WHERE ARE WWHERE ARE WSAFETY?SAFETY?

Lucian L. Lucian L. uc auc aHarvard SchoolHarvard School

WE IN PATIENT WE IN PATIENT

Leape, MDLeape, MDeape,eape,l of Public Healthl of Public Health

0213021302130213

Perhaps the most Perhaps the most i A ii A iin Americain America

8888

opinionated zip code opinionated zip code

The New York TimesThe New York Times

The future of healthThe future of healthThe future of healthThe future of health

•• How did we get hHow did we get h

•• Where do we neeWhere do we nee

H ill t tH ill t t•• How will we get tHow will we get t

h careh careh careh care

here?here?

ed to go?ed to go?

th ?th ?there?there?

The future of healthThe future of healthThe future of healthThe future of health

•• How did we get hHow did we get h

•• Where do we neeWhere do we nee

H ill t tH ill t t•• How will we get tHow will we get t

h careh careh careh care

here?here?

ed to go?ed to go?

th ?th ?there?there?

The Growth of SpecThe Growth of Spec

Innovation flourishedInnovation flourished

Outcomes substantialOutcomes substantialOutcomes substantialOutcomes substantial

Technology played anTechnology played an

Care became infinitelyCare became infinitely

cializationcialization

ly improvedly improvedly improvedly improved

n evern ever--increasing roleincreasing role

y more complexy more complex

Specialization Specialization -- dowdow

Costs soaredCosts soared

Patients’ expectationsPatients’ expectationsPatients expectationsPatients expectations

More patients were haMore patients were ha

More and more medicMore and more medic

D t b t tD t b t tDoctors began to treaDoctors began to trea

Health care became inHealth care became in

wnsidewnside

s roses roses roses rose

armedarmed

cal graduates chose specialitiescal graduates chose specialities

t th di t th ti tt th di t th ti tat the disease, not the patientat the disease, not the patient

ncredibly complexncredibly complex

Measurement and EMeasurement and E

Rise of the RCT: 1970:Rise of the RCT: 1970:

70’s70’s –– WennbergWennberg –– GeoGeo70 s 70 s –– Wennberg Wennberg –– GeoGeo

80’s 80’s –– Brook Brook –– appropriaappropria

90’s 90’s -- MPS MPS –– medical ermedical er

99 99 –– IOM: “To Err Is HIOM: “To Err Is H

EvaluationEvaluation

500 2006: 15,000 500 2006: 15,000

graphic variationsgraphic variationsgraphic variationsgraphic variations

ateness / underuseateness / underuse

rorsrors

Human”Human”

Societal ChangesSocietal Changes

Four warsFour wars

The civil rights movemThe civil rights movemThe civil rights movemThe civil rights movem

The explosion of inforThe explosion of infor

Increasing affluenceIncreasing affluence

G t f diG t f diGovernment funding oGovernment funding o

mentmentmentment

rmation technologyrmation technology

f h lthf h lthof health careof health care

Societal Changes Societal Changes -- EEgg

Patient empowermentPatient empowerment

Explosion of informatiExplosion of informatiExplosion of informatiExplosion of informati

Increasing cost of heaIncreasing cost of hea

EffectsEffects

tt

ion technologyion technologyion technologyion technology

alth carealth care

The future of healthThe future of health

•• How did we get hHow did we get h

•• Where do we neeWhere do we nee

H ill t tH ill t t•• How will we get tHow will we get t

h careh care

here?here?

ed to go?ed to go?

th ?th ?there?there?

A new model of heaA new model of hea

Stimulated by:Stimulated by:

Relentless upward cosRelentless upward cosRelentless upward cosRelentless upward cos

Experience with the cExperience with the cb db dteamteam--based carebased care

Increased patient focuIncreased patient focupp

The Massachusetts exThe Massachusetts exorganizationsorganizationsorganizationsorganizations

althcare?althcare?

st pressurest pressurest pressurest pressure

hronic care model of integrated hronic care model of integrated

usus

xperiment and accountable care xperiment and accountable care

A Paradigm ShiftA Paradigm Shift

FROM: OneFROM: One--onon--one one

TO: CollaborativeTO: CollaborativeTO: CollaborativeTO: Collaborative

FROM: OneFROM: One--sizesize--fitsfits--

TO: Accountable TO: Accountable

FROM FFROM F ff iiFROM: FeeFROM: Fee--forfor--serviservi

TO: Global paymeTO: Global payme

care based on experiencecare based on experience

e team care based on evidencee team care based on evidencee team care based on evidencee team care based on evidence

