1. The Status of Patient Safety Donald M. Berwick, MD, President and CEO Institute for Healthcare Improvement 10 th Anniversary of To Err is Human The Commonwealth Fund and Alliance for Health Reform March 17, 2010: Washington, DC

2. Topics 1.Trends, Impact, and Gaps in Patient Safety 2.Priorities for Closing the Gaps 3.Constructive Roles for the Federal Government 4.A Vision for the 20 th Anniversary of To Err Is Human 2

3. Trends since 1999 Firm documentation of widespread, avoidable harm to patients. Better understanding of the “safety science.” Better methods of detection and measurement. Better appreciation of a “culture of safety.” Breakthrough results in some organizations. 3

4. Hospital Standardized Mortality vs. Hospital Reimbursement Source: Sir Brian Jarman 2009

5. Institute for Healthcare Improvement Safety Campaigns 5 2004-2006 2006-2008

6. The Campaign “Planks” -- Twelve Changes for Safety 1.Rapid Response Teams 2.Evidence-Based Care for Heart Attacks 3.Medication Reconciliation 4.Prevent Central Line Infections 5.Prevent Surgical Site Infections 6.Prevent Ventilator-Associated Pneumonias 6

7. The Campaign “Planks” -- Twelve Changes for Safety 7.Prevent Pressure Ulcers 8.Reduce Methicillin-Resistant Staphylococcus Aureus (MRSA) Infections 9.Prevent Harm from High-Alert Medications 10.Reduce Surgical Complications (the Surgical Care Improvement Project (SCIP)) 11.Evidence-Based Care for Congestive Heart Failure 12.Get Boards on Board 7

8. 8

9. Sentara Williamsburg (Virginia) Zero Ventilator Pneumonias in Five Years! 9

10. 10 Seton Family of Hospitals (Austin, TX) Birth Trauma Prevention One Birth Injury in 10,000 Deliveries

11. Pressure Ulcer 11

12. Error Reduction at Ascension Preventable ErrorReduction in Rate Pressure Ulcer Neonatal Mortality Birth Trauma Ventilator-Acquired Pneumonia Falls with Serious Injury Bloodstream Infections 95% 79% 74% 56% 54% 32%

13. Palmetto Hospital Mortality Rates (South Carolina) 13

14. Does Improving Safety Save Money? IMPROVEMENTCOSTSAVINGSNET SURGICAL INFECTIONS ($110,000)$540,000$430,000 BLOODSTREAM INFECTIONS ($22,500)$4,780,000$4,757,500 VENTILATOR PNEUMONIAS ($1,268,500) (Reduced Revenue) $1,166,400($102,100) RAPID RESPONSE TEAMS ($390,000)? TOTAL($1,791,000)$5,320,000$4,695,400 14 HENRY FORD HEALTH SYSTEM

15. Closing Gaps – What Now? Governance – Boards – responsible for safety Better measurements of safety levels More transparency Science to devise standards that work “National learning systems” to spread the successes – Make “the best” become “the norm” National stewardship – a “public health” model Consequences for inaction 15

16. How Government Can Help: “Will, Ideas, and Execution” GAPGOVERNMENT Boards responsible for safetyMap into accreditation standards Better measurements of safety levels Support prompt, active research on measurements of safety More transparency Further develop Medicare data, measurement, and reporting capacity Science to devise standards that work Support research on safety sciences and health care process designs “National learning systems” to spread the successes Develop public and private “extension” capacities for knowledge management National stewardship – a “public health” model Annual reports on quality and safety, with Congressional and Executive review Consequences for inaction Unlink payment from volume; study “no pay” for defects 16

17. “20 th Anniversary Report” Injury Rates in American Hospitals Measured and Tracked National and Regional “Learning Systems” Spread Good Practices Safety Education Routine in Health Professional Development Health Care Sets a Benchmark for High- Hazard Industries Patient Injuries Reduced by 90% from 1999 Health Worker Injuries Reduced by 90% 17

18. The “Triple Aim” Population Health Experience of Care Per Capita Cost 18

19. How Do They Do That? High-Performing Communities in American Health Care 19 $10,250 to17,184 (55) 9,500 to <10,250 (69) 8,750 to <9,500 (64) 8,000 to <8,750 (53) 6,039 to <8,000 (65) Not Populated Everett, WA Sacramento, CA Temple, TX Tallahassee, FL La Crosse, WI Cedar Rapids, IA Sayre, PA Portland, ME Richmond, VA Asheville, NC

20. Price Adjusted Spending 2006 Increase in Spending 1992 – 2006 Annual growth rate All Others (232)$9,695$3,3763.6% Qualifying (74)$8,212$2,6453.4% Participants (10)$7,924$2,2973.0% Potential Annual Savings: 12.7% - 16.2% What Are They Doing? 20 Per-Capita Spending – and Spending Growth – Are Lower.