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Transcript of Web-assisted Teleconference (continued)

Session 1: What Is the Business Case for Patient Safety?

Can You Minimize Health Care Costs by Improving Patient Safety?


Cindy DiBiasi: Jim, your report refers to responsible healthcare purchasing. Can you describe exactly what you mean when you say that?

Jim Mortimer: I think it begins by recognizing the responsibility that the health plan you have, the benefit payments that you have, are really part of the quality problem so that you have a role to play. Following that up by asking questions. Finding out from your health plans. Finding out from providers in the community the facts. What are the quality problems that really need to be addressed by you, your covered employees? It is really only the facts that are going to give you enough certainty to know where you are going to go next.

Then I would say as Dolores said, strength in numbers. Find others who will join with you. Public sector organizations, private sector organizations, working together all have a stake in that local issue of healthcare quality. Working together with the providers, as Dolores pointed out, around the table so that the solutions really are where you start to work, improving the process of healthcare. Using evidence-based medicine. Things that the Agency for Healthcare Research and Quality has got lots of information about. Bringing that into your community.

We find in Chicago, for example, that in diabetes. We have got tremendous inpatient use of diabetes and we have got lousy outpatient care. Which means that people are having complications from diabetes and are winding up in the hospital when they should be maintained under proper follow-through care.

Cindy DiBiasi: Where do they go to get this information though? It seems like they would have to do a fair amount of investigation and go to multiple sources.

Jim Mortimer: That one is real easy because it is something that you can see in the Dartmouth Atlas of Healthcare. That is a resource that is available on the Web site of Dartmouthatlas.org. You can talk to the folks there. You can talk to coalitions such as ours that have learned how to use that as a tool. That is an easy one to spot. What you wind up doing is clinical training. Our members have got together and funded clinical training using best practices for clinical teams in town so that we get everybody in town so that they understand how to do good care for diabetes. It is data driven.

Cindy DiBiasi: But it is also really putting the purchasers in a proactive role.

Jim Mortimer: Right.  That is through a coalition. Most employers on their own won't try to do this. Most public organizations feel like they have got a lot of barriers as Dolores pointed out. But if you get together in numbers and hire some technical resources to share in your group, then you can begin to create for forums and discussion around the facts to work these things out with providers.

Dolores Mitchell: I think one of the things that many of the coalitions do, Jim's does, the Mass Health Care Purchasers Group does, a lot of other similar organizations around the country do is to try to provide this kind of information for our enrollees. We here in Massachusetts do an annual report on HMOs taking selected items from the NCQA Annual, it is called Quality Compass.  It is a set of measures that the industry has agreed upon as indicating good practice. Then we distill it down and try to put it in a format that is reasonably readable.

I think the thing that we have all struggled with is that people don't use it. That is one of the things that got the Leapfrog folks going is that people simply assume that if you are licensed as a physician you are by definition competent. If you are accredited at the hospital, you are by definition doing all that is appropriate and necessary and possible to protect the safety of the patient, and that there are no differences that are appreciable.

What is hard to do is to convey the subtleties underneath those licensures and those accreditations to enable people to choose what is best for them and for the condition that they happen to have, at least in those areas where there is any choice. That is what all of us who are purchasers have been struggling so hard to do.

But there is among our employees I think to be frank about it, a lot of resistance to entertaining the concept that they have to get involved in learning a little more about what are the kinds of things that really make a difference between superior performance and average performance and maybe below average performance where they might be at risk. I think it is a hard thing for people to deal with. It is understandably hard. I think you don't want to be in the position of being uncomfortable that maybe your physician isn't doing everything for you that might be done because he hasn't kept up, for example. That is asking a lot of the enrollee, to go that step beyond complete trust into the area where they feel comfortable in questioning the doctor.

Cindy DiBiasi: We have a question from Joanne Rawlings-Sekunda from Maine. It is sort of a question in this area because she says that you mentioned the strength in numbers, Dolores. Did private businesses get involved independently or did you really have to work to get them involved? If you did, then how did you do it?

Dolores Mitchell: Let me start out by saying that the State of Maine is also a Leapfrog member and I have met the folks up there and having their support is very important. The old saw in politics is that "As Maine goes, so goes the nation." Probably hasn't been true politically for a long time but I hope it is true in this instance. No, it hasn't been terribly difficult although it hasn't been a day at the beach either. Getting the attention of the appropriate people in a business organization and asking them to take a public stand on an issue about which they don't necessarily consider themselves to be experts, is not all that easy.

