Health Affairs Archives | Heartland Health Research Institute

Iowa DOT and Volvo Can Teach Medical Establishment a Thing or Two about Safety

Posted on: 11.19.19 By: David P. Lind

Before I comment about the never-ending problem of patient safety in our state and country, I want to provide kudos to the Iowa Department of Transportation (Iowa DOT) and Volvo for doing a great job of keeping vehicle drivers more safe.

Iowa Department of Transportation

When you drive on Iowa highways, particularly on our interstates, you will invariably see snarky, but clever, messages on 79 electronic message signs that may force a chuckle. You can thank the Iowa DOT and the public for these creative messages. The signs are designed to grab the driver’s attention with messages that are part of the ‘Zero Fatalities’ program the DOT launched back in 2014. The DOT promotes this program through blogs and social media. Additionally, the Iowa DOT pulls together safe driving and improved trauma care through a program called TraumaHawk.

Every Monday, the DOT messages change and relate to five driving categories such as buckle up, drive sober, stay alert, pay attention and slow down. But another statistic is commonly updated – sharing the latest number of fatalities on Iowa roads since the beginning of the year. This one always has my attention. Maybe it’s just me, but I am curious to know whether or not we have fewer fatalities.

I’m impressed that not only are the fatalities counted, but they are quickly shared with the public in ‘real time.’ According to the Iowa DOT website, a ‘fatality’ is considered “crash-related” when death occurs within 30 days (720 hours) of a crash. Complex crash investigations can delay the official fatalities report, so the numbers for the current months are preliminary and can change considerably.

Relating road fatalities with preventable medical error fatalities may sound like a stretch – but it’s not. The federal government and all 50 states have made vehicle fatalities and serious injuries a major safety priority. The design and manufacture of the vehicles we purchase are a direct result of these priorities.

Volvo’s Promise

At least one manufacturer, Volvo, has made safety it’s branded message – and market differentiator. This has been a huge success for Volvo when competing against a crowded field of car manufacturers. One of the visions listed by Volvo on its website is truly an eye opener:

No one should be seriously injured or killed in a new Volvo car by 2020.

There it is. Volvo has declared a zero tolerance for manufacturing unsafe vehicles. Quite an impressive Big Hairy Audacious Goal (special thanks to authors James Collins and Jerry Porras for coining the ‘BHAG’ term).

What About the Medical Care We Receive?

Why shouldn’t we have the same amount of commitment from the medical establishment, the federal government and all 50 states on tracking and reporting unsafe medical care? Great question, but we don’t.

Twenty years ago, the Institute of Medicine’s To Err is Human report was published, sending shock waves around the country that at least 44,000 and as many as 98,000 people die in hospitals due to preventable adverse events. The authors of this report called for developing a mandatory, nationwide system for reporting adverse events causing death or serious harm. Yet two decades later, we still have no system in place on a national basis. About two dozen states require providers to report adverse events, but these events are a narrow range of “never events,” which cover only a fraction of all harm events and errors. Iowa is not one of these states.

Tracking and reporting unsafe care boils down to disagreements on how to accurately measure patient harm. Arguments evolve around defining medical errors and avoidable harm, determining whether deaths were caused by errors or other factors, and heaven forbid, the inconvenience of having to collect this data.

Additionally, there is disagreement about the effectiveness of having healthcare staff voluntarily report adverse events or use other means, such as having automated harm surveillance tools embedded in the electronic health record (EHR). According to a 2011 Health Affairs article, voluntary reporting missed 90 percent of adverse events. It’s impossible to fix safety problems if only 10 percent of errors are observed and reported. Further, surveillance tools in EHRs can be manipulated to suit preference of results.

Apparently, ‘inconvenience’ seems to outweigh any perceived benefits of providing safer care. Seeking better measurements, however, should not hold up patient safety improvement efforts. Provider resistance to public reporting of errors is a big roadblock to making preventable medical errors a necessary reality. Unlike the Iowa DOT and Volvo initiatives, we have no ‘Zero Tolerance’ goal in eliminating preventable medical adverse events in Iowa or the U.S.

A New Relevant Role for Insurance Companies

Because the medical establishment and policymakers are unlikely to move forward to proactively improve healthcare outcomes and eliminate preventable medical errors, true payers – taxpayers, employers and their employees – must take charge. They must insist that ‘middlemen’ such as insurance companies implement initiatives, as I have outlined in my Des Moines Business Record article (2018), to proactively learn more from Iowa patients about their experiences with Iowa hospital and clinic encounters.

