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February 2009

Saying Sorry - by Suzanne Delbanco, Ph.D.

If our health care system were highly reliable, the debate whether to say sorry to patients harmed by preventable medical mistakes would occur far less frequently.  However, until we have the processes and systems in place to reduce the incidence of preventable errors drastically, everyone from individual clinicians to patients' families to CEOs of major health care systems will have to discuss what's right to do when mistakes happen.

In an on-line commentary posted yesterday to the BBC Web site, Sir Liam Donaldson, Chief Medical Officer for England, argues that the National Health Service (NHS) needs to apologize more, and to mean it.

NHS clinical staff have a range of attitudes about apologizing, with some favoring being open in the face of errors, and others saying "over my dead body."  Being fully or partly responsible for harming a patient can be just as painful emotionally for the clinician as for the patient or patient's family.  And while saying sorry may be the start of emotional healing for all parties, Donaldson suggests that an apology is not meaningful until it becomes the start of a process to learn from the mistake so that future patients are spared similar harm.

This is remarkable leadership from the head of a closely-watched health care system.  We have much more to learn about this issue and far to go in evolving "apology" policies that work for both health care professionals and patients.  Many have studied the connection between apologies and lawsuits, finding that saying sorry can reduce the likelihood of a patient bringing suit to seek compensation for injuries from medical care.  Liability concerns raise the costs of care through rising malpractice insurance premiums.  Such concerns may also lead to the delivery of defensive medicine, during which clinicians may, for example, order extra but unnecessary tests to avoid accusations of not being thorough.

Reducing the likelihood of medical mistakes through methods like Hospital Video Auditing from Arrowsight, Inc., as well as others, is a critical aspect of moving forward.  But let's figure out how to work in "saying sorry."  It's the right thing to do and the benefits will likely have a beneficial ripple effect for all involved.

Suzanne Delbanco is President, Health Care Division, Arrowsight, Inc.

Spotlight on Safety in Maternity Care -- by Suzanne Delbanco, Ph.D.

Free-baby-clipart-3 Childbirth is the number one reason for hospitalizations in the U.S. and is also the runaway leader in hospital charges.  Studies show that we over-use costly and risky interventions in maternity care, and underuse beneficial methods like continuous labor support that are generally safer and cheaper.  There are 4.3 million births in the U.S. each year, and evidence is mounting that the quality of maternity care is deteriorating in some areas, as indicated by recent increases in maternal death among some populations.  There are also incentives built into the delivery system to provide technology-intensive care to a primarily young and healthy childbearing population who may not need it.  The quality and safety of maternity care warrants the nation's attention.

The Millbank Memorial Fund recently published a report called Evidence-Based Maternity Care: What it Is and What It Can Achieve, authored by the leaders of Childbirth Connection, a national, non-profit organization.  The report contains a systematic review of maternity care practice and highlights that much of the care pregnant women receive has no basis in the evidence.  In fact, some of it can be harmful.  The Los Angeles Times op-ed about the report claimed, “The Obama administration could save the country billions by overhauling the American way of birth.”


I have been volunteering to support two efforts to focus attention on this topic that are likely of interest to others working to improve the safety and quality of health care. 


First, Childbirth Connection will be hosting what could be one of the most important discussions of 2009.  Transforming Maternity Care: A High Value Proposition, will be held on April 3 in Washington, DC.  Over 200 multi-stakeholder participants will be recommending ways to improve maternity care and to align payment with quality as part of producing a “Blueprint for Action.”

Second, the California Maternal Quality Care Collaborative (CMQCC) aims to eliminate preventable maternal death and injury and promote equitable maternity care in California.  The group works to bring resources, tools, measures, and quality improvement techniques to providers, administrators, and public health leaders. CMQCC has produced many of the measures of maternity care now included in standards and goals produced by the National Quality Forum, the Joint Commission, and other groups.

Improving maternity care will require more informed health care professionals and patients alike.  Since expectant parents have months to conduct careful research on providers and facilities, maternity care presents the ultimate opportunity for increasing consumer engagement in health care.  Careful measurement and tracking of maternity care outcomes, along with public reporting, could provide a solid start to reversing some of the negative trends toward excessive clinical intervention of recent years.  That would be a high value proposition for all involved.

