How Safe Is Our Health Care System?

Confidentiality & the Right to Know

Dr. Troyen Brennan raised three key questions about the Institute of Medicine (IoM) Report:

• What is it based on?
• What will the result be?
• What should we be doing about medical injuries?

Dr. Brennan believes the report will lead to physicians interpreting "error" as being the same as "negligence." The resulting moral overtones will lead to more secrecy in order to avoid increased malpractice. The result will be a drag on quality improvement efforts.

Dr. Brennan suggested that appropriate strategies to reduce medical errors would be to pursue:

• A no-fault liability system based on compensable events (no negligence inferred).
• Enterprise liability for integrated delivery systems (insurance based on facilities, not individual practitioners).
• Mandatory reporting to patients for compensation purposes.
• Development of a national database of root-cause analyses.
• Epidemiological analysis of compensable events.

Arthur Levin advocated for a strong role for State oversight in the area of medical errors. The public will not trust a reporting system unless it is totally transparent. Although States should never give up on finding the "bad apples" among practitioners, the issue of medical errors is not limited to malpractice or individual culpability.

The Center for Medical Consumers, as a public advocate, has been involved in State healthcare policy regarding the oversight of healthcare providers and professionals to protect safety and assure quality for more than 20 years. The State, as the entity responsible for licensing healthcare facilities and practitioners, is the focus of government oversight authority.

Because we do not have a national or State-based single-payer healthcare system, the job of setting up a Federal process of collecting healthcare data would create a tremendous new bureaucracy and burden on providers and professionals. Even with a single-payer system, where would the authority for a mandatory system come from? Would the licensing of providers and professionals become a national process?

It is likely that most States, if not all, already collect some healthcare data, although the what, how much, and whether voluntary or mandatory varies widely. The IoM report estimates that about 20 States have some variety of error- or incident-reporting system in place. The details vary from State to State.

If there is agreement with the IoM's goal to reduce the number of errors by 50 percent within the next 5 years, then it would appear that the States are the best place to begin that work. We cannot begin to reduce error until we know more: how many, what kind, where, and root causes. To do that and to track progress toward meeting the IoM error-reduction goal, States would have to collect data to identify and analyze systematic problems as well as suggest and measure remedies. Evidence is that some public reporting of data can change behavior.

The question is: Is it provider or consumer or purchaser behavior that is more likely to change? To date, it appears as if provider behavior is most affected by public release of performance-related information. New York State's experience with public reporting of cardiac surgery volume and outcomes has generally been positive, as outcomes measured by risk-adjusted mortality rates have steadily improved.

References

Brennan TA. Hospital peer review and clinical privileges actions: to report or not report. JAMA 1999 l;287(4):381-82.

Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: results for the Harvard Medical Practice Study I. N Eng J Med 1991;324(6):370-6.

Clancy CM. Informed consumers can play a vital role in improving health. Health Services Research 1999 Oct;34(4):807-11.

Hasan A, Pozzi M, Hamilton JRL. New surgical procedures: can we minimize the learning curve? BMJ 2000 Jan;320:171-3.

Jowell PS, Baille J, Branch SM, et al. Quantitative assessment of procedural competence. Ann Intern Med 1996;125(12):983-9.

Kraman SS, Hamm G. Risk management: extreme honesty may be the best policy. Ann Intern Med 1999 Dec;131(12):963-7.

Perez-Pena R. Data offer a head count in health care. The New York Times 2000 Feb 14; natl. ed.: B-1.

Studdert DM, Thomas EJ, Zbar BIW, et al. Can the United States afford a "no-fault" system of compensation for medical injury? Law and Contemp Probl 1997;60(2)1-34.

Wigdon RS. Measuring procedural skills. Ann Intern Med 1996;125(12):1003-4.

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