Healthcare.gov: Partnership for Patients: Better Care, Lower Costs

Partnership for Patients: Better Care, Lower Costs

Doctors, nurses and other health care providers in America work incredibly hard every day to deliver the best care possible to their patients.  Unfortunately, an alarming number of patients are harmed by medical mistakes in the health care system and far too many die prematurely as a result.

The Obama Administration has launched the Partnership for Patients: Better Care, Lower Costs, a new public-private partnership that will help improve the quality, safety and affordability of health care for all Americans.  The Partnership for Patients brings together leaders of major hospitals, employers, health plans, physicians, nurses, and patient advocates along with State and Federal governments in a shared effort to make hospital care safer, more reliable, and less costly.  The Partnership will help save 60,000 lives by stopping millions of preventable injuries and complications in patient care over the next three years and has the potential to save up to $35 billion, including up to $10 billion for Medicare. 

Over the next ten years, it could reduce costs to Medicare by about $50 billion and result in billions more in Medicaid savings.  Already, more than 500 hospitals, as well as physicians and nurses groups, consumer groups, and employers, have pledged their commitment to the new initiative.

The two goals of this new partnership are:

• Keep patients from getting injured or sicker. By the end of 2013, preventable hospital-acquired conditions would decrease by 40% compared to 2010.  Achieving this goal would mean approximately 1.8 million fewer injuries to patients, with more than 60,000 lives saved over the next three years. 

• Help patients heal without complication. By the end of 2013, preventable complications during a transition from one care setting to another would be decreased so that all hospital readmissions would be reduced by 20% compared to 2010.  Achieving this goal would mean more than 1.6 million patients will recover from illness without suffering a preventable complication requiring re-hospitalization within 30 days of discharge.

Improving Patient Safety
In 1999, the landmark Institute of Medicine study, “To Err is Human,” estimated that as many as 98,000 Americans die every year from preventable medical errors.  Despite progress in some areas, meaningful improvement was not made in the decade that followed.  Numerous patients continue to get injured or sicker from preventable, adverse events after being admitted to a hospital.  Patients are also vulnerable once they leave the hospital to continue healing at home, in an assisted living facility, or in other care settings; many are readmitted due to preventable complications.

• A study published in April, 2011 in the journal Health Affairs found that on average, 1 in 3 patients admitted into a hospital suffer a medical error or adverse event – nearly 10 times greater than previously believed.

• On any given day, about 1 in every 20 patients is affected by an infection related to hospital care.

• On average, 1 in 7 Medicare beneficiaries is harmed in the course of care, costing the government an estimated $4.4 billion every year.

• Nearly 1 in 5 Medicare patients discharged from the hospital is readmitted within 30 days – that’s approximately 2.6 million seniors at a cost of over $26 billion every year.

Successful efforts to improve patient safety have shown that collaboration and use of innovative practices to target specific types of medical errors and complications work.  For example, a collaborative effort in Rhode Island between insurers and hospitals reported a 42 percent decrease in central line-associated bloodstream infections.  In New Jersey, approximately 150 health care facilities reduced pressure ulcers by 70 percent.  And more than 65 Institute for Healthcare Improvement Campaign hospitals reported going more than a year without a ventilator-associated pneumonia in at least one unit.

Partnership for Patients – A Common Commitment 

Achieving the goals of the Partnership for Patients will take the combined effort of many key stakeholders across the health care system – physicians, nurses, hospitals, health plans, employers and unions, patients and their advocates, as well as the Federal and State governments.  Many important stakeholders have already pledged to join this Partnership in a shared effort to save thousands of lives, stop millions of injuries and take important steps toward a more dependable and affordable health care system.  They include:

• Hospitals and national organizations representing physicians and nurses: America has the best-trained and equipped health care system and workforce in the world, striving hard every day to care for patients.  These providers are committed to improving their care processes and systems, and enhancing communication and coordination to reduce complication for patients. 

• Patient and consumer organizations: Patients and their families are deeply affected by the harms from preventable health care complications.  These organizations are committed to raising public awareness and developing information, tools and resources to help patients and families effectively engage with their providers to avoid preventable complications.

• Employers, unions, health plans and States: Employers, unions, health plans and States can provide the incentives and support that will enable clinicians and hospital to deliver high-quality health care to their patients, with minimal burdens. 

