Medical Group Management Association

The Medical Group Management Association (MGMA) is pleased to submit this statement regarding the need to conduct extensive research on medical errors and patient safety in the ambulatory care setting. We commend the Agency for Healthcare Research and Quality (AHRQ) for organizing the National Summit on Medical Errors and Patient Safety Research and its exemplary leadership on this issue.

MGMA is the nation’s oldest and largest medical group practice organization representing more than 7,100 physician group practices in which over 185,000 physicians practice medicine. MGMA's membership reflects the full diversity of physician organizational structures today, including world-renowned integrated delivery systems, multi-specialty clinics, independent practice associations, small single specialty practices, hospital-based clinics, academic practice plans, management service organizations, and physician practice management companies.

In October of 1999, MGMA launched its own patient safety initiative. The goal of the initiative is to maximize patient safety in medical group practice and ambulatory care settings. MGMA's patient safety initiative will help organizations understand and control:

• Incidents and accidents in group practice and ambulatory care settings.
• Systems failures that lead to patient injury.
• Organizational and human factors associated with incidents and accidents that can be addressed through delivery system changes.
• Mechanisms for achieving maximum safety.

MGMA urges the steering committee to consider the following perspectives as it formulates the objectives and needs for future research on medical errors and patient safety.

Introduction

Over the past two decades, the health care system has evolved from a largely inpatient, hospital oriented delivery system to one increasingly utilizing ambulatory care. Medical and surgical procedures once performed only in acute care inpatient settings are now routinely carried out in ambulatory settings. In many cases, services can be provided in ambulatory care settings more cost-effectively with comparable patient care outcomes.

However, as more procedures are performed in the ambulatory care setting, there is greater vulnerability to system malfunctions and procedural failures that can result in medical errors and the reduction of patient safety. Unfortunately, research on the issue of medical errors/patient safety in the ambulatory setting has been largely overlooked. The literature review included in the Institute of Medicine (IOM) report, To Err is Human: Building a Safer Health System, cites fifty studies of medical errors. Among these studies, thirty-nine were inpatient hospital or long-term care facility studies; ten studies concentrated on population based surveys, medical record studies to determine incidence of errors or death certificate studies. Only an Australian study of 324 non-randomly drawn general practitioners providing self-reported data on medical errors could be construed as a study of patient safety in an ambulatory care setting.

Immediately after the IOM report was released, a flurry of proposals from the administration and Congress emerged to address the issue of patient safety. Unfortunately, much of the focus and dialogue regarding these proposals centered on creating reporting systems to identify those individuals involved in errors. MGMA believes this focus was misguided. Ample evidence from other industries suggests that the key to improving safety is to create a culture where blame is not the objective. Inputting errors into a database system where they can be analyzed to understand why accidents happen, rather than to punish those involved, will help us uncover systemic problems that hamper safe medical practice. Public disclosure of adverse events will do nothing but harm the quest for safer medical care.

Additional Research Needed

Extensive research ultimately is the key to effectively address the issue of patient safety. Specifically, MGMA believes more research is needed to uncover the structural, administrative, and cultural factors that impact patient safety in ambulatory care. MGMA contends that increased funding for AHRQ, as well as the establishment of a Center for Patient Safety within AHRQ, is an important component of implementing a successful research agenda. Increased funds and a patient safety center will allow AHRQ to take the necessary steps to lead the government’s efforts and carry out critical research. MGMA has urged Congress to adopt the Senate’s language pertaining to AHRQ in the FY 2001 Labor, Health and Human Services, and Education Appropriations bill, which recommends $270 million in funding and the establishment of a Center for Patient Safety.

MGMA has taken several steps to contribute to the goal of uncovering barriers to patient safety in the ambulatory care setting. MGMA co-sponsored a patient safety symposium in June of this year that examined the challenges, obstacles, and solutions regarding patient safety. In addition to MGMA, the conference partners included: The University of Minnesota's Carlson School of Management; Partnership for Patient Safety; Premier, Inc.; VHA, Inc.; The Harvard Risk Management Foundation; The National Business Coalition on Health; and The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). Experts concluded that more research must be conducted, particularly in the ambulatory care setting, to improve patient safety in the health care system.

