Gregg S. Meyer

The Top Patient Safety Strategies That Can Be Encouraged for Adoption Now

Over the past 12 years, since the publication of the Institute of Medicines report, “To Err is Human: Building a Safer Health System,” improving patient safety has been the focus of considerable public and professional interest. Although such efforts required changes in policies; education; workforce; and health care financing, organization, and delivery, the most important gap has arguably been in research. Specifically, to improve patient safety we needed to identify hazards, determine how to measure them accurately, and identify solutions that work to reduce patient harm. A 2001 report commissioned by the Agency for Healthcare Research and Quality, “Making Health Care Safer: A Critical Analysis of Patient Safety Practices” (1), helped identify some early evidence-based safety practices, but it also highlighted an enormous gap between what was known and what needed to be known.

Advancing the science of patient safety

Despite a decades worth of effort, patient safety has improved slowly, in part because of the limited evidence base for the development and widespread dissemination of successful patient safety practices. The Agency for Healthcare Research and Quality sponsored an international group of experts in patient safety and evaluation methods to develop criteria to improve the design, evaluation, and reporting of practice research in patient safety. This article reports the findings and recommendations of this group, which include greater use of theory and logic models, more detailed descriptions of interventions and their implementation, enhanced explanation of desired and unintended outcomes, and better description and measurement of context and of how context influences interventions. Using these criteria and measuring and reporting contexts will improve the science of patient safety.

Optimal methods for guideline implementation: conclusions from Leeds Castle meeting.

Background.Quality problems in medical care are not a new finding. Variations in medical practice as well as actual medical errors have been pointed out for many decades. The current movement to write practice guidelines to attempt to correct these deviations from recommended medical practice has not solved the problem. Objectives.In order to gain greater acceptance of these guidelines and to change the behavior of health care providers, the science of guideline implementation must be understood better. Research Design. A group of experts who have studied the problem of implementation in Europe and the United States was convened. This meeting summary enumerates the implementation methods studied to date, reviews the theories of behavioral change, and makes recommendation for effecting better implementation guidelines. Results.A research agenda was proposed to further our knowledge of effective evidence-based implementation.

Perspective: A Culture of Respect, Part 2: Creating a Culture of Respect

Creating a culture of respect is the essential first step in a health care organizations journey to becoming a safe, high-reliability organization that provides a supportive and nurturing environment and a workplace that enables staff to engage wholeheartedly in their work. A culture of respect requires that the institution develop effective methods for responding to episodes of disrespectful behavior while also initiating the cultural changes needed to prevent such episodes from occurring. Both responding to and preventing disrespect are major challenges for the organizations leader, who must create the preconditions for change, lead in establishing and enforcing policies, enable frontline worker engagement, and facilitate the creation of a safe learning environment.When disrespectful behavior occurs, it must be addressed consistently and transparently. Central to an effective response is a code of conduct that establishes unequivocally the expectation that everyone is entitled to be treated with courtesy, honesty, respect, and dignity. The code must be enforced fairly through a clear and explicit process and applied consistently regardless of rank or station.Creating a culture of respect requires action on many fronts: modeling respectful conduct; educating students, physicians, and nonphysicians on appropriate behavior; conducting performance evaluations to identify those in need of help; providing counseling and training when needed; and supporting frontline changes that increase the sense of fairness, transparency, collaboration, and individual responsibility.

House Calls to the Elderly — A Vanishing Practice among Physicians

BACKGROUND Despite the growth in other home health care services, the number of house calls by physicians has declined dramatically during this century. We determined the frequency of house calls made by physicians to elderly U.S. patients in 1993 and analyzed the characteristics of the physicians and patients involved. METHODS We analyzed a 5 percent random sample of the 1993 Medicare Part B claims data for beneficiaries over the age of 65 who were not enrolled in health maintenance organizations (HMOs). With supplemental information from the Area Resource File and the American Medical Associations Physician Masterfile, we determined how many house calls were made, their cost, and a number of specific characteristics of the physicians and the patients. RESULTS In our 1993 sample, 36,350 house calls were made to 11,917 of the 1,357,262 patients. When extrapolated to all Medicare beneficiaries over age 65 and not enrolled in HMOs, these figures correspond to 727,000 house calls to 238,340 patients nationwide. We estimated the cost of these house calls to be

Relationship Between Performance Measurement and Accreditation: Implications for Quality of Care and Patient Safety

63 million. The patients who received house calls from physicians were older than those who did not, were more likely to die within the calendar year, had higher rates of hospitalization, and were more likely to receive care from other home health providers, hospice programs, and skilled-nursing facilities. Patients residing in rural areas and those in areas with high physician-to-population ratios had an increased likelihood of receiving a house call. The physicians who made house calls were more likely than others to be generalists, osteopaths, older, male, board-certified, practicing in the Northeast, and in solo practice. CONCLUSIONS A very small percentage (0.88 percent) of elderly Medicare patients, mainly those who are very sick and near the end of life, receive house calls from physicians.