--all hospitals all hospitals

Care OrganizationsCare Organizations

t t i di id lt t i di id lce payments to individuals ce payments to individuals

ents to ACOsents to ACOs

Accountable Care OAccountable Care OM di l HM di l HMedical HomesMedical Homes

1.1. StandardizationStandardization

22 Patient EngagementPatient Engagement2.2. Patient EngagementPatient Engagement

3.3. InterInter--professional Teaprofessional Tea

4.4. AccountabilityAccountability

Organizations and Organizations and

amsams

The future of healthThe future of health

•• How did we get hHow did we get h

•• Where do we neeWhere do we nee

H ill t tH ill t t•• How will we get tHow will we get t

h careh care

here?here?

ed to go?ed to go?

th ?th ?there?there?

The MassachusettsThe MassachusettsThe Massachusetts The Massachusetts

Universal coverage (97Universal coverage (97Rising costsRising costsRising costsRising costsShortage of primary carShortage of primary carNo loss of support by pNo loss of support by pNo loss of support by pNo loss of support by pcompanies, governmencompanies, governmen? Global payments to A? Global payments to A? Global payments to A? Global payments to A

ExperimentExperimentExperimentExperiment

7.4%)7.4%)

re physiciansre physicianspublic business insurancepublic business insurancepublic, business, insurance public, business, insurance tt

ACOsACOsACOsACOs

The Patient ProtectioThe Patient ProtectioA f 2010A f 2010Act of 2010Act of 2010

3012 Quality measure de3012 Quality measure de

3023 National pilot on bu3023 National pilot on bu3023 National pilot on bu3023 National pilot on bu

3502 Funds development3502 Funds development

3508 Demo to integrate 3508 Demo to integrate education of health preducation of health prpp

on and Affordable Care on and Affordable Care

evelopment evelopment

undled paymentsundled paymentsundled paymentsundled payments

t of community health teamst of community health teams

QI and Pt Safety into clinical QI and Pt Safety into clinical rofessionalsrofessionals

Wh d ti tWh d ti tWhere does patient saWhere does patient saf t fit i ll f thi ?f t fit i ll f thi ?afety fit in all of this?afety fit in all of this?

TO ERR IS HUMAN:TO ERR IS HUMAN:HEALTH SYSTEMHEALTH SYSTEM

: BUILDING A SAFER : BUILDING A SAFER

Errors are not caused Errors are not caused by bad people, but by bad people, but by bad systemsby bad systemsy yy y

A Great Success StoA Great Success Sto

E h it l hE h it l hEvery hospital has a sEvery hospital has a s

Hospital mortality hasHospital mortality has

Government funding oGovernment funding o

NQF 34 fe p ti eNQF 34 fe p ti eNQF 34 safe practicesNQF 34 safe practices

Voluntary regional coaVoluntary regional coa

IHI: training; 100,00IHI: training; 100,00

Joint Commission safeJoint Commission safeJoint Commission safeJoint Commission safe

oryory

f tf tsafety programsafety program

s been going downs been going down

of safety research of safety research –– AHRQAHRQ

ss

alitions all over the countryalitions all over the country

00 lives campaign00 lives campaign

e practices (“Goals”)e practices (“Goals”)e practices ( Goals )e practices ( Goals )

IHI 100,000 Lives IHI 100,000 Lives --,,

•• 2 years: 12/04 2 years: 12/04 –– 113100 H it l3100 H it l•• 3100 Hospitals3100 Hospitals