That is why having the Leapfrog group at the national level with companies as prestigious as the ones that are the leadership of Leapfrog I think was absolutely crucial. I mean you can't just shrug your shoulders and say it is just a bunch of wild-eyed policy wonks that want to do this when companies as solid as the ones that have joined and started Leapfrog are leading it.

Cindy DiBiasi: Jim, let me ask you a question. This comes from Jennifer Taylor from New Hampshire. You talk about medical errors versus medical injuries. It is a semantics question but a significant one in terms of demonstrating lessons learned in injury prevention and control.

Jim Mortimer: Medical errors I think people sometimes mean medication errors as a family of things as opposed to errors more broadly which we talked about overuse, under use, misuse. We need to have a language we can all kind of understand and talk about quality problems. That is what we have tried to find in that trilogy of overuse/under use/misuse. There were all kinds of errors, but they have a different economic problem. If it is something that isn't done that needs to be done, you are going to pay more for that. But you are going to see a benefit from that over time as it shows up in productivity and absenteeism if you are an employer. But if it is overuse then you are paying extra for something that has no value, maybe even harm. Or if it is misuse, a mistake, that also is very costly.

I think it is a way of sorting these things out. Medical errors could be over use of inpatient care for medical treatment. It could be a medication error where you gave the person the wrong pharmaceutical or you gave a child a dose for an adult and had deadly complications.

Cindy DiBiasi: Dolores, a question from Mary Uyeda from Washington State. Wants to know what has the experience been so far in reporting the hospital information publicly?

Dolores Mitchell: What we did is to let every body know that they can access this data and the results of it on the Leapfrog Web site. Maybe I ought to just give that address while we are on that subject. It is www.leapfroggroup.org. It is all there. Any hospital that reported is designated and it is designated as to each of the components of the three components.

We have also done a lot of publicizing of the importance of this, kind of a build up. Why is it important? Why are these measures important? Why were they selected? Now that we have a substantial number of reports. We have got in Massachusetts, 28 hospitals plus four more that are just about to go on so we will have over half of our acute care hospitals as of the first of October. That gives you really a kind of a critical mass.

Then throughout the country there are 19 areas that are doing what we are doing. That is 30 million consumers. That is a lot of people who will be getting to focus on these issues. The thing that is important about it I think is that it works in two ways. One is if you are trying to get the other companies in the other areas of the country to participate, there is comfort in numbers and you can't overlook 30 million people being covered.

The other way that I think it works is that I think it has an important effect on the hospitals themselves. You also, if you are a hospital, can't ignore anything quite as big as that. So what we have done is we have sort of built up slowly and referred people to the Web site. We have it on our own Web site with a link so that you can get that information. We put it in our newsletter. This spring we will be putting it in our employee information booklets as we get ready for annual enrollment.

Cindy DiBiasi: Jim wants to add to that.

Jim Mortimer: I was going to add something to that, Dolores. Maybe you will agree with me. What we found with these report card kinds of examples, whether it is health plan data or hospital data or another piece of the system, is that the consumers really don't use them all that much. We aren't into that way of thinking routinely as a country yet. But what does happen is the hospital or the health plan that is being measured in these public displays takes those data very seriously.

Cindy DiBiasi: I imagine they would.

Jim Mortimer: You see some very serious work going on in that organization around these measurement points. Even though they I think also understand that not all consumers are really going to be using them. They don't want to have any kind of public exposure that would indicate that their performance is less than average.

Cindy DiBiasi: Nobody likes a bad report card, basically.

Jim Mortimer: Right.

Dolores Mitchell: It is bad enough to have to take the bad report card home to your parents. It is even more agonizing to have all of your friends, your peers know. I think that is the point that Jim is making. These are competitive institutions and physicians themselves are competitive people. They wouldn't be able to get themselves through the agonies of medical school if they weren't. So he is absolutely right.

If you want an example of that, New York State when it began doing a coronary artery CABG report card that they made available, it wasn't so much that patients left one physician and went to another or left one hospital and went to another. It was that each hospital improved its performance the next time around because nobody wanted to be below average. It is the Lake Wobegon phenomenon in reverse.