As an example, Wellmark can play a much greater, more relevant role – similar to the Iowa DOT and Volvo – and become the insurance company committed to the safety of their members – and not just function as a transactional player that processes claims with unknown outcomes. The premiums paid by Iowa employers and their employees should already include this ‘safety’ pledge that is not being acted upon. When you think about it, insurance companies are the stewards of our hard-earned money. We depend on them to use this money wisely.

Similar to our highways in Iowa today, imagine walking into your local hospital and seeing an electronic display showing real-time results of the ‘zero-tolerance’ program that reports preventable adverse events for that hospital. Now that would be a BHAG!

The next steps we take in Iowa will define our ethical commitment to this public health crisis.

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Hospital Patient Safety Culture Does Matter

Posted on: 11.20.18 By: David P. Lind

A few years back, I walked into an Iowa healthcare executive’s office to discuss an idea that I thought carried a great deal of merit regarding patient safety. The executive politely listened to me. The idea was both simple and very intuitive. Because the mission of this particular healthcare organization is to promote quality and safe care, I was assuming it would be open to potentially embracing this approach in Iowa.

This idea was generated from the Hospital Survey on Patient Safety Culture, which is a staff survey designed by the Agency for Healthcare Research and Quality (AHRQ) to help hospitals assess safety culture within their own walls. When you think about it, who better to ask about quality of service within a hospital than the frontline workers themselves – staff, nurses, technicians, etc.? In fact, a 2017 report in BMC Health Services reported that hospitals with “higher staff perceptions of safety culture were associated with better overall safety, as measured by a composite of reported harms and patient satisfaction.” Additionally, when noted physician, Marty Makary and his staff performed a joint study with risk management firm, Pascal Metrics, they found “hospitals that scored well on the staff survey had lower rates of surgical complications and other important patient outcomes.”

The simple idea? Have ALL Iowa hospitals undertake this survey every other year with the results becoming public. After all, this approach would tie nicely with the mission of the organization I visited that day. Including outpatient surgery centers would be ideal.

The response I received from the medical executive was not what I had expected. To paraphrase his feedback: “These surveys usually occur in larger eastern (U.S.) hospitals, but not in small rural hospitals, like Iowa. The data findings from Iowa hospitals would not be statistically relevant…” I was absolutely floored when I heard this half-baked argument. What this executive failed to understand – or more likely, refused to understand – was that such surveys can be used within hospitals REGARDLESS of employee size. To be effective, the two critical cautions for this survey are:

Mandatory participation of all staff within each department
Assure staff that honest responses are extremely important and any retributions for this honesty will not be tolerated.

Frankly, if a hospital is large enough to care for patients, then it should be large enough to be surveyed on how it reports its organization’s patient safety culture. Clearly, the executive did not want this to become public knowledge, as the results could undermine the trust the public places within each of the state’s 118 community facilities. For those hospitals that do utilize the culture of safety survey, their identity is hidden from the general public. In fact, AHRQ shared with me that “Hospital-identifiable data from the Hospital Survey on Patient Safety Culture Comparative Database are not available for public reporting purposes per the data use agreement AHRQ has with each hospital that voluntarily submits data to the database…reporting at state level can also put hospital confidentiality at risk especially in smaller states.” This means that we don’t even know how many hospitals participate in any given state. How’s that for transparency?

Safety of care, I have learned, can be more about the optics (carefully spoon-fed to the public) than actual substance. For example, developing safety awards for hospitals who report few errors can dangerously promote behaviors to withhold adverse event reporting, a solemn fact that I have learned from trusted, first-hand sources (in Iowa). Although well-intentioned, poorly-constructed safety awards can manipulate the system for a desired outcome – giving the public a false sense of security on receiving safe care. Manipulating sacred patient trust is a gross violation of professional ethical codes.

The November issue of Health Affairs dedicated the entire publication to the latest findings on patient safety-related matter. One article by Aiken, Et al., “Nurses’ And Patients’ Appraisals Show Patient Safety In Hospitals Remains A Concern,” summarizes the process of surveying hospital nurses from 535 hospitals in four states (California, Florida, New Jersey and Pennsylvania). The survey took place in 2005 and then again in 2016. In addition, patients from those hospitals were surveyed during that same time period. The bottom line is this: “Clinical work environments in most hospitals did not improve between 2005 and 2016.” The concluding summary of this article was to the point: “Our findings confirm that patient safety remains a serious concern. Failure to substantially improve clinical work environments in most hospitals, as recommended by the Institute of Medicine, may be hampering progress toward improving patient safety.”

