Making the Health Care System Safer: Welcome Address
Third Annual Patient Safety Research Conference
Carolyn Clancy, M.D.
I'm very pleased to welcome you to AHRQ's third annual Patient Safety Research Conference. Technically, actually, this is the third-and-a-half annual Patient Safety Research Conference. As you know, we originally planned to hold this meeting 6 months ago. I want to apologize for any inconvenience caused by the change of date, but I can assure you that we've used the extra time wisely. The agenda is very robust and exciting and more than 650 attendees represent a wide range of disciplines and perspectives.
We're all united by the theme of this conference, making the health care system safer. This is an auspicious year for this field. In November, we will commemorate the fifth anniversary of the Institute of Medicine's (IOM) report, To Err is Human. I would like a show of hands. Please raise your hand if you think the health care system is safer now than it was in 1999. I like enthusiasm. That's good. One more question, do you personally feel safer in the health care system now than in 1999? That's why we're here.
Another question that we'll face as we get closer to the anniversary is: Have we reduced the rate of errors by 50 percent? We know that the central issue is not about numbers. We need to find a way to convey that to those who are questioning us. The number of errors in the health care system is debated in scholarly journals, health care conferences, and in the media. Some of you may have recently seen a report saying that actually the IOM was wrong by a factor of two, that actually the number of errors was twice as high. The bottom line is that one preventable error is too many. We need to focus on the progress we've made in the last 5 years and how to build on it to move forward.
Our ultimate test is do we have a clear roadmap that will guide us to a high-quality safe health care system. We'll chart that progress over the next two days. I'm personally very excited about this program. As many of you are aware, AHRQ has a new mission statement. It now reads, "To improve the quality, safety, efficiency, and effectiveness of health care for all Americans." For those of you who think that these words sound familiar, you would be correct. The difference is that our mission statement used to say, "To support and conduct research (that hopefully will trickle down to improve health care)." We're now making it a much more direct responsibility.
The essence of that change is that while research is vital and important, findings alone do not change health care. I'm thrilled to see the work that began 3 years ago taking shape in the product café. I was here for the reception last evening when a small number of you were able to come. It was amazing to see the crowds gathering at different displays. You may need a lot of energy to work your way around there. It's very gratifying that your hard work has brought us not only the evidence for what makes the health care system safer, but it has also yielded tangible and practical tools that can translate the evidence of safety into practice. You should be very proud that you're on the leading edge of AHRQ's new mission and charge to translate research into practice.
In particular, I'm very pleased that we have nearly as many users of research in the audience as we do researchers. We want to hear from you directly. What do you need to provide, purchase, and use to make health care services safer? Your efforts will take the research discussed and presented at this meeting and the products in the café to the frontlines of American health care. To adapt a cliché, your fellow audience members, the researchers, are funded by the government and are here to help.
I'd also like to welcome the second class of the Patient Safety Improvement Corps (PSIC), which is supported by AHRQ in partnership with the Department of Veterans Affairs National Center for Patient Safety. The Corps comprises 21 State and hospital teams who have just completed the first week of a yearlong training program. They will use the lessons from this meeting to improve the safety of health care in their local communities.
Of course, we all know that issues of health care safety and quality don't recognize international borders, so I'm very pleased that we're joined by patient safety leaders from the United Kingdom, New Zealand, and Denmark who have traveled a long way to share their insights and experiences with us. We also have some colleagues from France.
As they say, timing is everything, and we say that a lot in Washington. I'm very excited to announce that this past Friday AHRQ published a new patient safety request for applications (RFA) titled, "Partnerships in Implementing Patient Safety." The goal of these cooperative agreements is to help health care institutions implement practices that show evidence of eliminating or reducing medical errors as well as harms associated with the process of care. The RFA is now on our Web site, and there are copies at the booth in the product café. Also tonight, AHRQ staff will be available to answer any questions. We also have a technical assistance call planned for October 6. The receipt date for the RFA is January 20, 2005.
I know that many of you are aware that AHRQ will launch a new patient safety electronic newsletter this week. It will help keep you up to date with AHRQ patient safety news and instructions for signing up for the newsletter are available at the AHRQ booth as well. Again, that's in the product café. Forthcoming issues of the patient safety electronic newsletter will contain an announcement of some $60 million in new AHRQ health information technology grants and contracts.
I know some of you are asking about whether our focus on patient safety has shifted from patient safety to health information technology. As an answer, I'd like to remind you of a quote from the IOM report that was published in November 2003. "Americans should be able to count on receiving health care that is safe. This requires first a commitment by all stakeholders to a culture of safety and second improved information systems." In other words, we need both to get to health care that is reliably safe.
Patient safety and health information technology are bound together as is your work and that which will soon be undertaken by AHRQ's new health information technology (health IT) grantees. Your research is the foundation for our new grants in HIT and your research has identified where errors occur, why they occur, and what we need to do to eliminate them. Health information technology is a means to the end that you've identified.
In addition, as the IOM has said, as we all know, "Health information technology will have very little effect unless we experience a culture change in health care." Your groundbreaking research has spurred that culture change, which will be nurtured through your continued research efforts in translation of your findings into improved safety and quality.
I'd also like to mention that there are two journals interested in publishing information from your work. Please stop by the AHRQ booth in the café for information on a call for papers for the Joint Commission Journal on Quality and Safety and for the Journal of Patient Safety.
We can be very proud of the progress we've made in the past 5 years but this is hardly a time to rest on our laurels. We have much more to accomplish to achieve the goal of a safe, high-quality health care system. Before I introduce our keynote speaker, I want to thank the AHRQ planning and implementation team for this conference, Dan Stryer, Marge Keyes, Eileen Hogan, Denise Burgess, Mary Rolston, Howard Holland, Karen Migdail, and Ned Robinson. In particular, thanks go to Deborah Queenan who has been the ultimate maestro and conductor of the symphony here at this conference. Thanks also go to Susan Rittenhouse and her conference planning team at Westat as well as our colleagues from the Patient Safety Research Coordinating Center at Westat. I'd actually like to ask all of the people from AHRQ to stand for just a moment. Thank you.
We're extremely fortunate to have as our keynote speaker today Sister Mary Jean Ryan. Her biography is in the meeting materials, but I would like to highlight a few accomplishments in her distinguished career. Sister Mary Jean is the president and CEO of SSM Healthcare, one of the nation's largest Catholic health care systems. Under Sister Mary Jean's leadership, SSM was the first recipient of the Malcolm Baldridge Quality Award. I had the privilege of attending that day as Sister Mary Jean accepted the award on behalf of her organization. Adding to a crowded shelf of awards, recently AARP voted SSM Healthcare one of the top 10 employers in the country for its treatment of older workers.
Sister Mary Jean has emphasized three key themes during her tenure:
- Preservation of earth's resources.
- Valuing ethnic and gender diversity.
- Commitment to continuous quality improvements.
I had the privilege of speaking at an SSM diversity conference a couple of years ago and it was obvious from the moment I arrived that her commitment and dedication have permeated the entire organization. Sister Mary Jean is one of those seemingly tireless leaders who expect the best in her people, organizations, and service and they deliver. She has been quoted, "If there is a better way to mop the floor, we'll find it." Her long CV lists a number of accolades in the headlines of articles that have been written about her. My favorite, and the one that sums her up best is, "Sister Ryan is a health care powerhouse."