On June 9, the House Energy and Commerce Health Subcommittee held a hearing on patient safety and quality initiatives.
In his opening statement, Subcommittee Chair Nathan Deal (R-GA) cited the 1999 Institute of Medicine report, “To Err is Human,” which estimates that 44,000 to 98,000 patients die each year from medical errors. Rep. Deal acknowledged that “we should be doing more” and said that the subcommittee would work to pass a patient safety bill before the August recess.
Describing patient safety as a “broad and complicated issue,” Rep. Lois Capps (D-CA) focused her comments on the national shortage of nurses, highlighting the “direct link” between the number of registered nurses and the quality of patient care. Noting that a 2002 report from the Joint Commission on Accreditation of Health Care Organizations (JCAHO) confirms that “overworked, overstressed medical professionals make more mistakes,” Rep. Capps argued that legislation (H.R. 1372) she has introduced to establish staffing level standards would “have a real impact on patient safety.”
Agency for Healthcare Research and Quality (AHRQ) Director Carolyn Clancy outlined the agency’s efforts to improve patient safety in America. In addition to the current annual public safety conference, with “a dual focus on patient safety and health information technology,” Dr. Clancy said that “since FY2001, AHRQ has funded over 225 patient safety and related health information projects.” These include:
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Dr. Clancy highlighted the importance of establishing a “culture of safety,” stating: “Health care professionals need to feel safe to honestly acknowledge errors or ‘near misses’ within the institutions in which they practice. Institutions also need to feel safe to seek help in identifying and resolving organizational and system-based threats to patient safety without retribution.”
JCAHO President Dennis O’Leary explained that JCAHO is a “private sector, not-for-profit entity dedicated to improving the safety and quality of health care provided to the public,” which “currently accredits over 15,000 organizations in the United States.” Noting that “some notable progress has been made” on safety issues, he warned that “we may actually be falling further behind as new drugs, procedures and technologies are introduced every day.” Dr. O’Leary defined “the creation of organization cultures of safety which embrace continuous attention to safety-focused, systems improvement efforts” as “the most significant near-term opportunities for achieving major advancements in patient safety.” He said that the new International Center for Patient Safety, established by JCAHO in March 2005, includes a website that “will serve as a central repository of resources and information related to all aspects of patient safety.” The site also is designed to “become the focus of the Center’s effort to create a worldwide collaborative network of patient safety leadership organizations.”
National Partnership for Women & Families (NPWF) Director of Health Policy Jane Loewenson stated, “The National Partnership is committed to improving the quality of our health care system because health care is central to the vitality and economic security of women and their families. The responsibility to make health care decisions for their families often falls to women. Yet there is very little meaningful information to help with such important decisions as choosing a doctor or hospital…Not only do we believe people have a right to this information, there is strong evidence that measurement drives quality improvement and that quality improves even more dramatically when information is publicly reported.”
Ms. Loewenson described the NPWF’s newly created Consumer-Purchaser Disclosure Project, “a coalition of large employers, business coalitions, and consumer organizations and labor unions that have united around a common goal of making our health care system more transparent by: 1) championing performance measures that reflect consumer and purchase needs through the National Quality Forum’s (NQF) consensus-based endorsement process; 2) encouraging the implementation and public reporting of NQF-endorsed measures by public and private purchasers, accreditation bodies, health plans, and other key stakeholders; and 3) encouraging the development of new standardized quality measures such as infection or complication rates, or patients’ experience with providers, so that consumers and purchasers have a more meaningful picture of the quality of care.” Additionally, she said, the NPWF “recently launched a major initiative, with support from Robert Wood Johnson Foundation, to engage consumer advocates at the local, state, and national level on these issues.”
Regarding legislation on patient safety, Ms. Loewenson stated, “The legislation should provide a clear definition of patient safety information. A certain level of confidentiality and protection from legal discovery is needed to encourage the voluntary reporting of medical errors and near misses. This protection, however, should not shield information from a patient that they would otherwise have access to, nor should it preclude information where appropriate, from use in criminal proceedings. Legislation should also protect federal, state, and local reporting requirements, such as those for public health.”
