Greater New York Hospital Association

Additional Statement, Submitted by Tracy Miller, Vice President for Quality and Regulatory Affairs, Greater New York Hospital Association

I am Tracy Miller, Vice President for Quality and Regulatory Affairs, for the Greater New York Hospital Association (GNYHA). Thank you for the opportunity to submit this statement. GNYHA represents the interests of 175 hospitals and continuing care facilities in New York City and surrounding areas. Our members are either not-for-profit, charitable organizations or publicly-sponsored institutions that provide acute tertiary care as well as post-acute and chronic care, and often serve as the principal source of primary care in their service areas. Greater New York Hospital Association members and their related medical schools also conduct extensive medical education and training, and undertake cutting-edge medical research.

Our member institutions have developed extensive programs to improve health care quality for the patients they serve. Their programs range from projects at individual institutions to improve care for patients with diabetes, congestive heart failure, cancer, and innumerable other conditions to quality improvement initiatives that cut across large health systems to collect data, analyze the findings, and provide feedback to improve performance. In addition, GNYHA member hospitals participate in major research projects to contribute to the development of new knowledge and approaches to advance quality improvement. Some of our member facilities have also made large investments in information technology such as the electronic medical record and physician order entry systems to reduce errors and advance health care quality.

At the same time that member facilities have made significant investments of funds, clinical expertise, and staff time to improve health care quality, they have faced extraordinary financial pressures due to reduced Medicare funding, reductions in payments by other public and private payers, and the growing number of uninsured patients routinely treated in their facilities. For this reason, GNYHA has led the effort in New York State to increase coverage for the uninsured, and is participating in a national campaign to reverse the cuts required by the Balanced Budget Act that have caused a severe revenue shortfall in many member facilities. GNYHA members remain committed to advancing on the issue of health care quality. However, GNYHA urges recognition of the fact that budget cuts directly affect the funds available for providers to undertake quality initiatives and other programs central to the mission of medical practice and not-for-profit health care facilities.

GNYHA Initiatives to Advance Patient Safety

In response to the challenge to improve patient safety set forth by the Institute of Medicine (IOM) and the Quality Interagency Coordination Task Force (QuIC) reports, GNYHA has mounted a major new initiative on health care quality. GNYHA's commitment to making patient safety a priority to better assist our member facilities on this crucial issue is reflected in the creation of a new position of Vice President for Quality and Regulatory Affairs, with my appointment to serve in that capacity.

GNYHA's new quality initiative will build on its prior activity on health care quality. In 1995, GNYHA devised the Quaesitum Measurement System, a system of data analysis that uses information reported by hospitals to New York State to provide member institutions with detailed risk-adjusted benchmarked information on outcomes, including mortality and major complications of certain procedures. Every year, GNYHA prepares a report for each member facility with a facility profile, including comparison of the facility's performance to other facilities in the region and to a peer group selected by the facility. GNYHA has also offered member institutions training on root cause analysis, participated in the Institute for Healthcare Improvement (IHI) breakthrough series, and conducted numerous training meetings on New York State's incident reporting system.

A key element of the new quality initiative at GNYHA will be the development of improvement projects that can be widely implemented by our members, will reduce medical errors in areas that affect crucial patient outcomes, and embody best practices for the health care industry. To assist in carrying out these initiatives, GNYHA has convened a workgroup of the leadership on health care quality from a number of our member institutions and networks.

To prepare for formation of the workgroup and other initiatives, I recently met with Federal and State policymakers as well as representatives of major national organizations that focus on health care quality. In these meetings, I sought the tools and prototypes for patient safety initiatives that our members could undertake. In particular, I sought initiatives that: (1) have a proven evidence-base; (2) do not require a highly specific information technology platform or significant new financial investment in such technology; and (3) have available tools for implementation that are publicly accessible and tested. I identified few such initiatives, even for errors leading to the most serious harm such as wrong patient or wrong-site surgery.

Meeting the Information Needs of Health Care Providers-A Toolkit of Best Practices

Research and work in health care quality over the past decade have provided the knowledge base for clinical guidelines, advanced the nascent science of quality measurement and reporting, and produced some outstanding quality improvement initiatives at individual health care institutions around the nation. Unfortunately, funding and efforts to disseminate this knowledge and put it into practice have lagged far behind. As a result, advances in quality improvement and patient safety remain largely idiosyncratic to individual health care institutions or health systems, building on information technology and other platforms for implementation that cannot be readily adapted at other institutions. For the most part, funding has not been available from the private or public sectors to track the outcomes of existing programs, and to disseminate the measures, training materials, and guidelines used in improvement initiatives. As a result, health care institutions have no choice but to reinvent the wheel as they seek to improve quality and reduce errors, leading to extraordinary redundancy of effort and expenditure of resources in terms of staff time, leadership, and expertise.

