Patient safety should be hospitals' focus, health experts say
Medical mistakes are the third leading cause of death, after heart disease and cancer, resulting in as many as 440,000 preventable deaths a year, according to a new documentary on patient safety, “To Err is Human.”
The film and its data on medical mistakes, often called a silent epidemic, was the springboard for a panel discussion by regional and national health care administrators who watched a screening of the film Tuesday at Lehigh University’s Iacocca Hall.
“By screening this documentary, we hope to raise awareness about the importance of systems thinking and working together to eliminate medical errors,” said Ana-Iulia Alexandrescu, director of the healthcare systems engineering program at Lehigh University, which hosted the screening with the Lehigh Valley Business Coalition on Healthcare, a nonprofit organization that purchases health insurance for businesses.
“To Err is Human” was written and directed by Michael Eisenberg, the son of the late Dr. John Eisenberg, considered the father of the modern patient safety movement. Since its release in April, the film has been shown at medical schools, hospitals, and film festivals across the country.
Dr. Matthew McCambridge, senior vice president, chief of quality and patient safety at Lehigh Valley Health Network, said the network held a screening of the film about two months ago for some of its staff and plans to make it required viewing for all of its employees.
The film tells the story of Sue Sheridan of Boise, Idaho, who talks about her newborn son’s missed diagnosis of jaundice that left him with cerebral palsy and another medical error that cost her husband his life after a test showing malignant brain cancer was never reviewed by his physician.
Commentary by some of the nation’s experts and pioneers in patient safety is woven into the documentary, including interviews with Leah Binder, president and CEO of The Leapfrog Group, an independent organization that issues an annual safety grade to hospitals, and who was among the panelists Tuesday.
Many of the panelists spoke about the need for patient safety to be an inherent part of a hospital’s culture and for hospitals to be transparent about the process and their metrics.
Binder said one way hospitals can be more transparent is by voluntarily participating in The Leapfrog Group’s annual safety grade report that is issued to all general hospitals and made public. Hospitals are given a letter grade, A through F.
Hospitals are asked about such things as infection rates, Caesarean birth rates and other medical procedures and protocols and given a score on how well they meet standards, Binder said.
“It’s our way of engaging the public and engaging purchasers, to hold standards for accountability for all of us,” Binder said.
“It’s not just for the public, by the way, it’s also for people who work in hospitals, who are probably more dedicated to the issue of patient safety than many of us who are outside hospitals looking in because they live this every day. This matters deeply to them. This is what they are about in their life,” Binder said.
Dr. Marc Granson, founder and CEO of SurgeonCheck, based in Bethlehem, said the public needs to understand Leapfrog’s importance.
“They’re independent. They’re conflict-free. They have one thing in mind and that’s patient safety,” he said.
Other groups have a “pay-to-play formula” that make a profit when they connect patients to hospitals, Granson said.
Capital BlueCross, which serves 21 counties in Central Pennsylvania and the Lehigh Valley, implemented Leapfrog’s hospital incentive program to improve patient safety, said Dr. Jennifer Chambers, senior vice president for clinical solutions and chief medical officer at Capital BlueCross.
“We have found that it’s been incredibly powerful in a couple of different ways,” Chambers said.
“First, for the hospitals that have chosen not to participate, they’ve gotten some peer pressure. That’s gotten recognized by the people who are purchasing services from them,” she said.
Capital BlueCross invited hospitals, both in and out of its network, to discuss best practices for patient safety.
“We don’t see patient safety as a competitive thing; we see this as a community thing. All of us have to participate,” Chambers said.
She compared the patient safety crisis to the opioid crisis, where action on multiple levels didn’t occur until the public became outraged.
“I believe Leapfrog grades and other measures of quality and safety in hospitals need to be paid attention to by employer groups who are purchasing, by patients who are utilizing those services, by health plans that are negotiating and contractually relating to our hospital providers,” Chambers said.
“Transparency is good, but unless there are consequences and accountability for those outcomes, we’re not going to make any gains,” she said.
Chambers said the Lehigh Valley was fortunate because its two top health networks, LVHN and SLUHN, have top safety grades, “but that’s not the case everywhere.”
Donna Sabol, vice president and chief quality officer, St. Luke’s University Health Network, said the film was affirming in some ways because “it was like a checklist of things that we’ve been doing to improve quality and patient safety.”
But she said it was sobering when Chambers told her many hospitals in the country are not following all of these safety initiatives and evidence-based care and protocols.
“That was a reality check for me,” Sabol said.
Transparency is important, she said.
“It’s important to educate the community and groups like this on the challenges related to patient safety, but also how well we do in our hospital systems in the region. We work hard at it, our doctors, our nurses, our staff work hard at it. And it’s a work in progress. For me, I’m never satisfied.”
Dr. Terrill Theman, adjunct professor, healthcare systems engineering program, Lehigh University, said patient safety has an economic cost, in addition to the human cost.
“The cost of doing it right is so much less than treating the consequences of not doing it right,” Theman said.