Best Practices: New Strategies to Reduce Medical Errors

Opening Remarks on Medical Error Reduction
The Mayflower Hotel, Washington, DC
February 22, 2000
Henry E. Simmons, M.D., M.P.H., F.A.C.P.
President, National Coalition on Health Care

Good morning and welcome everyone to our conference on “Best Practices: New Strategies to Reduce Medical Errors.” Before I begin my formal remarks, I want to take a moment to acknowledge a number of people who were instrumental in the development of the report you are about to hear and in organizing this conference. I want to especially thank Dr. Lucian Leape for all his efforts in chairing the work group that helped identify the success stories in the report. And also the error reduction work group members — Dr. Donald Berwick, who is President of the Institute for Healthcare Improvement (I.H.I.) and our partner in this initiative, Doctors’ Ellison Pierce, Steven Meisel, David Bates, Marilyn Sue Bogner. Three of our senior Coalition staff also did a great deal of work in organizing today’s seminar. They are Dr. Peggy Rhoades, our Executive Director, Pat Shoeni, our Director of Public Affairs, Alyssa Keefe, Pat’s associate, and Joel Miller, our Policy Director. Also, thanks to our former staff member Steve Findlay, for his work in organizing and editing our report. Thank you all for an excellent product.

I am Dr. Henry Simmons, President of the National Coalition on Health Care, which is the nation’s largest and most broadly representation alliance working to achieve the comprehensive reforms necessary to address the three major problems plaguing our health care system, i.e. rising costs, decreasing coverage, and most importantly, the central problem and the subject of our session today, poor quality. Our 80 members include corporate giants such as DaimlerChrlyser, Ford and GTE, as well as the nation’s largest unions, consumer and provider groups and all three of our nation’s major religious groups. Since our members employor relate to more than 100 million Americans, the potential leverage and health care purchasing power represented in our effort is enormous. We are committed to using that influence and purchasing power in a constructive way to address the critical problem on our agenda today, i.e. poor quality.

Our Coalition is non-partisan. Presidents’ Carter, Ford and Bush honor us as Co-chairs and our working Co-chairs are former Iowa Republican Governor Bob Ray who served on the President’s Quality Commission and also as chairman of HHS’s Rural Health Advisory Committee. Our other Co-chair is former Democratic Congressman Paul Rogers who for a decade served as chairman of the Health Subcommittee of Energy and Commerce, where he was known as “Mr. Health” in the U.S. House of Representatives. You will hear from both of them later.

This event is the first of a series of symposia that will be held as part of our “Accelerating Change Today or A.C.T. Initiative”. This is a joint undertaking of our National Coalition and the internationally known and respected Institute for Healthcare Improvement, headed by Dr. Don Berwick. The primary goal of this initiative is to help improve the quality of our nation’s health care by accelerating the identification, adoption and wide spread dissemination of best practices.

Why do we need such an effort, why do we need it now and why have our two organization’s committed ourselves to achieving it?

There are two reasons. First of all, no reasonable observer can any longer doubt that we have very serious and pervasive quality problems, even in our finest institutions. A variety of studies show that medical accidents and errors are rampart and that the combination of negligence, errors, accidents, and poor quality constitute the nation’s “hidden epidemic”.

Extrapolating from the evidence we have, Dr. David Lawrence, President of the nation’s largest H.M.O. recently concluded that fatal mistakes and the misuse of medical technology are now the third leading cause of death in the United States, and that aside from the problem of the uninsured, the safety of health care is the single most important health care issue today. A RAND quality study our Coalition commissioned concluded that the gap between the kind of care Americans should receive, and the kind of care they do receive is very wide.

After a year of study, the President’s Quality Commission summarized the evidence as follows; “Exhaustive research documents the fact that today, in America, there is no guarantee that any individual will receive high-quality care for any particular health problem. The health care system is plagued with overuse, underuse, and misuse of health care services.”

As a result it is estimated that each year these quality problems are unnecessarily injuring millions, killing over a hundred thousand people and wasting hundred of billions of dollars. Despite the magnitude of our problem, some continue to try to patch it with a patients bill of rights or other partial remedies while our nation’s soon to be two trillion dollar health care system continues to operate in a virtual quality central vacuum.

There is no other business in this country, that would be allowed to continue to operate even a day with quality problems of this magnitude, nor would society pay more than a trillion dollars a year for its services. Yet, this is now the case in our health care system.

But the most tragic fact of all is that these quality problems do not have to exist. Our session today will show that we know how to make dramatic improvements and that the price paid by the American people for not doing so is enormous and will grow.

So reason number one to finally and for the first time get serious about our quality problem is its magnitude and the inadequacy of current efforts to address it. But there is another equally important reason why we must address the quality problem now. That is, that unless we do so, we cannot fix our other major problems of rising costs and decreasing coverage. The reason is that these three problems are inextricably intertwined. As already noted poor quality is a major cause of cost escalation. Paul O’Neil, the chairman of ALCOA, and an expert in his own right on the quality problem has estimated that poor quality in our health care system may waste one-half of all the resources we expand on health care each year.

