System-level Changes Are Key to Improving Patient Safety

Massachusetts health care leaders acknowledge that we’ve made great strides in patient safety but that much remains to be done.

In 2000, Dr. Lucian Leape, the Massachusetts pediatric surgeon who is often described as the father of the patient-safety movement, spoke before a U.S. Senate subcommittee, saying medical errors “are seldom due to carelessness or lack of trying hard enough. More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes. They can be prevented by designing systems that make it hard for people to do something wrong and easy to do it right.”

More than eight years later, Leape says he would tell the subcommittee the same thing. “I stand by every word of that,” he told the Mass. Medical Society recently. “We’ve learned that what we’re trying to do sounds simple, but is not easy at all.”

Leape cited an example of a hospital patient acquiring a preventable infection. “The answer isn’t that a patient’s doctor should be fined or fired,” he said. “It’s that we ought to ask about the system. The doctor is not the only one who made that infection happen. The issue is, how do we get the system to respond?”

Interviews with patient-safety experts in Massachusetts suggest that the state is populated with health care professionals and executives determined to place the Commonwealth at the forefront of efforts to reduce, if not eliminate, medical errors. But at the same time, there is agreement that much work remains to be done to fully achieve that end, here and in the rest of the nation.

“We’re still a long way from where we need to be,” said Dr. B. Dale Magee, immediate past president of the MMS president. “We’re not yet doing as well as we can.”

Nevertheless, the raw material for systemic patient safety breakthroughs exists today in Massachusetts. Leape, an author of the landmark 1999 Institute of Medicine report “To Err is Human,” notes that much patient-safety research is done here, and that “everyone who is in health care in Massachusetts gets a lot of information and support. There can’t be many places where patient safety is more on the minds and agendas of people than in Massachusetts.”

Those at the forefront of the patient-safety movement in the Commonwealth agree with Leape that the key to eradicating medical errors and advancing patient safety is to create systems for health care delivery that doctors, nurses, and others providing care can rely on. That means changing the mindset — among physicians and others — that doctors are personally and individually responsible for not making mistakes.

“We’re trained to be independent, heroic, to take chances,” Magee said. While these are often necessary and positive characteristics for physicians, he added, “we have to learn to accept certain routines and protocols as a matter of professionalism. Change will occur if we have systems that support consistency.”

He likened this to the way most people now automatically fasten their seatbelts before traveling by car. “You don’t think that you could hit something while driving,” Magee said. “You just fasten your seatbelt. We have to adopt that kind of thinking.”

Already in 2008, there have been some well-received systemic efforts in Massachusetts to improve patient safety and health care quality. First, the board of directors of the Beth Israel Deaconess hospitals approved goals to eliminate all ‘preventable harm’ to patients by Jan. 1, 2012 — and those goals will be tied to senior-management bonuses.

Not long after, Blue Cross Blue Shield of Massachusetts proposed changing the way it pays doctors and hospitals. Looking to curb cost increases and improve the quality of care, the insurer wants to pay a flat amount per patient per year, adjusted for age and sickness, rather than by each patient visit or treatment. Although the plan has raised the specter of flawed ‘capitation’ systems of the past, it would provide bonuses to providers who improve patient care.

Leape also noted the move by Medicare not to reimburse for the extra cost of treating preventable errors in hospitals beginning in October of this year, and a request late in 2007 by the Mass. Hospital Assoc. asking hospitals not to charge patients or insurers for certain preventable errors.

Leape concluded that economic incentives and consequences may be a necessary catalyst for preventing medical errors. But such programs will have to be implemented carefully. After all, he said, “you can’t not pay doctors for something they have no control over.”

Tom Walsh is a partner at RDW Group Inc., communications counsel to the Mass. Medical Society. He is a former political reporter and editor at the Providence Journal. Walsh has also written for the Washington Post, the Christian Science Monitor, Newsweek, and various regional magazines; twalsh@rdwgroup.com