Members of the Partnership will identify specific steps they will take to address reduce preventable injuries and complications in patient care.  For example, the Association of American Medical Colleges also launched a complementary harm reduction effort – Best Practices for Better Care – a multi-year initiative to improve the quality and safety of health care. 

More than 200 teaching hospitals and health systems have joined the effort, and are pledging to take simple steps such as using surgical checklists for safer surgery and using proven practices to reduce central line infections.  In addition, Partnership member California Public Employees' Retirement System (CalPERS), has already implemented an integrated care program that has reduced hospital readmissions by 22 percent, and has pledged to continue its efforts to improve patient safety.

To see which organizations have already joined the Partnership, visit partnershippledge.HealthCare.gov.

Investing in Better Care
Using up to $1 billion in new funding provided by the Affordable Care Act, the Department of Health and Human Services (HHS) will work with a wide variety of public and private partners to achieve the two goals of this partnership – keeping patients from getting injured or sicker in the health care system and improving transitions between care settings.

• Preventing Harm: The new Innovation Center at the Centers for Medicare & Medicaid Services (CMS) will dedicate up to $500 million to test different models of improving patient care and patient engagement and collaboration in order to reduce hospital-acquired conditions and improve care transitions nationwide.  The Partnership will target all forms of harm to patients but will start by asking hospitals to focus on nine types of medical errors and complications where the potential for dramatic reductions in harm rates has been demonstrated by pioneering hospitals and systems across the country, including preventing adverse drug reactions, pressure ulcers, childbirth complications and surgical site infections. The Innovation Center will help hospitals adapt effective, evidence-based care improvements to target preventable patient injuries on a local level, developing innovative approaches to spreading and sharing strategies among public and private partners in all States.

• Improving Care Transitions: The new Community-based Care Transition Program at the CMS Innovation Center will provide $500 million in funding to community-based organizations partnering with eligible hospitals for care transition services that include timely, culturally, and linguistically-competent post-discharge education, medication review and management, and patient-centered self-management support within 24 hours of discharge.  Starting April 12, 2011, eligible community-based organizations and acute care hospitals that partner with community based organizations can begin submitting applications for that funding.  Applications are being accepted on a rolling basis.  Awards will be made on an ongoing basis as funding permits.  Those interested in applying should visit: www.cms.gov/DemoProjectsEvalRpts/MD/itemdetail.asp?itemID=CMS1239313

 The programs announced today are just two of the many ways the Affordable Care Act is helping improve the health care system.  Last month, HHS announced the first-ever National Quality Strategy, which will serve as a tool to help coordinate quality initiatives between public and private partners as well as to leverage and coordinate existing efforts by federal agencies and departments to improve patient care.

HHS also announced new rules to help doctors, hospitals, and other providers better coordinate care for Medicare patients through Accountable Care Organizations (ACOs).  By 2015, a portion of Medicare payments to the majority of hospitals will be linked to whether hospitals are delivering safer care, using information technology effectively and meeting patient needs.  Payment incentives and supports to improve quality and lower costs will also be available to State Medicaid programs.

 For more information about the Partnership for Patients, visit www.HealthCare.gov/center/programs/partnership.  For more information about the Community-based Care Transitions Program funding opportunity visit:  www.cms.gov/DemoProjectsEvalRpts/MD/itemdetail.asp?itemID=CMS1239313.

Posted: April 12, 2011

Institute of Health Systems Research 2008: MEDICAL ERRORS IN MOH PRIMARY CARE CLINICS

MEDICAL ERRORS IN MOH PRIMARY CARE CLINICS

By Khoo EM, Sararaks S, Lee W K, Sebrina S, Liew SM, Azah AS, Rohana l, Cheong AT, Hanafiah AN, Yusof Ml, Lidwina EA, Maimunah AH, Kalsom M, Azman AB. Medical errors in MOH primary care clinics.  A Project under the Letter Of Intent for lmproving Patient Safety. [PC 2; PS 9/2008 (I13)]. Kuala Lumpur. Institute for Health Systems
Research 2008. (full pdf document available...)

KEY FINDINGS:
- A high percentage of medical errors,
- 57.2% occur in primary healthcare sites.
- 93% of medical errors were deemed preventable.
- The majority of medical errors are related to medication
- A lack of knowledge and skills of MOH staff has been shown to contribute to medical errors.
- There is a need to improve the quality of healthcare services provided by MOH health clinics.

