The April 18 Department of Medicine grand rounds featured Robert Wachter, M.D., chair of the American Board of Internal Medicine, professor and associate chair of the Department of Medicine and chief of the Division of Hospital Medicine at the University of California, San Francisco.
Often credited with helping to create the hospitalist specialty, Dr. Wachter gave a fast-paced presentation, “The Quality, Safety and Value Revolution,” which included a historical timeline from 1999 to the present. Twelve years ago, “most people thought quality and safety in health care were excellent,” Wachter said. Consequently, there was no business case for improving quality and safety, no local expertise being developed and no resources devoted to improvement.
Then the Institute of Medicine (IOM) released “To Err is Human: Building a Safer Health System,” a November 1999 report that equated the number of annual deaths due to medical errors to the loss of lives caused by one large airplane crash every day of the year. The patient-safety field was launched.
In March 2001 the IOM issued another report, “Crossing the Quality Chasm: A New Health System for the 21st Century,” which called for fundamental change to close the quality gap and redesign the American health care system. The report contained 10 new rules, known as the starter set, to guide patient-clinician relationships. It also suggested a way to better align incentives in payment and accountability and recommended key steps to promote evidence-based practice and strengthen clinical information systems.
Pressure to transform health care continues to have an effect. “There was a huge amount of policy change in 12 years,” Dr. Wachter said, enumerating such milestones as:
- In 2002, the National Quality Forum listed eight serious errors that never should happen, “Never Events,” such as wrong-site surgery.
- In 2003, the Accreditation Council for Graduate Medical Education limited the number of hours that residents may work to no more than 80 per week.
- In 2004, the Joint Commission announced that advance notice of surveyor visits would be reduced from two years to 30 minutes.
- In 2004, Medicare’s Hospital Inpatient Quality Reporting program launched online.
- In 2005, the Institute for HealthCare Improvement began the 100,000 lives campaign, led by Don Berwick, M.D., with a view to save 100,000 lives from being lost due to medical mistakes.
- In 2008, Johns Hopkins Hospital intensivist Peter J. Pronovost, M.D. introduced an intensive-care checklist protocol that saved 1,500 lives and $100 million over an 18-month period in Michigan alone.
- In 2010, “Safe Patients, Smart Hospitals: How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out,” by Dr. Pronovost was published.
- In 2012, CMS finalized rules for the Inpatient Prospective Payment System in preparation for Fiscal Year 2013, the first year in which value-based incentives are available under the program.
While relatively weak pressures, such as social pressure, accreditation requirements with a low chance of failure and transparency measures have resulted in some improvement, eventually the driver to create better health care systems and processes will involve payment changes.
We will see more and more pressure to revolutionize quality, safety and value. The business case is growing, not only for safety but for efficiency and waste reduction, Dr. Wachter said.
But with crisis comes opportunity, he said. Many forces are promoting quality, safety and value. The patient will benefit in the end.