Transcripts For CSPAN2 Patient Safety 20140829

Die of Heart Disease and 574,000 byte of cancer died of cancer. What isnt known and what the function of put the function of the hearing is about and i hope to do my best with the help of fellow senators and members of the panel is to start focusing attention on the third leading cause of death in the United States of america. And that will come as a great surprise to most people and the third leading cause of death in this country has to do with preventable medical errors in hospitals. A recent article published in the journal of Patient Safety estimates that as many as 440,000 people a year may die from preventable medical errors in hospitals. 440,000. That is more than a thousand eight each day. They die from preventable mistakes outside of the hospitals such as misdiagnosis or injury and medication. Nearly 15 years ago the institute of medicine published a report. It is a well publicized report entitled to air is human which found that as many as 98,000 people die in hospitals each year due to preventable medical errors. According to the 2010 report, more recent report, from the department of health and human services, 180,000 medicare patients alone, just medicare patients died from preventable adverse events in hospitals. According to the cdc, one and 25 hospital patients get an infection for being in the hospital and in 2011 b. s hospitals cost 700,000 people to get sick and a 75,000 people to die. Clearly, these errors caused an immense amount of human suffering. But they are also from a financial point of view very, very expensive for the government and for individual families. Medical errors cost the u. S. With your system more than 17 million in 20 08 a. M. But when indirect costs are taken into account such as lost productivity and missed workdays and medical errors may cause to the elite 1 trillion each year. In the midst of this situation that we will be discussing today coming and i think that we agree this is an issue that is taking place all over the world and countries all over the world, Healthcare Systems trying to combat it the good news is that there has been progress made in recent years and we are going to hear from the panelists about the kind of progress that has been made and more importantly, where we have to go. We all understand the tragedy occurs and people die for all kinds of reasons, but the tragedy that we are talking about here on the deaths taking place that should not be taking place and that is what we are going to be focusing on. Some of the advances that we have seen and we will be discussing this morning come from following practices interestingly enough that have been established in other highstakes field like aviation and Nuclear Safety people are dealing with very dangerous situations. For example, through the implementation of checklists have dropped dramatically in advances in technologies such as electronic prescribing and medication and a robotic tools which create smaller incisions during surgery can reduce the risk of infection. Further, there has been increased attention to something that seems pretty obvious they needed to wash hands on a regular basis in hospitals one would assume that would be pretty obvious. This is a problem that hasnt received any of the attention that it deserves and today. Senator warren . I dont have an opening statement. Im eager to get to the testimony and the questions. Senator whitehouse . Think the term and very much for holding this hearing and i want to thank the chairman for allowing us to go forward because this is really an extraordinarily important issue for all of the work and the the fuss and the fighting fast and the fighting that has surrounded the Affordable Care act their remains in very large financial problem in the Health Care System that it costs about 50 more than the most inefficient other industrialized countries with your system in the world. We have an inefficiency premium of about 50 over the Major Economies that we compete with and the end hundreds of thousands of american lives for all the good the Affordable Care act did those two problems remain before us and im delighted and i in particular want to welcome the doctor that weve never met before. But hes the architect. On the quality institute. Keystone principles and applied it in our intensive care units and dramatically reduced the intensive care unit statistically zero. Interestingly it also had the side effect of making the nursing staff in the intensive care unit empowered enough that nursing turnover experienced a considerable drop off that they were so excited about what they were doing. So there are wonderful ways that we can do this and obviously when you are talking about saving peoples lives, saving peoples money it is a secondary concern but here we have a very fortuitous alignment between savings, lives and saving money. This is a very important topic and i applaud you for having brought this Wonderful Group of witnesses together and helping this hearing. Thank you. Thank you senator whitehouse. Lets get to work. Doctor james is the founder and what im going to do is introduce you. He published an article in the Patient Safety which found that somewhere between 2010 and 440,000 americans die each year from preventable medical harm in the hospital. Doctor