Holding Hospitals Accountable for Patient Safety

My friend Helen Haskell’s son Lewis, a top ranked scholar, athlete, and saxophone player, was 15 years old when he checked into a hospital for scheduled surgery. As happens sometimes, there were complications, which worsened during his stay. Helen repeatedly called for help. Then came the unspeakable: Lewis died. The cause was preventable complications of surgery.

Today, 21 years after her son’s death, Helen is a one of the country’s leading advocates for patient safety, and thanks to her and others, including the Patient Safety Movement Foundation and my organization, the Leapfrog Group, the country made progress preventing the errors, complications, and infections that kill too many Americans like Lewis. Still, it’s not enough. Researchers estimate over 680 people a day die from these breakdowns in hospitals, which helps explain why medical errors are the third-leading cause of death in the United States. Advocates hope to finally fix this, but early signs are mixed that the Biden administration comprehends the urgency of this problem. This is especially worrisome given research that indicates patients’ and clinicians’ concerns about hospital safety have risen during the pandemic.

One of the most important achievements since Lewis’s death is that the Centers for Medicare and Medicaid Services (CMS) publicly reports, by hospital, rates of errors, accidents, injuries, and infections, including deaths from surgical complications. That gives families lifesaving information: Surgical patients who suffer complications are more than twice as likely to die at the worst-performing hospitals than at the best performing hospitals. This affects the economy as well: Businesses pay thousands of dollars per hospital admission for the price of preventable complications and problems, but because those costs are rarely itemized on hospital bills, they rely on CMS to calculate the risk and give them the data.

This spring, CMS issued its annual proposed rule for inpatient care that included a plan to stop reporting on deaths from surgical complications, arguing that formula for counting the deaths needs adjustment. This prompted strong protest from advocates, who pointed out the measure and its calculation has been tested and studied over years and refinements in the methodology could be made without removing critical information from the public domain. Thankfully, CMS listened and, in an unusual action, reversed course, publishing a final rule retaining public reporting on the deaths.

CMS also proposed this year to remove payment penalties for hospitals that score poorly on a measure called PSI-90, which is a bundle of complications that cause mostly preventable suffering and death in hospitals. It contended that “costs associated with the measure outweigh the benefit of its use in the program,” presumably referring to the costs for hospitals of reporting all these hazards. Advocates argued that the cost to Medicare beneficiaries and other patients should matter most, and those are extraordinarily high — far higher than the administrative burdens of reporting them. PSI-90 includes painful, frequently deadly, and expensive complications such as sepsis, blood clots, lacerations, kidney punctures, falls, pressure ulcers, and other preventable problems. Thankfully, CMS agreed to continue reporting on PSI-90, but unfortunately plans to stop dinging hospitals financially if they do poorly on PSI-90.

But CMS is taking action in one area that we think is wrong: It will “suppress” data it collected from hospitals, meaning that it will not use that data to calculate rates of hospital-acquired infections and other hazards that occurred during the second part of 2020. CMS cited pandemic surges that plagued hospitals during that time as the reason for this move. While everyone is sympathetic to the enormous challenges hospitals have endured, the pandemic should not serve as a free pass to ignore other life-threatening contagious infections and breakdowns. Moreover, suppression of data blocks researchers from analyzing how the pandemic affected patient safety, so we can understand the nature of the problem and do better in the future.

When CMS exempts or downgrades reporting on patient safety, the data cannot be replaced. No other entity is influential enough to require hospitals to mine their records for the specific information needed to calculate valid safety measures for each hospital and make it public. And virtually all health plans, employers, consultants, navigators, digital developers, media, and hospitals use CMS data to compare hospitals. The transparency of CMS affects every American.

There are some areas where CMS is taking commendable action, including its bold commitment to push for the automatic reporting of quality data through electronic medical records. The Biden administration should fully support this important goal with funding and inter-agency talent like that of the Office of the National Coordinator of Health IT. In addition to providing the public with more timely data, it could give clinicians more real-time insights so they can intervene before initial complications cascade into tragedies. Currently, hospital EMR systems vary in capacity to raise alarms when symptoms are troubling or mistakes occur, and as many as nine out of 10 hazardous events may be missed.

But given the mixed actions by CMS this year, it risks sending the message that it does not see patient-safety-related problems as an urgent priority. Now is a singularly bad time to send that message. Worrisome early data suggests the pandemic has already significantly undermined patient safety. Press Ganey, the company that monitors health care worker perceptions of safety, issued a white paper that was uncharacteristically dark in tone, noting that clinicians are less likely to report their hospitals are safe. My organization studied patient perceptions of their care, and found similar areas of concern. For instance, a startling percentage of parents reported they did not feel comfortable speaking up when they saw something unsafe in the hospital caring for their child.

The Biden administration can and should turbocharge patient safety policy by summoning the many resources of the federal government that have a hand in preventing patient harm. They include the health systems for the active military and veterans and such parts of the Department of Health and Human Services as the Centers for Disease Control and Prevention, the Food and Drug Administration, the Indian Health Service, and the Agency for Healthcare Research and Quality.

In addition to restoring the measures and data that CMS just removed from public reporting and payment penalties, there are other policy ideas that would move us forward — all of which have bipartisan support. None is expensive. The include the following:

• The administration should advance the multi-stakeholder proposal to form a National Patient Safety Board, akin to the National Transportation Safety Board, as well as the widely endorsed proposal by AARP and Leapfrog to collect and report infection rates for the full range of health care facilities.
• The administration should support the “moonshot” policy agenda of the Patient Safety Movement Foundation, which is focused on improving transparency related to information about patient safety problems in all health care settings, and aligning payment for health services with reductions in preventable patient harm.
• CMS should publicly report more safety data on outpatient surgery, ambulatory surgery centers, emergency rooms, assisted living, and other health settings where we have limited or no knowledge.

At a minimum, the administration should join patient safety advocates and the families and individuals harmed by medical errors  in participating in the Unite For Safe Care worldwide event on September 17 to mark World Patient Safety Day.

Hospitals deserve enormous credit for fighting the pandemic with courage and resilience. They are saving many lives and saving our country. Indeed, it is precisely because hospitals are so important to American life that we must continue to hold them accountable for the protection of their patients and full transparency. The administration needs to accelerate progress and once and for all eliminate the kind of unimaginable suffering Helen’s family — and too many others — have needlessly endured.