Gastroenterology Workforce Modeling

This study examined the association between the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accreditation scores and the Agency for Healthcare Research and Quality’s Inpatient Quality Indicators and Patient Safety Indicators (IQIs/PSIs). JCAHO accreditation data from 1997 to 1999 were matched with institutional IQI/PSI performance from 24 states in the Healthcare Cost and Utilization Project. Most institutions scored high on JCAHO measures despite IQI/PSI performance variation with no significant relationship between them. Principal component analysis found 1 factor each of the IQIs/PSIs that explained the majority of variance on the IQIs/PSIs. Worse performance on the PSI factor was associated with worse performance on JCAHO scores (P = .02). No significant relationships existed between JCAHO categorical accreditation decisions and IQI/PSI performance. Few relationships exist between JCAHO scores and IQI/PSI performance. There is a need to continuously reevaluate all measurement tools to ensure they are providing the public with reliable, consistent information about health care quality and safety.

More quality measures versus measuring what matters: a call for balance and parsimony

OBJECTIVE To examine the current supply and distribution of gastroenterologists and project future supply under various scenarios to provide a paradigm for workforce reform. DESIGN An analysis of current practices and distribution of gastroenterologists and a demographic model, using the 1992 gastroenterology workforce as a baseline. MAIN OUTCOME MEASURE Comparison of current supply, distribution, and practice profiles with past data and future projections, using analyses of data from the 1993 Area Resource File, 1992 Medicare Part B file, age- and sex-specific death and retirement rates from the Bureau of Health Professions, managed care staffing patterns, the National Survey of Internal Medicine Manpower, and the Bureau of the Census. RESULTS Rapid growth in the number of US gastroenterologists has resulted in a gastroenterologist-to-population ratio double that used on average by health maintenance organizations. In addition, the work profile of gastroenterologists is shared significantly by primary care physicians and other specialists, with the exception of a few specific and uncommon procedures. CONCLUSIONS Empirical evidence suggests that, even in the absence of detailed models to describe the desired supply/need balance for gastroenterology, the US health care system and clinicians may benefit from a reduction in gastroenterology training programs. The Gastroenterology Leadership Council endorsed a goal of 25% to 50% reduction in trainee numbers over 5 years, and recent National Resident Matching Program data indicate that a voluntary downsizing process is in full force. This study illustrates a paradigm for workforce planning that could be useful for other medical specialties.

Contemporary performance of U.S. teaching and nonteaching hospitals.

External groups requiring measures now include public and private payers, regulators, accreditors and others that certify performance levels for consumers, patients and payers. Although benefits have accrued from the growth in quality measurement, the recent explosion in the number of measures threatens to shift resources from improving quality to cover a plethora of quality-performance metrics that may have a limited impact on the things that patients and payers want and need (ie, better outcomes, better care, and lower per capita costs). Here we propose a policy that quality measurement should be: balanced to meet the need of end users to judge quality and cost performance and the need of providers to continuously improve the quality, outcomes and costs of their services; and parsimonious to measure quality, outcomes and costs with appropriate metrics that are selected based on end-user needs.

The Future of the Academic Medical Center under Health Care Reform

Purpose To compare the performance of U.S. teaching and nonteaching hospitals using a portfolio of contemporary, publicly reported metrics. Method The authors classified acute care general hospitals filing a Medicare Institutional Cost Report according to teaching intensity: nonteaching, teaching, or Council of Teaching Hospitals member. They compared aggregate results across categories for Hospital Compare process compliance, mortality, and readmission rates (acute myocardial infarction [AMI], heart failure, pneumonia); Surgical Care Improvement Project (SCIP) performance; compliance with Leapfrog standards; patient experience; patient services and key technologies; safety (computerized physician order entry, intensive care unit staffing, National Quality Forum safe practices, hospital-acquired conditions); and cost/resource utilization (Medicare-adjusted expense per case; Leapfrog efficiency and resource use standards). Results Availability of patient services and advanced technologies were associated with teaching intensity (P < .0001), as were most hospital safety metrics. Teaching intensity was favorably associated with SCIP performance, AMI and heart failure process scores, and mortality (P < .0001). It was unfavorably associated with higher AMI and pneumonia readmission rates (P < .0001) and lower scores for individual patient satisfaction measures. Costs per case were similar (P = .4194) across hospital categories after correction for federally allowed adjustments (case mix, wages, and low-income patient care). Conclusions Teaching hospitals offer advanced clinical capabilities, educate the next generation of providers, care for disadvantaged urban populations, and are leaders in health care research and innovation. However, many stakeholders may be unaware of an additional value—relatively higher quality and safety in many areas, with similar adjusted costs.