james retired early in 2014 as the chief toxicologist and received his phd from the university of maryland. Doctor james, thanks very much for being with us. Make sure that its on red. To start the counter . Okay we will start the count. I think the chairman for inviting me to testify about Patient Safety. I speak today on behalf of hundreds of thousands of americans whose voices have been silenced forever by preventable adverse events. The Patient Safety activists occurred in the summer of 2002. My son was 19yearsold and had returned for his junior year at baylor university. While running in the evening of august 20 he collapsed on the University Campus has helped recover that was taken to the local hospital. He was evaluated for four days by cardiologists and underwent electrophysiology test in another hospital. Five days after his discharge he had a followup and they gave him a clean bill of health. In a week he returned. On september 15 at the two weeks after he presumed to running i received a call late in the evening that he had collapsed again while running this time his heart had stopped and he was in an unresponsive coma. He died three days later in the hospital the hospital where he was first taken for evaluation. Once you been able to get his medical records i discovered that my suspicions of the call of death were borne out. During the first hospitalization i had to do to the cardiologist that potassium was low and this might have been the cause of his initial collapse. He discounted the possibility and and decided to see them replacement was never administered. In fact as much leader at least three catastrophic errors were made by his doctors. When they failed to apply a guideline to the National Council on potassium and clinical practice. Number two they failed to diagnose the syndrome and number three committee knew that he should not return to running. They sent his medical records but they never warned him not to run. His only discharge instructions and running were to drive or not to drive for 24 hours. Ive written about the details of this and published in 2007. More have read the book and none have disputed my analysis. In fact an electrophysiology staff to reading my book affirmed to me in an email that she had been frustrated and paid more attention to potassium. Because of the past few years i completed a 25 25 invited reviews of cardiology manuscripts for the cardiology journal. As it unraveled the errors in my sons care and then discovered that his mri was never done properly, i began to realize that medical errors like those were not uncommon. I saw that the institute of medicine estimated up to 98,000 americans die each year from medical errors in hospitals. Other reputable estimates at that kind of size 284,000 deaths. Remarkably if the patient does survive, then with few exceptions the hospital would be paid to fix the harm. How much harm is there . By 2011 i noticed the studies that used the global trigger tool to identify adverse event in medical records. The Peer Reviewed studies and two were from the office of the inspector general. This tool was much more than identify identifying the evidence and unguided decisions. I noted that individual studies gave a remarkably consistent picture of the prevalence of the lethal adverse events. In addition other studies have been published showing that medical records often do not contain evidence that is discoverable of harm when the patient is no they were seriously harmed. In 2013 i published the study in the journal of Patient Safety. The calculation is rather simple. There is no statistic here. There were 33,000 hospitalizations and approximately 9 involved lethal adverse events and approximately 69 on average were judged to be preventable. This is an estimate of 210,000. However, the trigger of the mission has many errors of omission, communication context and diagnosis. It would not have detected any of the catastrophic errors made by my sons doctors. Furthermore no evidence appears in the medical record correcting for these limitations estimate of more than 400,000 lives shortened by preventable adverse events each year. What are the solutions . The senate should establish the standalone committee on the Patient Safety. It should establish a national Patient Safety board. Three committee board. Three committee should have the National Patient bill of rights. No cost for the test and elective procedures before hand. To know when the drugs are prescribed into the warned and to be warned about that lifestyle choice. To have care by teams up officials that build individual and Team Excellence and the performance reviews these are anonymous reviews by patients, supporters, colleagues and readers anonymously. In my opinion it isnt going to improve substantially until the Playing Field between the ill patients and the Healthcare Industry is level by the enforced bill of rights. Despite the high per capita expenditures on Health Care Industry ranked last overall in compared to the systems and other developed countries. That needs to change. Thank you for your attention. Thank you very much. Senator, i think senator, i think you were going to introduce the next panelist. I have the honor of introducing doctor professor of Health Policy and management at the Harvard School of Public Health. Hes also