•• Implement 6 safe pImplement 6 safe p•• 122,300 lives saved122,300 lives saved

ResultsResults

12/0612/06

practicespracticesdd

“Getting to Zero”: Th“Getting to Zero”: Th

68 Hospitals 68 Hospitals

N CLBI VAP fN CLBI VAP fNo CLBI or VAP forNo CLBI or VAP for

-- Lives saved: 1578Lives saved: 1578Lives saved: 1578Lives saved: 1578

-- Hospital days saveHospital days save

-- Costs saved: $165Costs saved: $165

he Michigan Experiencehe Michigan Experience

March 04 March 04--June 05June 05

th 6 thth 6 thr more than 6 monthsr more than 6 months

8888

ed: 81,000ed: 81,000

5 million5 million

Surgical Checklist Surgical Checklist ggDeaths and CDeaths and C

14

12

14

%

8

10

atio

ns %

4

6

Com

plic

a

0

2

C

0

Complications

Pilot StudyPilot StudyyyComplicationsComplications

Before After

Deaths

A Great Failure StorA Great Failure Stor

Evidence of overall imEvidence of overall im

No one has implemenNo one has implemenNo one has implemenNo one has implemen

–– Leapfrog 1256 Leapfrog 1256 –– 30% 30%

Shocking rates of wroShocking rates of wroforeign bodies persistforeign bodies persist

Recurring scandals: IRecurring scandals: I

ryry

mpact is sparsempact is sparse

nted all of the NQF 34nted all of the NQF 34nted all of the NQF 34 nted all of the NQF 34

compliance with any of 6 s.p.compliance with any of 6 s.p.

ong site surgery and retained ong site surgery and retained

Indiana babies; vincristineIndiana babies; vincristine

What Have We LearWhat Have We Lear

1.1. Old habits die hardOld habits die hard

2.2. Implementing safe prImplementing safe pr2.2. Implementing safe prImplementing safe prseemsseems

33 Doctors and CEOs havDoctors and CEOs hav3.3. Doctors and CEOs havDoctors and CEOs hav

4.4. Safety is about relatioSafety is about relatio

rned?rned?

ractices is not as easy as itractices is not as easy as itractices is not as easy as it ractices is not as easy as it

ve to own itve to own itve to own itve to own it

onshipsonships

Safety is about relaSafety is about rela

It’s not just about repoIt’s not just about repopracticespractices

It’s about working togeIt’s about working toge

InterInter professionalprofessional–– InterInter--professionalprofessional–– Mutual respectMutual respect

Teamwork is the secreTeamwork is the secresucceeded in becomingsucceeded in becoming

ationshipsationships

orting, protocols, safe orting, protocols, safe

ether in teamsether in teams

et of every industry that has et of every industry that has g safeg safe

U S Airways 1549 JanU S Airways 1549 Jannuary 15, 2009nuary 15, 2009

Patient safety is aboPatient safety is abo

Teamwork and mutuaTeamwork and mutua

Patients as true partnPatients as true partnPatients as true partnPatients as true partn

StandardizationStandardization

AccountabilityAccountability

out culture changeout culture change

al respectal respect

ers in careers in careers in careers in care

How does this applyHow does this applyHow does this apply How does this apply

Are decisions teamAre decisions team--baba

Why is itWhy is it possiblepossible to gto gWhy is it Why is it possible possible to gto g

Are patients engagedAre patients engaged

–– DecisionDecision--makingmaking

–– Planning therapyPlanning therapyPlanning therapyPlanning therapy

–– Execution of therapyExecution of therapy

to Radiation Oncology?to Radiation Oncology?to Radiation Oncology?to Radiation Oncology?

ased?ased?

get a double dose?get a double dose?get a double dose?get a double dose?

? ?

Paul O’Neill on SafPaul O’Neill on Saf

Every worker’s experieEvery worker’s experie

•• I am treated with respeI am treated with resperegardless of position, eregardless of position, e

•• I have the education anI have the education ansupport to develop to msupport to develop to msupport to develop to msupport to develop to m

•• My work is noticed and My work is noticed and

fetyfetyyy

ence, every day:ence, every day:

ect by everyone else, ect by everyone else, education or payeducation or pay

nd training, the tools, and the nd training, the tools, and the my full potentialmy full potentialmy full potentialmy full potential

appreciatedappreciated

Paul O’Neill on SafPaul O’Neill on Saf

Every worker’s experieEvery worker’s experie

•• I am treated with I am treated with resprespregardless of position, eregardless of position, eg p ,g p ,

•• I have the education anI have the education ansupportsupport to develop tto develop tsupportsupport to develop tto develop t

•• My work is noticed andMy work is noticed and•• My work is noticed and My work is noticed and

fetyfetyyy

ence, every day:ence, every day:

pectpect by everyone else, by everyone else, education or payeducation or payp yp y

nd training, the tools, and the nd training, the tools, and the to my full potentialto my full potentialto my full potentialto my full potential

appreciatedappreciatedappreciatedappreciated