As stated in our ‘Silently Harmed’ white papers, preventable harm in healthcare is a public health crisis, and much of this problem stems from organizational systems tolerating (or hiding) poor safety cultures. I received a very descriptive comment from Donna Helen Crisp, who spent eight years writing a book about what happens in hospitals when things go wrong. In North Carolina, Ms. Crisp served as a nurse, nursing professor medical ethicist, dying patient, and author (Anatomy of Medical Errors: the Patient in Room 2). As an advocate, Crisp helps raise awareness about preventable medical errors and adverse events so that they can be eliminated – or at least mitigated.

Her extensive background provides a wealth of perspective that lends great credence to this topic. As she indicated, “All the time and energy spent arguing about how many medical errors occur, or how patients abuse the legal system to make money, or why doctors and surgeons deny and delay the truth, or how dying patients should not be counted in medical error statistics – all this time and energy would be better spent by pursuing the following:”

Changing the medical paradigm by putting patients and families first.
Learning to see and accept the problems inherent in hospital care.
Developing core values to address and decrease medical errors.
Improving patient safety through transparent care.
Supporting clinicians who want to be truthful but fear retribution.
Training clinicians how to ethically support patients.
Training clinicians how to identify and ameliorate suffering.
Making safe care a higher priority than training doctors or corporate profit.

Because most medical errors go unreported, it is necessary to establish baselines, however they are determined, to track future progress on eliminating these errors. But we can learn a great deal by heeding Ms. Crisp’s words.

I only hope this same courage allows others who serve in crucial roles throughout our healthcare delivery system (including those we elect) to proactively do the right thing and provide the transparency in care that we so desperately need.

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Healthcare Waste – It’s About Priorities and Opportunity Cost

Posted on: 12.08.16 By: David P. Lind

We know that healthcare spending continues to grow at an unsustainable rate. Each election cycle, we expect policy makers to find meaningful ways to slow that growth and ultimately reduce spending – while maintaining quality and access.

As mentioned in our previous blog “Time to Move Upstream and ‘Invest’ in our Health” co-authored with Dr. Yogesh Shah, the prudent approach is to simultaneously move upstream and address the social determinants of health. This thinking might sound ‘pie in the sky’ to some, but controlling costs cannot happen without addressing the environment in which we live, learn, work and play.

In addition, there is another culprit that must be eliminated – healthcare waste. If we are successful in eliminating this waste, by most national estimates, we can reduce our costs by 18 – 40 percent. The midpoint of waste is about 30 percent of healthcare costs. Per the Robert Wood Johnson Foundation, this waste comes in many different categories:

Failures in Care Delivery – poor execution or lack of widespread adoption of best practices, including effective preventive care practices or patient safety practices.
Failures of Care Coordination – Fragmented and disjointed care of patients when transitioning from one care setting to another.
Overtreatment – Care that ignores scientific findings, perhaps due to outmoded habits. Defensive medicine is an example, such as unnecessary tests or diagnostic procedures to guard against malpractice lawsuits. Here is just one example.
Administrative Complexity – Having multiple ‘administrators’ with divergent protocols and practices, such as the government, insurance companies or accreditation agencies who create inefficient and overly bureaucratic procedures.
Pricing Failures – This waste is baked in to our healthcare ‘system’ because the price of a service exceeds what would be found in a properly-functioning marketplace. In healthcare, we lack appropriate competition at the right levels and have little transparency on cost and outcomes.
Fraud and Abuse – This is the cost due to fake medical bills and scams, in addition to the cost of inspections and regulations to thwart any wrongdoing.

Iowa Healthcare Component Costs

Based on the population of 3.033 million Iowans in 2009, the cost per capita in Iowa for healthcare was $6,921, totaling almost $21 billion. The largest portion of this cost comes from hospital care, which consumes about 39 cents of every dollar spent on healthcare ($2,713 per capita). This amount includes the total net revenue (gross charges minus contractual adjustments, bad debts, and charity care). Assuming the midpoint waste average in Iowa is 30 percent, and we have little reason to believe it is measurably different from national norms, the total annual amount considered to be wasted on hospital care would be $814 per Iowan.

Using a similar waste factor of 30 percent for each of the nine health components, the total waste per capita would amount to $2,076 (see graph below). Because many of the components are interconnected with one another, it is extremely difficult to cull out the actual waste factor within each component. Some components may have much lower inherent waste, while others may not. Costs such as insurance program administration, research and construction expenses are not included.