Detailed findings
+ 39.8% (Cl 26.6-53.0 %) of errors were likely to cause serious morbidity or mortality.
+ 93.4% (Cl 33.6-100%) of errors had strong evidence for preventability.
+ 29.0% (Cl 19.5-38.6%) Of errors were due to some form of missing documentation  whereby:
       - 54.7% (Cl 43.3-65.6%) had no documentation of physical examination.
       - 49.5% (Cl 38.8-60.2 %) had no documentation of history.
       - 43.0% (Cl 27.6-55.1%) had no documentation of problem or diagnosis.
       - 22.6% (Cl 12.8-32.4 %) of errors were due to illegibility.

- Medical assistants saw 81% of total records assessed

Below is the hotfile site for downloading the file, a little slow if you do not want the premium method of download or upload of files. Courtesy of Sifu, Madviruz, my UM class of 1979 pc wizard!

 

Medical Errors in MOH Primary Care Clinics.pdf document

1M Clinics: Seek views of all parties first

Letter to Editor, The Star, Thursday January 7, 2010

Seek views of all parties first

THE setting up of 1Malaysia clinics is presumably to help meet the needs of the urban people.
Tan Sri Dr Ismail Merican, the director-general of health, claims that the sole objective of this move is to ensure the delivery of equitable, quality healthcare to the public. This is of course a laudable move but the issue at large is the quality of these clinics.

According to him, there is a growing trend in most developed countries, like Australia and the UK, to delegate routine follow-ups and monitoring of stable patients with chronic illnesses such as diabetes, hypertension and even stable heart disease to staff nurses.

This may be possible in these countries as the nurses there are senior staff and degree holders in their profession, but the same does not hold true for medical assistants in Malaysia who undergo a 3+1 nursing training programme.

A study in 2009 revealed that medical assistants at government health clinics and government hospitals were found to be responsible for many medication errors. Of the 1,612 prescriptions generated by medical assistants in a single week, 1169 errors were noted and some were critical errors, involving the use of at least one medication categorised as Group B medicine, which only medical officers are authorised to prescribe. It must be noted that medical assistants are trained to assist medical officers and not to provide treatment in the same manner as medical officers.

Another issue that needs to be considered is the administrative cost involved in establishing these clinics. The cost involved in running public health institutions has not been studied comprehensively and it is well-known that some district hospitals are under-utilised, mainly because patient attendance is poor.

So setting up primary care organisations among klinik desa, district hospitals and other primary healthcare centres will incur further costs and may fail for want of attendance.

Another consideration is that access to healthcare cannot be provided in an ad hoc manner. It is not clear how the system will operate and the supervisory roles of medical officers are ill-defined. This will be especially critical in an emergency as well as when there is a need to seek a second opinion.

The views of all parties involved should be sought before any decisions are made and finalised. While it was claimed that senior officers from the relevant divisions of the ministry were involved in drawing up comprehensive guidelines for the establishment and running of these clinics, the fact remains that the views of other stakeholders, for example the MMA, and the NGOs were not solicited.

Despite these shortcomings, there are remedial measures that can be put in place to make these 1Malaysia clinics workable. There is no error-free system involving human intervention but it is possible to design a system to avoid or minimise the errors, such as a primary healthcare team made up of pharmacists, midwives, physio­therapists, senior nursing sisters, etc, to run these clinics.

For example, a patient coming in with a minor sports injury can be treated by a physiotherapist; a pregnant lady can be assessed by a midwife; minor surgery by the medical assistant; and the pharmacists would be able to pick up prescription errors and correct them before any harm occurs. This will ensure a check-and-balance of prescriptions and different treatment options.

The Government should consider the views of other stakeholders before embarking on this project because backpedalling after establishing these clinics would be a colossal waste of public funds.
The KPI of 1Malaysia clinics to provide equitable and quality healthcare can never be fulfilled if the clinics themselves are plagued with potential medical and system errors.

Dr Jayabalan T,
Dr Mohamed Azmi Ahmad Hassali and
Dr Asrul Akmal Shafie,
George Town.

Should Doctors be more ready to say Sorry?

Recently a New York Times article Doctors say "I'm Sorry" before "See you in Court" and a follow-up editorial Doctors Who Say They're Sorry addressed the uncomfortable issue of medical errors, especially those associated with having caused harm to patients.

For practising medical practitioners out there, medical errors are considered a near-taboo subject, one which is best left behind the radar screens of scrutiny. Yet we are aware that medical errors, especially those which are inadvertent or which result from unexpected patient/individual reactions or peculiarities, do happen, albeit not too frequently.