he is also a practicing physician of internal medicine at the boston va. As an undergraduate degree from college and medical degree and masters degree in the masters of Public Health from harvard university. He founded the initiative of the Global Health quality at the Harvard School of Public Health and his research is on the quality and reducing the cost of healthcare in the United States and around the world. In the 2013 he was elected as a member of the institute of medicine. His work has been groundbreaking and it is an honor to have him here today. Thank you very much for being with us. Thank you for that warm introduction. So it has been 50 years since they estimated that about 100,000 americans die each year from preventable medical errors. And when they first came out with that number come it was so staggeringly large that most people wonder could it possibly be right . The evidence 15 years later in hindsight the evidence is in and the evidence is very clear they probably got it wrong. It is an underestimate of the toll of human suffering that goes on from preventable medical errors. Beyond the problem of the senate and exactly how many people are suffering from these injuries, there is a second pressing question that it has been 15 years in a reasonable person might ask how much progress have we made in the last 15 years . Have we done . And you are going to hear from the doctor and others about the various areas we have had progress. But its the mental question as if i walk into an American Hospital today, and i demonstrably safer than i would have been 15 years ago . The unfortunate answer is no we havent moved the needle in any meaningful demonstrably overall. In certain areas been far better and in certain areas that are probably worse that we are not substantially better off than compared to where we were. The last piece of distressing news in my mind is that as you eluded to. What we find is no matter where you look, the size cover scope, the complexity of the problems are remarkably similar and the u. S. When we compare ourselves is right in the middle of the pack. We are better in some areas and worse in others but there is no country i think the point to that i can say theyve really get it right consistently. Beyond all that distressing stuff lets talk about the progress that has been made. That is probably the place weve made the greatest progress and when i talk about that topic i usually point to the two agents but i think have made a central role in reducing infections. One of them is the speaker of two down from me. His work has probably saved tens of thousands of lives if not more and im not going to talk about it because he will do a much better job of explaining it. But the other agent was talking about is the cdc through its surveillance programs. Its surveillance programs around the infections have been i think fundamental to the improvements that we have seen. If you take a step back and ask how is it that we improve and get better at anything in our lives and the key element in my mind is data and the metrics that are valid and credible. If you dont have the data and metrics, you dont know how youre doing, you dont know how you compare to anyone else and you have no way to judge whether the efforts are making a difference or not. Develop it in the tricks of infections and feeding that information back to hospitals. And i think that has been fundamentally important in the kind of improvements that we have seen. So here we are 15 years later and the question we should ask ourselves is how do we avoid another hearing five or ten years down the road where we say we are 25 years after the report. We still have not made much progress or none of us wants to be your. So how do we avoid . How do we begin to make Real Progress and i have three suggestions i think are very doable. First, i think we need to expand the efforts. There is no reason to think what theyve been able to do around the infections they cant do in other areas such as medication they can partner with the fda that cdc has a phenomenal track record and this is a publichealth problem. That cdc is the publichealth agency. I think they have a central role to play. The second is on electronic records. The country is in the midst of digitizing the record system. Weve seen phenomenal progress in the adoption of electronic records and i think it has a lot of potential. But the potential is not going to be realized unless they are focused on improving Patient Safety. The tools themselves wont automatically do it. And i think we need to make that a priority under a very specific thing congress can do in that area and the third is around incentives. We cant continue to have unsafe medical care. We are a regular part of the business and healthcare. And they have a very Important Role to play. Medicare has an Important Role to play. I think that they take important steps in this area that we can do so much more. To finish up, you know, we have a cadre of physicians and nurses in the country who are incredibly welltrained, dedicated and caring individuals who go to work everyday trying to do the best for their patients. We have a system that fails then and that patients who expect and deserve health care that is not only safe, im sorry not only effective but safe and improve their health and not