Patient Safety Clearinghouse

GNYHA strongly supports development of the Center for Quality Improvement and Patient Safety (CQuIPS) at the Agency for Healthcare Research and Quality (AHRQ) and creation of a Patient Safety Clearinghouse as part of the Center. GNYHA urges that the Clearinghouse serve as a national resource on best practices, disseminating specific information and tools to facilitate implementation of quality improvement initiatives including, but not limited to: (1) clinical protocols; (2) patient education brochures, home monitoring tools and other materials; (3) staff training materials and programs; (4) a breakdown of resources needed for implementation, including details of information system technology capacity; (5) quality measures; and (6) data analysis and feedback processes to achieve improvement. In other words, the Center should provide the tools on evidence-based best practices essential to enable and foster implementation by all providers.

Similarly, many of the initiatives that the QuIC will undertake for providers that are part of the Federal system could also inform the efforts of health care providers nationally including: (1) the training program to develop the skills to analyze adverse events and move from that analysis to effective interventions; (2) the collaboration with the Institute for Healthcare Improvement to reduce errors in "high hazard areas"; (3) analysis of large data bases to identify error prone procedures, products and systems; and (4) research on strategies to provide effective feedback to clinicians. GNYHA and its members would welcome the opportunity to learn from these initiatives, and encourage the QuIC to build on its work as a prototype for national dissemination.

Reducing Egregious Errors

Collection and dissemination of evidence-based protocols that have been proven effective should also be the touchstone of other Federal initiatives to eliminate egregious errors. In particular, the QuIC report states that the National Quality Forum will be charged to define within 12 months: (1) a set of egregious errors that are preventable and should never occur; and (2) patient safety practices that institutions should implement to reduce errors. These practices should be accompanied by the tools and protocols to implement the practices identified. By making this information widely available, the National Quality Forum could provide not only a set of goals, but also the means for health care providers to achieve those goals.

Likewise, the U.S. Health Care Financing Administration (HCFA) has announced its intention to create a program to collect data on preventable medical errors that result in significant harm to patients, ultimately moving to a national mandatory reporting system for such errors. GNYHA recommends that HCFA devote resources to developing the protocols and toolkit for providers to adopt best practices to reduce these errors.

Fostering Collaboration to Apply Best Practices: The Importance of Funding and Confidentiality Protection

GNYHA strongly supports a collaborative approach between government and the private sector to promote education, track patient safety initiatives, and translate research findings into practice. Specifically, GNYHA urges AHRQ to allocate increased funding to initiatives under its Translating Research Into Practice (TRIP) program, with expedited projects on key issues of patient safety to respond to the sense of urgency generated by the IOM and QuIC reports. In this regard, GNYHA members would welcome collaboration with Federal agencies as discussed in the QuIC report to develop and evaluate safety models.

Collaboration among private health care providers is also crucial to advance patient safety by providing databases large enough to identify error prone procedures more readily, and create a platform for shared problem-solving. At the present time, the loss of confidentiality protection for data shared outside an institution or health system is a serious barrier to such collaboration. GNYHA urges that QuIC develop a model policy for adoption by state governments and Federally-funded collaborative research that effectively addresses this barrier by expanding and ensuring protection for information shared for quality improvement purposes. While changes in law to extend peer review protection to collaborative research must be made at the state level, national leadership could prompt and inform state action.

Using Reporting for Improvement

As noted in the IOM report and the national discussion that followed the report's release, New York State has played a leadership role nationally in developing a system for reporting adverse events. Since 1985, hospitals have reported to the New York State Department of Health on a wide range of adverse events defined in both statute and regulation.

The QuIC report states that the CQuIPS will identify existing state reporting systems, evaluate their suitability for helping to build a national system of errors reporting, and determine how data collection or enforcement efforts can be improved to enhance the value of those systems in achieving public accountability. The QuIC report focuses almost exclusively on research and analysis to support the use of reporting to foster public accountability. GNYHA urges that QuIC and AHRQ also lend their expertise and leadership to advance development of reporting systems as a vehicle to promote improvement. Hospitals and other health care providers that report on errors should be engaged as partners in learning from the information reported. As noted in the IOM report, even states that have been leaders in reporting have lacked the resources to conduct analysis of the aggregate reported data and feed that analysis back to providers to improve patient safety. Federal expertise and funds should be targeted to state governments that have shown leadership on reporting to devise best practices for states to use the data reported to facilitate improvement, working in a collaborative relationship with health care providers.

Conclusion

GNYHA and its members are committed to building on the quality initiatives and infrastructure already under way at member institutions as well as the clinical, administrative, and health quality expertise of our members to advance patient safety. We will launch our collaborative effort on patient safety in the coming weeks. We welcome the information tools to expedite our efforts, and urge that development and dissemination of such tools should be a priority for QuIC as it exercises national leadership on health care quality.

Current as of September 2000

Internet Citation:

Greater New York Hospital Association. Additional Statement. National Summit on Medical Errors and Patient Safety Research. September 2000. http://www.quic.gov/summit/anyhospitals.htm

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