In addition, the MGMA Center for research is currently conducting a project aimed at improving office-based practice systems for early diagnosis and treatment of breast cancer. The Breast Management Outcomes Assessment Study is designed to assess the effects of the use of specifically designed guidelines for the diagnosis of breast lumps and lesions in clinical practice. The project has developed a unique program intervention, the Breast Evaluation System (B.R.E.S.T.), to substantially increase guideline use and improve the process of care and patient outcomes. The study seeks to evaluate the hypothesis that by increasing provider understanding of the proper management of breast problems and by employing a validated systematic approach to breast problem management though the B.R.E.S.T. system, rates of diagnostic delay and treatment discontinuity will significantly decrease, while patient compliance and satisfaction improves. Currently in its third year, the study is funded by grants from the COPIC Insurance Company, the Susan G. Komen Breast Cancer Foundation, Denver Affiliate and the Front Range Risk Management Group. The study is presently in its final data collection and analysis phase.

Findings from the COPIC Breast Cancer Management Studies will be presented at MGMA’s patient safety conference, co-sponsored by the Health Care Financing Administration (HCFA) and AHRQ, to be held later this year. The conference will convene experts, practitioners, and other stakeholders in patient safety to develop a research agenda that will lead to understanding patient safety in ambulatory care, and to identify effective methods to improve and ensure ambulatory patient safety. The conference will focus on what is currently known and what we need to learn to improve ambulatory patient safety. It will present key questions that need answers, and identify promising strategies that need to be tested.

MGMA also has entered into a partnership with the American Hospital Association (AHA) to focus attention on medication safety issues in ambulatory care settings. A survey of MGMA members showed that 30 percent of them consider drug interactions to be the greatest patient safety risk faced in their practices. Through AHA’s partnership with the Institute for Safe Medication Practices (ISMP), ISMP has developed a comprehensive tool for use by medical staff and hospital-based pharmacies to identify, understand, and reduce medication errors. MGMA will work with AHA and ISMP to develop similar tools to be used by physicians in both their medical groups and in hospitals.

Reporting Systems

MGMA contends that an effective reporting system could be one important component of a broad and comprehensive approach to improving patient safety. However, the primary goal of a reporting system must be to analyze and understand why accidents happen, rather than to punish those individuals or entities involved. Therefore, an effective reporting system must include sufficient tools and resources that will enable researchers and other individuals to analyze data and identify systemic flaws that exist in the health care system. Before any reporting system is implemented, whether on a national or local level, MGMA believes it would be prudent to evaluate the reporting systems that currently are in place (e.g., Veterans Administration, JCAHO, various states) to determine their effectiveness. Furthermore, any existing medical error data should be analyzed to decipher where, and to what extent, the most significant flaws exist in our health care system.

In order for any reporting system to be effective, it must contain confidentiality, peer review, and discoverability protections. The intent behind a national reporting system must be to correct inherent deficiencies in the health care delivery system, not to punish individuals who make a mistake. Promoting open and candid disclosures of medical errors is a crucial component of effectively increasing patient safety; this will only be accomplished if reported information remains confidential. Without assurances that the information will remain confidential, providers and health care entities likely will not divulge important information fearing lawsuits and other legal repercussions.

MGMA appreciates this opportunity to provide its views regarding the issue of patient safety. It is an extremely complex issue, which can only be effectively addressed through a multifaceted approach. MGMA believes any approach must start with thorough and extensive research, particularly in the area of ambulatory care settings, to uncover the various factors that impact patient safety. MGMA looks forward to working with HCFA, AHRQ, and other organizations to reduce medical errors and improve patient safety.

Current as of September 2000

Internet Citation:

Medical Group Management Association. Additional Statement. National Summit on Medical Errors and Patient Safety Research. September 2000. http://www.quic.gov/summit/amgma.htm

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