harm it. This time i will introduce doctor gandhi is an associate professor of medicine at Harvard Medical School and she is the president of the national Patient Safety foundation. She received her undergraduate degree from Cornell University and her medical degree and her masters and a publichealth degree from harvard university. Before serving on the national Patient Safety foundation, she was the chief quality and Safety Officer at Partners Healthcare and served as executive director of quality and safety at Brigham Womens hospital. This. Southernmost Common Elements that occur is chillier to follow up on test results. We cannot just tell clinicians to try harder and think better we need better systems to minimize cognitive errors such as computerized algorithms. Better systems are needed to manage the test results to make sure every test ordered is completed the provider receives the results back signifies a patient. Leslies transitions of care. They occur all the time and health care. For example, living hospital to home or to Emergency Department we know transitions are a high risk time when people pieces of information can be lost for after hospital discharge within five days onethird of patients were taking medication differently than prescribed in the hospital. Another study shows 40 percent of patients are discharged with test results and repenting in have not come back yet but often not seen by the subsequent provider. Efforts are under way, after having post discharged followup calls and to ensure complete information and transfer but there is much work to be done. A major theme the ms Patient Engagement to partner to achieve care and clinicians need to be better is engaged to undershirts understand they agree with their care plan. And why the medication or test is ordered a and why it is important and what the plan is after lose some leaving the hospital. It is to assure the goals of the patients are being met. To summarize their ambulatory studies with safety issues that need more focus attention we need to first develop a more mower robot robust infrastructure for a culture change and process redesign. We need to identify better metrics of vindicatory safety to conduct more research to understand how they can be improved. You heard about the metrics that do exist there are very few if any that exist for the inventory setting. Hawthorne also redesign care to ensure we are in gauging patience in this process so we can deliver the safest care. Thank you. Thank you very much. Our next guest is practicing anesthesiologist dash Critical Care physician and also for your safety and quality to develop the scientifically proven checklist record to reduce infections with catheters and also with the who World Alliance for Patient Safety. He won a Macarthur Fellowship genius grant. In make us all very nervous. [laughter] tell my daughter that. Award for his work for urd his Patient Safety receive from john hopkins thank you for being with us. You should take comfort to know that your states have used the checklist you directly reduce infections. Thank you for hosting this important hearing in for inviting me to testify. And for the great work you do to keep this country strong her family just returned from the yellowstone on vacation by an act of congress a t72 and we have an opportunity to do that good great thing to keep this country great. You heard but medicine does perform miracles every day and there is hardworking wellintentioned doctors and nurses but underlying these deaths is that number one why is it 50 years we still have to guess how many people die . Why is that the public doesnt have a routine way to monitor these numbers of harm . Because outside of Health Care Acquired Infections we do not have an Accurate Monitoring system to routinely looked at with the public and we should. Why is that when a death happens one at a time silently it warrants less attention than what happens in groups of five or 10 1000s . What these numbers say is that every day to of 747 as are crashing and 9 11 is occurring every two months and we would not tolerate that preventable harm in any other form because the suffering of people who lose one at a time is just as real as those who lose in groups of tens of thousands. Capacious 80 bales in comparison to the magnitude of the problem today. Medicine today invests heavily in Information Technology but with productivity has frankly not been a real. Of the health care need has been negative since 1990. But we have a Success Story to guide us. But these inspections used to kill as much as breast or Prostate Cancer each year, 30,000 now with collective efforts from the cdc how to measure with work from the nih to understand the science with funding to pull groups together to work to reduce it these infections are down 70 since reported. Infection rates have been reduced from six down at 1. 