Jim Mortimer: We have a big group of employers across the country, public sector groups as well, working with the National Quality Forum to support their efforts to standardize quality measures at the hospital level it would get around to physician level. Talking to consumers they tell us they want to know about the doctors. They don't really don't have that much thinking about the hospitals and the health plans. "What do health plans have to do with quality?" would be some of their feedback. But getting to physician-level information, standardized, validated, that is where I think a lot of the purchasers are trying to drive this disclosure bus.

Dolores Mitchell: He is absolutely right and it has got to be the hardest barrier of all because there is enormous reluctance to go to physician, it is sometimes called physician profiling. I think the subtleties of it, because people will say well, my patients are sicker than so and so's patients and it is unfair to compare how we do without building some kind of a risk adjustment into it. They are right. You have got to have some measures that take into account the nature of the population being treated. But Jim is absolutely right that provider-level information is where we need to be headed.

Cindy DiBiasi: We have a follow-up question from Mary Yuada from Washington State. She wants to know, Dolores, what else does Massachusetts use in addition to the Leapfrog initiative and how are these identified?

Dolores Mitchell: Well, let's see. How far back do I want to go?

Cindy DiBiasi: We only have another 45 minutes (end of tape)

Dolores Mitchell: Have built into our contracts requirements to try a couple of different ways to improve healthcare quality. One was we did something called an Early Risk Intervention. We are doing that now in which, it is a pilot. One of our larger health plans is administering it in which a computer-based program takes the claims data from pharmaceuticals, from doctor's diagnoses, and runs them through its magic black box. Where they find evidence-based rules of misuse, under use or over use they essentially flag the case and a doctor-to-doctor phone call takes place. Why did Mrs. Smith not get a beta-blocker even though she appears to be a classic case for having that administered? Sometimes you find out that the doctor did in fact write the prescription but Mrs. Smith didn't fill it. You have got to be careful not to jump too fast to criticize. But sometimes the doctor just didn't do it for whatever reason.

Why do two drugs that have a very bad effect if they are both given to the patient? Why were they both prescribed? Sometimes the doctor is in fact frankly not aware that there are some side effects from one of the newer drugs that he didn't know about. So that early risk intervention is one.

Let me get a breakthrough initiative that was kind of interesting. Again, we paid a bonus for successful completion and we penalized for failure to participate. Cindy stop me if I am going on too long but this is a very interesting one. We asked each plan to do a pilot study on something that really was a breakthrough and that was measurable and we approved the plans. They chose them but we approved them so that nobody would give us any puffballs. Then we tracked them. What we found was a little disappointing frankly. One of the health plans did a screening project on trying to identify undiagnosed cases of depression in patients coming for somatic complaints. It worked. The results were stunning. They did find undiagnosed cases of serious clinical depression and they didn't want to carry it forward because the doctors didn't want to take the time to administer the test. There was a problem.

But some of them were wonderful. We did one on cardiac rehab out in the central part of the State. They had wonderful results. So we keep ginning up new ideas and urging our health plans. By urging I usually mean saying do it or you can't have a contract, and coming up with some interesting results.

Cindy DiBiasi: We have a question for you Dolores from Richard Carr who is the medical director of Wisconsin State Medicaid program. He again is referring to your strength in numbers suggestion saying that the problem is the numbers consist of non-health people attempting to identify and suggest ways to correct system weaknesses to medical people. Why not form a coalition composed of involved medical personnel and purchasers of healthcare services to provide guidance in the healthcare area? He is suggesting that we might consider partnerships with State medical societies, specialty groups, that type of thing.

Dolores Mitchell: There is nothing wrong with it and indeed I belong to a coalition that is exactly what he is describing. It is called the Massachusetts Coalition for the Prevention of Medical Errors. I am in fact on its Board of Directors. It is a coalition of the Department of Public Health and the Hospital Association and the Medical Society and so on. It is a very broadly representative group.

The trouble with coalitions of that sort, I shouldn't say the trouble. The advantage is exactly the kind of broad representation in voice at the table that the question is suggesting. But that kind of coalition is very, very slow and it tends to be very, very cautious. So while I think you have to keep on talking and I think you have to belong to those kinds of coalitions, I think if you want to do a breakthrough and stir the pot a little bit more vigorously and turn up the fire a little bit, I think it takes a little bit more and a slightly different approach.

They are not mutually incompatible. I think a little bit more energy on some of these things from time to time is a good idea.

Jim Mortimer: Dolores, I think the purchasers really have to drive that kind of a group. If it is just to sit around the table and try to think of what could be done better, you are right, it is going to be glacially slow. But if the purchasers have the information to drive the agenda and are willing to put their money on the line, then they can set the agenda. They can challenge the people who are involved and things do happen.