Cost escalation in turn is a major cause of the growing number of uninsured. Lack of insurance is now a major contributor to our quality problem because in the absence of insurance coverage, needed care is becoming increasingly difficult to get. When you can’t get the care you need, health and quality is adversely affected. In fact, studies show that, other than aging, one of the biggest risk factors associated with a poor outcome or death is the lack of health insurance. Whether or not you receive timely care (which is increasingly determined by your insurance status) can determine whether you live or die.

We have, then, a vicious cycle that feeds on itself: misuse of technology and poor quality raises costs, rising costs lead to decreasing insurance coverage, decreasing coverage leads to poor quality, and poor quality in turn increases cost. We have created a perpetual motion machine headed in the wrong direction. For all these reasons, quality has become a central problem. That’s why this problem must now finally be adequately addressed.

Which explains the reason for the A.C.T. initiative we will be discussing today. This initiative has the following goals:

• Building public awareness of the need for major quality improvements and creating a grassroots movement to support this goal.
• Identifying and accelerating the spread of “best practices throughout our health care system. We have defined best practices we have defined as — innovations that are yielding better patient outcomes; increasing access to timely medical care; lowering costs; making the health care system easier to use; and reducing medical errors and inappropriate or unnecessary care.
• Changing the culture of medicine to nurture a greater focus on best practices and “evidence-based” care.

This effort began a year ago when our Coalition and the IHI decided to join our unique strengths to collaborate on an initiative to improve quality. Our first product on error reduction will be presented today. You will hear eight case studies that demonstrate how a wide variety of institutions in various regions of our nation have successfully, dramatically and cost effectively reduced medical errors and improved the quality of care.

Each case study will be shared with you today and in subsequent days, using the extensive communication channels and website of our Coalition members this information will be disseminated to millions of other providers, consumers, payers and media outlets throughout our nation. In addition, we have enlisted a number of major organizations to partner with us in this education and dissemination phase of our initiative. These partners include the:

• U.S. Chamber of Commerce
• American Hospital Association
• American Association of Health Plans
• Midwest Business Group on Health
• Pacific Business Group on Health

We will also join our partner, IHI in sponsoring symposia on best practices to a variety of audiences throughout our country.

But as important as education and dissemination efforts are, they are only a first step of a continuing process, which we recognize will be necessary to move the nation’s quality agenda forward.

Over 50 years of experiences have taught us that knowing there are better ways to proceed will not alone lead to widespread and rapid adoption. We do not intend to repeat that mistake.

A discussion of the quality problem is very timely because at this moment Congress is attempting to craft a “Patient Bill of Rights” to “fix” the quality problem which has allegedly been caused by managed care. This is a graphic example of how poorly understood the quality problem is.

We do have serious quality problems, but the real problems are not due to managed care and will not be solved by more appeals, greater access to specialists, more second opinions, more choice, an increased right to sue, or unlimited amounts of health care.

The reason is that the basic underlying cause of our quality problem is inadequate science, a lack of evidence-based medicine, poor technology assessment, and deficiencies in our data and major gaps in our quality control, quality assurance, standard setting, and information dissemination systems. So our quality problem includes but is far bigger than the problem of medical errors. The whole problem must be addressed, but error reduction is an excellent place to start.

In order to succeed we recognize there are major barriers that have to be removed. New policies have to be adopted and substantial new government and private sector resources have to be allocated to a major quality improvement effort. In addition, the necessary financial and other incentives have to be put in place.

Our Coalition members are committed to working together and with Government and other private sector groups, and also to use our collective influence and billions of dollars of purchasing power to see that these necessary steps are ultimately taken. Throughout our efforts we intend to work in a no-fault environment, for we recognize no single group is at fault and pointing a finger of blame is no longer productive. We as a nation have a serious quality problem and we as a nation have to come together to fix it. As Don Berwick has so often reminded us, the status quo in health care quality is simply unacceptable.

To coordinate our efforts our Coalition has formed a Quality Improvement Partnership Committee of Coalition members. We will seek as partners other committed organizations. We are developing strategies for action based on the A.C.T. report on reducing medical errors and other reports which will follow. The goals of our effort are to disseminate knowledge about best practices in medical error reduction and to develop a process, which will “align incentives: which encourage and reward the adoption of medical error reduction programs and other quality improvements.

Our Coalition will also study and recommend ways to integrate quality-related information and payment policies into benefit contracts.

So this is what we are planning to do and why we are planning to do it. Our next “best practices” initiative will deal with care at the end of life and will be released later this year followed by other best-practices initiatives.

With this as background, we are now ready to proceed with the rest of today’s program which will include presentations by Dr. Don Berwick and Dr. Lucian Leape. You will then hear the eight case studies on error reduction followed by comments from key leaders of our Coalition on the steps they plan to take to move the national quality improvement agenda forward. We will also be hearing from Dr. John Eisenberg, the head of Agency for Healthcare Research and Quality and our Coalition board member John Sweeney, President of the AFL-CIO.

The curriculum vitae for all our speakers are in your handouts and there will be opportunities for Q&A;’s throughout our day.

I now have the pleasure of introducing to you our distinguished partner in this initiative, Dr. Donald Berwick.