Suzanne Delbanco is President, Health Care Division, Arrowsight, Inc.

Arrowsight Medical Impact Newsletter Winter '09

Newsletter cover Hot off the press, we are pleased to share our Winter 2009 newsletter:  Arrowsight Medical Impact.  In the newsletter, you will find helpful descriptions of how we work with hospitals and the outcomes we can produce in partnership. 

We have yet to see anything else on the market that does as comprehensive a job as Hospital Video Auditing at estimating compliance with patient safety practices that must be measured through observation.  And without the 24/7 measurement that HVA provides, there is no other way to produce near-real-time feedback to clinicians about their performance on an ongoing basis.

 Let us know what you would like us to cover in subsequent newsletters!

Hospitals Using Clinical Information Technologies Have Better Outcomes

39161571 There is always a lot of debate about whether clinical information technologies really improve patient outcomes, or if they just systematize errors. 

In the first study of its kind, researchers from the University of Texas Southwestern Medical Center and Johns Hopkins University conducted a cross-sectional study of urban hospitals in Texas, measuring the hospitals' level of automation and its association with inpatient mortality, complications, costs and length of stay.

Based on 41 of 72 hospitals responding (58%) to requests to complete a clinical information technology assessment tool, the study found that a 10-point increase in the automation of notes and records was associated with a 15% decrease in the adjusted odds of fatal hospitalizations.  Higher scores in order entry were associated with 9% decrease in the adjusted odds of death for myocardial infarction and a 55% decrease in the adjusted odds of death for coronary artery bypass graft surgery. Higher scores for decision support were associated with a 16% decrease in the adjusted odds of complications for all causes of hospitalization.  In addition, higher scores on test results, order entry and decision support were associated with reduced costs for all hospital admissions.

While the study does not take into account the return on investment to hospitals of putting the clinical information technologies in place, such as the costs of installation, it does suggests that once they are in place, the benefits can accrue to both the patients and the institution.

Does Public Reporting Prompt Hospitals to Reduce Infections? -- by Suzanne Delbanco, Ph.D.

16357414 In the U.S., exactly half of the 50 states now require public reporting of hospital-specific rates of hospital-acquired infections.  There are multiple purposes behind public reporting, including making hospitals accountable to the communities they serve, and providing information to help patients make informed decisions about where to seek care.  But does public reporting prompt hospitals to reduce the incidence of hospital-acquired infections?

In Pennsylvania, where the Pennsylvania Health Care Cost Containment Council has been reporting hospital outcomes publicly for many years, the evidence is mounting that public reporting is associated with improved outcomes over time.  The Council released a report on January 22 that analyzes data from 2007 and compares it to data from 2006.  The data submitted by hospitals was the same for both years, allowing a first year-over-year comparison.  From 2006 to 2007, the Council found an 8% decrease in the number of infections contracted by patients in Pennsylvania hospitals.

Pennsylvania hospitals must have implemented variety of measures to reduce the spread of infections between 2006 and 2007.  The spotlight shined on the problem by the Pennsylvania Health Care Cost Containment Council no doubt added to their vigilance.

Curious about a new approach to assuring infection control practices are implemented?  Learn about Hospital Video Auditing (HVA) by clicking here.

Suzanne Delbanco is President, Health Care Division, Arrowsight, Inc.

Even Patient's Bath Basins Can Harbor Infections

In a study released January 1, 2009 in the American Journal of Critical Care, researchers found that patient's bath basins are a reservoir for bacteria and could be a source of transmission of hospital-acquired infections.

Three hospitals participated in the study:  Presbyterian Hospital in Albuquerque, New Mexico; Wishard Health Services in Indianapolis, Indiana; and Westerly Hospital in Westerly, Rhode Island.  Across the three facilities, researchers analyzed 92 bath basins from three intensive care units and a rehabilitation unit.  They swabbed the basins after they had been used to bathe patients and had been given a chance to air dry, and sent the samples to a microbiological testing laboratory.

Some form of bacteria grew in 98% of the samples, including enterococci, staphylococcus aureus, vancomycin-resistant enterococci and methicillin-resistant S aureus.  These findings suggest a need to develop and implement bathing protocols that protect the patient from exposure to pathogens.  The researchers site prepackaged bathing supplies as a helpful component.

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