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Innovations in Patient Safety
Helen Burstin, MD, MPH
Director, Center for Primary Care, Prevention,
and Clinical Partnerships
Academy Health
June 6, 2004
Bridging the Quality Chasm
Where
We Are
Where We
Want To Be
Implementation
Health IT
Diffusion
Adoption
Diffusion of knowledge
Clinical Procedure
Landmark Trial
Current rate of use
Flu Vaccine
Pneumococcal Vaccine
1968
1977
64% (2000)
53% (2000)
Diabetic Eye Exam
Mammography
Cholesterol Screening
1981
1982
1984
48.1% (2000)
75.5% (2001)
69.1% (1999)
Balas EA, Boren SA., Managing Clinical Knowledge for Health Care
Improvement. Yearbook of Medical Informatics 2000.
RAND Study: Quality of Health
Care Often Not Optimal
Patients’ care often deficient, study says.
Proper treatment given half the time.
On average, doctors provide appropriate health care only half the
time, a landmark study of adults in 12 U.S. metropolitan areas suggests.
Medical Care
Often Not
Optimal
.Failure to Treat Patients
Fully Spans Range of
What Is Expected of
Physicians and Nurses
Medical errors corrode
quality of healthcare system
The American healthcare system,
often touted as a cutting-edge
leader in the world, suddenly
finds itself mired in serious
questions about the ability of its
hospitals and doctors to deliver
quality care to millions.
To Err is Human
Building a Better Healthcare System
 1999 IOM Report
 Between 44,000 and 98,000 die as a result of
medical errors annually
– Would be the 8th leading cause of death
– Ranks higher than MVAs, breast CA, AIDS
 Total costs: $17-29 billion
44,000-98,000 Lives
Based on extrapolation from two studies:
 Analysis of New York hospitalizations: adverse
events occurred in 3.7% of which 27% were
negligent and death occurred in 13.6% (Brennan et
al, NEJM, 1991)
 Analysis of Utah and Colorado hospitalizations:
adverse events occurred in 2.9% of which about
30% were negligent and death occurred in 6.6%
(Thomas, Medical Care 2000)
Medical Injuries During
Hospitalization
Based on 18 types of medical injuries:
 >32,000 attributable deaths occur annually
 2.4 million extra days of hospitalization
 $9.3 billion excess charges
(Zhan, Miller; JAMA 2003)
HHS Reports: Quality and
Disparities in Health Care
 First national comprehensive efforts to measure
the quality of health care in America and
prevailing disparities in health care
– Presents data for clinical conditions, including
cancer, diabetes, end-stage renal disease, heart
disease, HIV and AIDS, mental health, and
respiratory disease
– Includes data on maternal and child health,
nursing home and home health care, and patient
safety
Reports available at: http://www.qualitytools.ahrq.gov
National Healthcare Quality Report:
Missed Opportunities
 Only 20.9% of patients with diabetes receive
all recommended tests
 90% of adults are screened for high blood
pressure – but only 25% are controlled
 Nearly 1/3 of adults and children with asthma
do NOT receive effective Rx
 Almost 20% of persons with a usual source of
care report that they are not asked about
medications to prevent interactions
A Culture of Safety
 Non-punitive policies to address adverse
events
 Organizational commitment to open
communication about errors to encourage
reporting, analysis, prevention and mitigation
 Alignment between legal and clinical staffs to
ensure openness without compromising the
organization
Stages of Problem Recognition
 “The data are wrong.”
 “The data are correct but it isn’t a problem.”
 “The data are right, it is a problem but it isn’t
my problem.”
 “I accept the burden of improvement.”
Innovations in Patient Safety
 Panelists (i.e. the innovators):
– Ada Sue Hinshaw
– Brent James
– Jonathan Perlin