The following graph provides the total healthcare costs (in $) for each of the nine components, in addition to the potential wasted spending. Again, using hospital care as an example, if 30 percent of waste was eliminated in Iowa hospitals, the price tag could have dropped from $8.2 billion to $5.7 billion – resulting in a $2.5 billion ‘savings’ – or unnecessary overpayment.

Healthcare Waste of $6.3 Billion

I share this information for a reason. Much like the individual choices made daily in our lives, there are opportunity costs for the choices we make, or fail to make. The notion of opportunity cost plays a crucial role in attempts to ensure that scarce resources are used efficiently. If the midpoint assumption of 30 percent waste occurs in healthcare delivered in Iowa, then overspending $6.3 billion annually (and growing due to increased costs) is a huge opportunity cost for Iowans. Think about it, what other ‘opportunities’ can we invest in and receive much better ‘returns?’

Most Americans detest waste – especially when it affects our pocketbooks and the potential impact it has on our health and well-being.

Waste is anything that doesn’t add value to the end product. In manufacturing, waste can be rooted out by using different proven programs, such as lean manufacturing. Doing so allows the manufacturer to build higher-quality products at a more competitive cost. The same process can be used in healthcare. Having the right kind of incentives to change the willpower and behavior of those providing (and paying) for this care, is crucial.

Community Needs in Iowa

In Iowa, communities have a myriad of health needs that go unmet, but most often have limited resources to address these problems. According to Mid-Iowa Health Foundation’s website, there are many community needs for our youth that require attention and affect the social determinants of our health and well-being:

20 percent of children in Iowa lack adequate food
Roughly 7,000 school age children in Iowa are homeless
Over one-third of Iowa fourth graders read at or above the proficient level
Over 13 percent of youth in Iowa are exposed to drug use in their home
Approximately 12,000 children are victims of abuse and neglect
About 10 percent of central Iowa children say they do not live in a happy home
Almost 13 percent of Iowa youth had serious thoughts about killing themselves in the last year
More than 20,000 children are living below the poverty level in Polk County
80 percent of Iowa children with mental health needs never receive treatment
Only 45 percent of youth in the Des Moines community are hopeful for the future

This list represents just a small sampling of social determinants that eventually affect the healthcare we pay. By smartly eliminating waste in our healthcare system, and thoughtfully re-directing the ‘savings’ in areas that matter most to our communities, we can further stem our healthcare-cost epidemic. Imagine the sizeable dent we make in our communities by culling out billions of dollars annually from the waste we pay. The discussion of displaced healthcare jobs and the potential ‘economic impact’ requires further exploration in a later post.

Following the election, we will continue to debate the fate of Obamacare – who will pay and how much – but this discussion is being made with greatly inflated dollars. We would be well-served to dedicate equal energy to squeeze the waste from healthcare and redirect resources to benefit our communities.

We know the waste is there. But what about our willingness to eliminate it?

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The Lure of Opioids

Posted on: 06.21.16 By: David P. Lind

One medical topic clearly on today’s radar is the use (and abuse) of opioids – medications that are often used to relieve pain, such as: hydrocodone (e.g. Vicodin), oxycodone, morphine, codeine and other related prescription drugs.

It is relatively easy to become addicted to opioids. Like many others, I have been prescribed various opioids (typically Vicodin) in the past when having lower back pain or a dental procedure that required pain management. Thankfully, I used only a very small portion of the prescribed pills during each incident, which resulted in the accumulation of many ignored (and expired) bottles in our medicine cabinet.

For many, the continued use of opioids to control pain may quickly evolve into a habit, and eventually, addiction. Without seeking and receiving appropriate rehabilitation for opioid addiction, accidental deaths happen far too often. In 2014 alone, the number of opioid deaths due to overdose in the United States was 28,647, a number that exceeds the size of Marshalltown, Iowa’s 16th most populated city. A 14 percent increase from 2013, this number represents an age-adjusted rate of 9.0 Americans per 100,000.