Cindy DiBiasi: Jim, let's talk about the cost savings that you were talking about earlier in this program. Where do those numbers come from? I think you said it was $1,700 per patient?

Jim Mortimer: That estimate is an estimate. It is based on three things. One, health services research, looking at quality problems sometimes estimates the costs that goes with those things and the footnotes in our report gives you some of those citations.

Second, the Juran Institute, who was our partner, is a worldwide consultant in quality management for all kinds of industries, not just healthcare. Their work has shown these kinds of waste figures in all kinds of industries. One of the clients of Juran is the Mayo Clinic in Minnesota, a prestigious organization. They found the expected 30 percent waste in their main operations once they used the Cost of Poor Quality analysis techniques so I think it is validated by Juran's experience.

The third thing is we had an expert panel. World-renowned clinicians on medicine and quality advise us. It is their judgment, their opinion that also factors here. Some of those folks said our estimate is way too low, that we should use a much higher figure. We know that it varies a lot from community to community so if you take our numbers as a starting point and then dig in from there, I think you will find there is a lot of opportunity for improvement.

Cindy DiBiasi: Did you take an average of the numbers or did all three groups come up with just about the same number?

Jim Mortimer: We looked at it two different ways. We look at the global case using the information that I have talked about. We also tried to look in the specific area of say overuse or the specific area of under use and come up with a factor for that. I will tell you, the research is just too thin at that level. We need AHRQ to do more research in those areas to give us better numbers and when they look at quality problems be sure to look at the cost of those quality problems as well.

Cindy DiBiasi: I am glad you were here today to get that plug in to get them started on something else.

Dolores Mitchell: Cindy, may I chime in?

Cindy DiBiasi: Of course.

Dolores Mitchell: OK. While Jim has been talking I have been shuffling though my papers because I knew I had it here somewhere and I feel as though I sort of shortchanged the subject matter title of this conversation about the business case. Let me give you a couple of data points if it isn't too tedious to listen to a couple of numbers.

On computerized physician order entry, the estimate is that you will save or prevent rather, eight out of ten serious drug errors. Brigham and Women's Hospital, which has computerized physician order entry, reports a per-event cost of an adverse drug event of $4,500 each. That is $2.8 million a year. That data reference by the way is the National Committee on Quality Healthcare. So OK, that is the money to be saved.

What did it cost them is a fair question. It cost for them to put in that system almost $1.5 million and it costs about half a million dollars a year to maintain it. But, that gives you a net savings if you add all the avoidance of those adverse drug events and add to it something that people don't think about is one of its virtues: you get much greater efficiency of drug use. You can select the less expensive drug in the same therapeutic category and so on. So it has got a return on investment that is rather significant.

Cindy DiBiasi: But ultimately who is going to benefit from the return on investment from this cost savings?

Dolores Mitchell: The hospital does benefit itself. Remember, if they are on a DRG system and the patient has to stay another three days, they have to eat it. I know there are some stop-loss things where some insurance kicks in for that sort of thing, but nevertheless, the additional days cost the hospital. And it does cost human life and sometimes morbidity as well as in addition to mortality.

Cindy DiBiasi: Jim, going back to your cost savings, does that cost then get passed on?

Jim Mortimer: Dolores, I don't think it is always true that the people taking the initiative get rewarded. In fact, I think no good deed goes unpunished is probably more apt because people who do improve quality and reduce cost as a provider typically don't keep any of that savings. It gets passed on to the health plan that maybe keeps it or maybe they share it with their people. So one of our principles in the Responsible Purchasing Model in step 4 is share the savings.

Dolores Mitchell: I think you are absolutely right.

Jim Mortimer: By contract, so that the innovator gets a piece of it, the plan gets a piece of it, the employer that is paying gets a piece and the consumer sees a piece. Only if all parties get a piece of that savings will there be the financial reason to go ahead and do the next project which is going to give us more savings. So we have got that part pretty screwed up.

Cindy DiBiasi: Everybody needs to share in the responsibility. Everybody needs to share in the savings.

Dolores Mitchell: I think he is absolutely right.

Cindy DiBiasi: We have a phone call from Patty O'Reagan from Florida. Hello, can you hear me? Patty?

Patty O'Reagan: Yes?