Many of these can be safely diffused by being honest and direct with the patients involved, and by careful candid explanation as to why these had happened and why they should not have, and that they would not be allowed to recur.

Most importantly, these types of errors should be treated as high priority and with empathetic sensitivity. Affected patients must be given every avenue to resolve or lessen the harm with the least incurring of pain, suffering or costs.

Of course, medical centres and hospitals must work together with doctors to address these so that cost sharing or waiver/compensation can be implemented expediently and efficiently. The patient should leave the facility satisfied that all that could be done, had been done.

More egregious are those errors due to diagnostic inaccuracy or therapeutic misadventure, incompetency or careless negligence--which are often deviously obfuscated, with blame deflected, or simply denied a full hearing or explanation to harmed patients. It is this group which when exposed, that oftentimes cause much anger and demand for compensation or even calls to reprimand or to punish the erring doctor or facility. Hence, the resultant litigation process which every doctor dreads.

But, admitting to medical mistakes is easier said than done. Besides, in most medical cultures, it is not permissible or safe to do so. Yet, we know that more can and should be done.

Although some 10 years ago, when Lucian Leape's group from the Institute of Medicine reported that as many as 98,000 patients died as a result of medical errors in the United States ("To Err is Human")--many are adamant that this was exaggerated. Many still denied the actual enormity of the problem.

Then some time in the early 2000s, when the Consumer Association of Penang (CAP), SM Idris alluded to a similar state of unrecognised medical errors in Malaysia, as the then editor of the Berita MMA, I objected quite vehemently that to extrapolate based on the experience in the US was wrong and unacceptable.

I called instead for more in-depth study and urge our health community to research this by gathering more accurate data, so that we can get a clearer picture as to the scale and the scope of this serious problem. I also called for pre-emptive attention to detail and a systemic overhaul of procedures and processes to help reduce these possible errors from taking place.

Perhaps CAP's statement to the press was too artless and seemed to denigrate the overall goodness of the medical care experience, that I had felt duty-bound to defend.

Since then however, I have been privy to several adverse patient experiences resulting from complaints to the Malaysian Medical Council (MMC). Most of these complaints are about unexpected adverse outcomes resulting from some medical therapeutic options which have gone awry, and/or unhappiness with the patient-doctor communication or implied dishonesty.

(Most of these MMC complaints are however, not ethical in nature and does not impute serious professional misconduct. This is not to say that there have not been medical errors or misadventure having taken place, but that the MMC is not the board or forum for resolving disputes as to negligence or incompetence, unless there is a recurrent pattern of egregious conduct which can endanger other patients. Unfortunately many among the public has mistaken the latter as the role of the MMC.)

Sometimes inadequate information is given or not at all; at other instances, when untoward bad outcomes result, not enough information or explanation is given. Too much delaying tactics or deflection to very legitimate queries, create unresolved feelings that the doctor and the hospital are hiding something.

It is this need to have closure and/or meaning that many aggrieved parties seek out the MMC or worse the courts to prove medical negligence, and ultimately seek retribution and recompense.

Of course, there are many lawyers out there who are quite ready for such pro bono work to litigate against such incompetent doctors or hospitals, and so the problem escalates.

Thus, many medical centres and doctor groups have begun experimenting with the new deal of becoming more forthcoming, and saying sorry first and early too.

Some 30 states in the US have enacted laws to protect the admissibility of such apology-related disclosure from medical malpractice challenges. And it appears that it is working. In some medical centres, early resolution with smaller compensation claims have already resulted, with some medicolegal costs falling by as much as two-thirds!

Thus perhaps for Malaysians too, this might be a way forward. Saying 'Sorry' and admitting candidly a medical error should not be taken as license to litigate, but as trying to resolve a bad situation from becoming worse. However, there must be mechanisms to protect such disclosure too, and perhaps we should also legislate to ensure that admissibility of such information is protected from medical malpractice claims.

Another approach is through a wider Mediation process which has already been in place in Singapore. At the last MMC meeting in mid-May, Dr Thurairatnam, (a past-president of the Malaysian Dental Association and Dental Council member) presented a short lecture on how this can come to fruition--the MOH is considering some way to explore this option further.

"Sorry seems to be the hardest word," so sang Elton John, but perhaps we as doctors can learn to say so earlier, sooner than later, and be ready to help our patients resolve better as a result, when medical care goes wrong.