Iowa Opioid Fatalities

The Kaiser Family Foundation analysis shows that 158 opioid fatalities occurred in Iowa during 2014. With an adjusted death rate of 5.3 Iowans per 100,000, Iowa ranks considerably below the U.S. average. The adjusted rates of fatalities per 100,000 for each of Iowa’s six neighboring states are listed below:

Nebraska – 3.2 (56 fatalities in 2014)
South Dakota – 4.1 (33)
Minnesota – 6.0 (318)
Illinois – 9.4 (1,205)
Wisconsin – 11.1 (627)
Missouri – 12.0 (696)

The below-average rates for Iowa, Nebraska, South Dakota and Minnesota leads one to ask, “What are these states doing differently?” Have these states implemented actions preventing individuals from becoming addicted and treating those who are addicted? Do they have narcotics detectives and emergency medical technicians who help guide individuals to treatment rather than arrest them? Some states have indeed implemented programs to address this emerging topic of national concern.

The Center for Disease Control and Prevention (CDC) recently released guidelines to help physicians prescribe opioids appropriately and responsibly. The opioid crisis should not just be the concern for providers who prescribe opioid medication. In fact, everyone has a role to play mitigating this epidemic, including those addicted and their family members, those who treat the addicted, educators, law enforcement agencies, and the efforts of a well-coordinated community. As two authors commented in a recent Health Affairs publication, the opioid crisis is “a multi-faceted problem [that] requires a multi-faceted solution.”

For each of us, a frequent reconnaissance of our medicine cabinets to ‘search and safely dispose’ is a good first step to eradicating opioid misuse and abuse.

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Healthcare Patients Want ‘Good Value’ for the Money

Posted on: 04.08.15 By: David P. Lind

…we are now entering into a new era in healthcare that appears to alter our behaviors toward the care we are receiving…

Similar to national data, Iowa spending on healthcare and insurance premiums has risen at historically lower rates in the last three years. However, according to the Kaiser Family Foundation, only three percent of Americans said health costs are “going up slower than usual,” and 52 percent said costs are “growing faster than usual.” The other 35 percent say costs are about the same.

The amount that Iowans with employer-based health insurance pay for premiums has risen 167% in the last 14 years, while Iowa weekly wages have risen about 40%* and general inflation 43 percent. As we know, our incomes are suppressed by increasing health premiums, which certainly impact take-home pay and, ultimately, our capability of making consumption trade-offs for other priorities, such as food, shelter, education and retirement savings.

In addition to the premium cost, Americans are asked to pay increasingly more of the medical care they seek, through higher deductibles, copayments and out-of-pocket maximums. With lower-relative income, finding the financial resources to pay is problematic for many employees, causing them to put off receiving care or incur more medical debt.

In a recent Wall Street Journal article, Drew Altman, president and CEO of the Kaiser Family Foundation, wrote that Americans with health coverage care about:

Their premium costs, or the share of premiums they pay if they have employer coverage;
Their deductibles and other forms of cost-sharing, especially when deductibles have been rising steadily;
Their drug costs;
Whether they can go to the doctor or hospital they want without having to pay more;
The hassle and red tape in healthcare and health insurance. People care about getting information to be informed about their health and make smarter insurance and healthcare decisions;
Seniors care a lot about Medicare and sometimes vote on this issue.

Most people would agree to this list.

However, Mr. Altman then mentioned that “Americans don’t care as much as experts do about improving quality and eliminating unnecessary care. In general, people think that quality is good and they want more care not less.”

Perhaps this was true in the past, but we are now entering into a new era in healthcare that appears to alter our behaviors toward the care we are receiving. One prime example is a recent study that says cost is not the most important determinant of the care we seek – it is quality. From this report, when patients are provided hospital safety score grades and cost information together, they will choose safer hospitals 97 percent of the time, REGARDLESS OF COST.

Of course, this may also depend on WHO pays…the patient or a third party.

Making sure that such report cards reflect the most relevant performance measurements will be extremely important – if not critical – to the patient. Unfortunately, we don’t have this luxury at the present time. A March article on the Johns Hopkins Medicine website reports that national rating systems on the quality and safety of hospitals are too confusing because each will stress different measures from each other – sometimes providing a wide variation of grades on the same hospital (study source: Health Affairs).

In my blog last August, I wrote that the Urology Department at Cleveland Clinic received a top score by the U.S. News & World Report, yet received the lowest possible score by Healthgrades for prostatectomy outcomes. This type of reporting will only serve to confuse the general public before seeking care.

As healthcare delivery and payment initiatives continue to morph, look for quality and safety measurements to emerge with the cost component. The convergence of reliable safety and quality information with ‘real-time’ cost information can eventually catapult the healthcare industry into the 21^st century.

Until then, many hurdles must be successfully cleared in order to achieve the desired value we all want.

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*2014 data from the Iowa Workforce Development is not yet available, and therefore, excluded.