Cindy DiBiasi: Can you hear me? This is Cindy DiBiasi. Go ahead.

Patty O'Reagan: Hi Cindy. I am a nurse practitioner in Florida and I work for a huge hospital consortium down here. My main question is whether or not any of these groups have included within them focus groups that include the victims of medical errors, particularly those who are healthcare providers. You have a huge resource there and given that the systems that have been intact for years, the hospital systems have allowed errors to perpetuate. Those people who have a real strong incentive and motive for change, those who have been victims, especially the providers, could be really helpful in making changes in the system. I wondered if you have any kind of outlet or a resource connection for those folks who would like to be a part of this and who risk daily, jeopardy of their jobs as they try to induce change by themselves with in the system that exists?

Jim Mortimer: We have members who have done focus groups among their employees that talk about healthcare quality. A round table where people are asked to share their experience or the experience of someone in their family with healthcare is guaranteed to produce the kind of anecdotes that get people really thinking about this. The power of the story is very strong. In our expert panel, world-class clinicians, when we started to talk in this project about quality problems, guess what? They all had an experience with healthcare that is very much mind-blowing kinds of problems. People that have experienced high error rates. So we all are patients. I think if we sit around the table and share our experience it quickly comes to light.

Focus groups are also a powerful way of testing the tools that we are after as well. To take these information tools and work with focus groups and help them see it through their own eyes and give us the feedback so I would encourage people that are working in this area, if you want to know what the consumers think, that is ultimately the answer we are after, get them together and get them talking as a group.

Dolores Mitchell: I am very interested in the language that our caller used. She referred to the providers as "victims." I am wondering whether at the back of her mind isn't something that I personally feel rather strongly about in this subject matter, which is that nurses sometimes, maybe too often, take the rap for an error. I don't know if she is still on the line and wants to comment or not. But...

Cindy DiBiasi: Patty, are you there?

Patty O'Reagan: Yes I am.

Dolores Mitchell: But I think there is an unfortunate amount of truth to that statement.

Cindy DiBiasi: Patty, do you want to comment on that?

Patty O'Reagan: I would love to.  

Cindy DiBiasi: Go ahead.

Patty O'Reagan: I would agree with you, Dolores, there but what I was really trying to get at. Myself, my mother died from medical errors. I happen to be a nurse practitioner. I happen to work in a huge healthcare system that is stuck in the very slow clogging process that has been going on for years that doesn't change easily and indeed that just allows the medical errors to persist. I am one of those who has been, even before my mother died from the medical errors, very outspoken about quality care. Those of us who are on the inside who happen to be family victims, on the outside, those of us working hard on the inside oftentimes risk our jobs because we are not seen as part of the system when we speak up about these things. We really need some forces from the outside to help us be able to speak up without risking our own jobs every day.

Dolores Mitchell: There is a lot of conversation and this is sometimes what is meant by the culture of safety. Sometimes it is used a little vaguely. Sometimes they mean the culture in which safety is the primary concern. Sometimes they mean the culture in which one feels safe in saying, "hey, wait a minute, Dr. So and So, I think that suture is loose" or whatever it is you wonderful folks do. There is a fear of retribution if you speak up and a lot of anxiety about whether or not near misses, as they are called, should be reported as a way of collecting the data to improve the systems. I think one of the virtues of the IOM report was that it pointed out that you can look for somebody to blame all you want, but if you look at the medical malpractice system it clearly has not eliminated medical errors. But maybe the conspiracy of silence has. That is the thing that our caller is pointing out and I think it is one of those things that the profession itself, not just her profession but the medical profession and the hospital profession, have to deal with. It is indeed the intent of folks like the Leapfrog Group and others to say listen folks, we are not trying to blame people and say that you are doing bad things; we are saying a lot of these errors are systems errors. They are not human errors. Even if they were human errors, human error is never going to be eradicated. People make mistakes. The whole point is to try to organize the system to minimize those mistakes. To minimize the possibility. The physician order entry one is, I use it, it is not the only one because it is so easy to understand. The number of transactions between the doctor deciding what he wants to write, between the pharmacy getting the order, between the order being legible, between the right drug being pulled off the shelf, between the right drug being put on the trolley to go up to the right floor to the right patient to the change of shifts in the hospital when the night shift comes on and the day shift goes off. The opportunities for a mistake are so manifold that we have to do something to improve that system so that an individuals likelihood of making a mistake gets cut down to the barest minimum.

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