I have written extensively on the issue of resilience in health care organizations with emphasis on the need to balance clinical, financial and human costs in pursuit of good outcomes. So, it was with interest I read a perspective by four government physicians writing on building a system that ensures resilience. Their primary concern was patient safety, citing data showing deterioration in various measures during the pandemic.
“Managing the competing priorities of providing care for large numbers of patient with COVID, as well as those without COVID who need care every day, and of maintaining safety efforts such as robust infection-control practices is both difficult and essential.
The fact that the pandemic degraded patient safety so quickly and severely suggests that our health care system lacks a sufficiently resilient safety culture and infrastructure. We believe the pandemic and the breakdown it has caused present an opportunity and an obligation to reevaluate health care safety with an eye toward building a more resilient health care delivery system, capable not only of achieving safer routine care but also of maintaining high safety levels in times of crisis.”
The authors present several examples showing increases in negative safety rates such as central line blood stream infections, falls, pressure ulcers, and catheter-associated urinary tract infections, all of which have been the focus of concerted effort for at least a decade, and all of which had improved prior to the pandemic. They also reviewed various factors likely to be causing the observed deterioration, including fatigue, burnout, and disruption of normal routines related to patient volume.
“As we emerge from this public health emergency, we at CMD and the Centers for Disease Control and Prevention (CDC) are committed to a renewed focus on patient safety…We are also developing safety metrics that draw on the rich clinical data captured digitally in electronic medical records, which incorporate information from all health care payers. Some electronic clinical quality measures are already being considered for inclusion in patient safety monitoring in the CMS Quality Payment Program.”
My cynical side reads this as a governmental CYA—we don’t want to be blamed for what happened. So perhaps it is instructive to review how we got to where we were in 2019. The safety movement got started in places where there was a physician champion, like Dr. Peter Pronovost, and spread to a statewide trial in Michigan, and eventually developed into a program that included “plug and play” programs from the Institute for Healthcare Improvement, (IHI). Initial spread of the movement was, like many medical innovations, by osmosis as individual champions appeared and argued that if “they” could achieve better results, then so can we. But instituting these programs required additional resources of computers and data processing, people for data collection and analysis, etc., so many financially strained institutions held off. CMS stepped in and raised the ante by providing scoring systems and attaching payment penalties, which forced participation, but did not change the fundamental “add on” aspect of safety programs and the data collection needed to track results, and the cost was largely foisted onto the billing institution. The authors recognize this history and state the following.
“The United States deserves breakthrough thinking about systems built on foundational principles of safety, akin to those used in other industries in which safety is embedded in every step of the process, with clear metrics that are aggregated, assessed, and acted on. We also need renewed national goals of harm elimination…[including] promoting radical transparency, addressing workforce shortages, and continuing to strive for safety while being sensitive to such trade-offs as reporting burden and costs.”
Of course, the obvious issue is who pays? Right now, patients pay if they suffer harm, the hospitals and providers pay to operate the systems to report the data to get payment from CMS, and staff have to make sure the data are right, since money hinges on the outcome. While the sentiment about building in safety is correct, making the change is likely to require governmental intervention, both in terms of specifying what is required for everyone, and how it is to be done, as well as infrastructure funding, including for people, nurses, etc. Clearly a better way is a noble goal, but I fear we are going to get more of the same—more reporting requirements to maintain stable payment levels in a zero-sum game. CMS and Medicaid programs have not been structured to maintain infrastructure, and, in fact, each wants to pay only the “marginal cost” of care. Private insurance companies currently provide the margins supporting infrastructure, but are not happy about it, and neither are private payers who are paying the hidden tax.
I provided medical director services to a non-profit large dialysis organization for many years. Some of the doctors did not think it was their obligation to deal with the money. But one wise doctor would usually remark, “The ultimate disservice to our patients is to go bankrupt.” Our “system” is bankrupt. Perhaps we can get in line for some infrastructure money, but I would not count on it.
22 February 2022
 Fleisher LA, Schreiber M, Cardo D, Srinivasan A. Health Care Safety During the Pandemic and Beyond—Building a System that Ensures Resilience. N Engl J Med 2022;3836(7):609-611. doi:10:1056/NEJMp2118285.
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