New Alliance to Tackle Medical Errors, Define Safety

Donna Young

Three health systems—Wellmont Health System of Tennessee, Adventist Health System of Florida, and Novant Health of North Carolina—announced in May that they are aiming to do something that the U.S. health care community has yet to do: define what it means to be a safe hospital.

Various groups, including the Institute for Safe Medication Practices, the Institute for Healthcare Improvement, the National Quality Forum, the Partnership for Patient Safety, and the Leapfrog Group, have issued numerous quality improvement guidelines and identified hundreds of patient safety measures, said Richard Salluzzo, president and chief executive officer of Wellmont Health System.

"They all mean well, and they are doing great things," Salluzzo said during a May 17 media briefing in Washington, D.C. But, he said, "it's not comprehensive, it's not organized," which, Salluzzo said, has left the nation with a fragmented and overwhelming approach to safety.

Plus, he said, the various patient safety groups do not have the authority to hold hospitals accountable when guidelines are not heeded, "so it becomes a voluntary exercise."

The topics of reducing medical and medication errors and improving patient safety have been "talked to death" since the Institute of Medicine (IOM) issued its earthshaking To Err Is Human report in 1999, Salluzzo said, noting that the medical community's first response was to dismiss the report's findings.

But, he asserted, in the wake of the IOM report, the nation's hospitals have not improved their safety or reduced their medical and medication errors over the past eight years.

He noted the results of a recent study by Colorado-based HealthGrades of more than 40 million patient records that revealed that medical errors have continued to rise in American hospitals, resulting in billions of dollars every year in additional costs.

"Why haven't we improved?" Salluzzo asked.

The major reason, he contended, is that, in spite of numerous patient safety efforts, the health care community has failed to clearly define what makes a hospital safe.

"People in health care . . . feel they are taking a sip of water from a firehouse because we have all of these criteria for safety being thrust upon us, and we don't know where to start," he said. "So if we can give people a clear idea of what they need to do to be safe, to earn a safety sticker, we're going to advance safety in health care dramatically."

Wellmont, Adventist, and Novant, with more than 50 hospitals among the three organizations, have banded together to form the Safest Hospital Alliance, which aims to create metrics and identify best practices to determine how hospitals should safely function, Salluzzo said.

Over the next two years, he said, the group will collate and prioritize existing quality measures, which, Salluzzo contended, "has not been done, believe it or not."

The alliance, which has invited other health systems to join, will also create new safety measures "around key diagnoses and processes . . . from the perspective of health care providers," he said.

Salluzzo said the group has been in discussions with the Joint Commission, which is serving on the alliance's advisory board, about the potential of creating an accreditation process for facilities designated as "safest hospitals."

"We are still working the details of that out," he said, adding that outgoing Joint Commission President Dennis O'Leary had expressed frustration that the U.S. health care community has not yet figured out how to "operationalize" safety.

"And I hear that a lot from all of the organizations," Salluzzo added.

The alliance, he said, is hoping that its safest hospital template for error-free care will become a nationally accepted standard.

Salluzzo argued the alliance's initiative is more than just "the newest mousetrap for safety."

"We are deeply committed from top to bottom to this initiative," he declared. "We have a full commitment of board leadership, and we are putting a real commitment of financial resources and human resources into it."

A spokesperson for the alliance said that each health-system member will be responsible for providing those resources.

The initiative will develop an operational definition of a safe hospital based initially on a safety target of 3.4 errors per 1 million patient encounters, said alliance board member Kenneth Kizer, outgoing president of California-based Medsphere and former president of the National Quality Forum.

He noted that the 3.4 errors per 1 million figure is the same rate established by Six Sigma, a method developed by Motorola for measuring and reducing the variables that lead to defects or errors.

Patient safety, Kizer said, cannot progress until a clear definition of a safe hospital has been established. He noted that a recent report by the Rand Corporation revealed that the U.S. government, though having spent billions of dollars on emergency-preparedness activities since 2001, has not developed measures to assess whether those funds were spent wisely.

Under a contract with the Department of Health and Human Services, Rand is convening expert panels and conducting literature reviews to define preparedness, according to a recent report from the Government Accountability Office.

Kizer stressed not to expect the alliance to have "all of the answers" or a perfect definition of a safe hospital right away.

Although the goal is to have hospitals improve their safety by 80%, if facilities improve by even 50%, Salluzzo said, "that's tremendous."

"Sometimes the perfect is the enemy of the good," he said.