published in the journal Health Affairs. The study found that adverse events occur in roughly 1 in 3 hospital admissions, or at 10 times the number previously estimated.

At the same time, Sebelius pointed to hospitals that have made tremendous strides in making care safer. By adopting sophisticated production processes from the carmaker Toyota, for example, Virginia Mason Medical Center in Seattle, Washington, has reduced the number of patient falls by 25%, and bed sores by 75%. In addition, introducing a surgery checklist developed by Johns Hopkins Hospital in Baltimore, Maryland, helped a coalition of Michigan hospitals decrease the occurrence of a common infection by two thirds, saved 1500 lives, and cut costs by $200 million in just 18 months.

One major thrust of Partnership for Patients is taking best practices found at patient safety superstars such as Virginia Mason Medical Center and sharing them with other organizations. Dr. Berwick summed up that approach with the mantra "If there, why not everywhere?"

Both Dr. Berwick and Sebelius said that the new program works hand in hand with the new healthcare act, which measures and pays for the kind of high-quality, coordinated care envisioned in the initiative. In addition, similar to the Affordable Care Act, Partnership for Patients addresses the problem of runaway healthcare costs.

"The options are either to cut care or improve care," said Dr. Berwick. "I'm against cutting. I'm for improving. Doing [healthcare] right costs less than doing it wrong."

For more information about Partnership for Patients, visit the HHS Web site.

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