3 per thousand catheter days. Saving lives and saving money in producing more productive americans. What policy should we implement . We had good science and we engaged clinicians and we also reported infections and had accountability. But even headed deeper level what we found is that clinicians told a different story. Prior to this we said they are inevitable but with this work we said there preventable and i could do something about it. Stories are powerful forces for change weather jfk saying hello to put a man on the moon or martin mr. King and his dream ronald reagan, tear down this wall change the story and we change everything. So where do we need for stories . We need to say first that harm is preventable and not tolerable. That Patient Safety is a science and it must guide it and they must be designed not designed on the heroism of our clinicians so what might be due . First charge the cdc with developing transparently reporting with a top causes of harm. Second crise standards for the reporting of Health Care Quality and cost measures similar to 1934 when you created the sec security exchanges active major Financial Statements are accurate right now we have no guarantee the measure reported is accurate. Johns hopkins hospital was both congratulated the and criticized for performance on the exact same measure for the exact same time period for infections is using administrative data and got it right 13 percent of the time so we will hire an army of nurses to cope better but not improve care ben franklin that is now with the incentives should drive the hospitals to do it is disrespectful not to have accurate data and billing data is not up to the tasker we should be transparent about how accurate it is to not say it is not good enough. Also would finance the science of Patient Safety to make sure we have a workforce who have the skills to do this to implement programs and finally invest in Systems Engineering to improve productivity and safety. We rely too much on heroism our nurses and a false alarm every 90 seconds we spend too fte double checking pain medicines because devices dont talk to each other. We had success with the checklist every harm has a checklist every checklist may have five or 10 items every item may have to happen three or four times a day if you added up clinicians are expected to do 100 to 000 things every day with no Information System listed. we have now said it senators is going building up plane as of crack some catchers to say at one the send a signal to the cockpit is the landing gear is up for dhabi will have to guess ambling says no problem we will still buy it even though it will cost. When we need to do great things because 25 patients died during this hearing. Thank you very much. Dr. Julien is a professor at university and has provided leadership to National Organizations to improve patients safety including past terms of the American Association of Critical Care nurses as well as a chair for aarp. Over the past well fears of faculty leader for the Nurses Initiative to educate more than 1500 nursing faculty in safety science. She received her b. S. In nursing from university of wisconsin and msn from university of alabama and ph. D. From university of michigan. Thank you for being with us to. Hq. Thank you. Good morning. For hosting this very important hearing from a bike to begin my comments by providing context first of there to be commended for tackling this issue i to understate the problem not only dealing with 1,000 preventable deaths per day but also tend thousand serious complications per day which results in a quality of life that might be comparable to death for some such as the woman from minnesota who went of bilateral mastectomy for cancer only to find out shortly after surgery there was a mixup in the biopsy reports and she did not have cancer. Seconds the most bipartisan issue that exist today since we have been patients or family members or will be in the future and affects all of us. This is one of the few issues that money alone cannot solve as many say in my lectures even bill gates cannot guarantee safe care for himself or his family. This morning i will highlight the key factors to make three recommendations for action. First lead of the factors that compromise safety many have then mentioned the perverse financial incentive than the growth of technology which could be a blessing and a curse for Edition System barriers make doing the right thing hard and to reinforce doing things quickly. Will also have strong traditions and health care to discourage people from speaking up for examining problems from the system viewpoint. Interestingly the joint Commission Found three factors to be most commonly involved in serious preventable events the inadequate orientation orientation, fatigue, edge of destruction, complacency and bias. Communication errors whether oral or written or electronic and technology can help but it does add to the burden. Third, leadership. This is just rather than fixing problems we must take a Systems Approach to adopt fundamental changes of health care organizations. I proposed three strategies when taken together with our colleagues will make a difference. , must ensure we have nurses is educated with a voice for Decision Making with patient care at the bedside. Registered nurses are the cornerstone of the american Health Care System to form the largest element in our there 24 7 and on the ground floor. It is the nurse who sees the skin breakdown that leads to a bedsore and also puts in place strategies to prevent a fall in and often the last line of defense. Unfortunately the bureau of labor statistics anticipates this shortage by 2022 grew to to the growing demand in replace those retiring. The good news more i is entering nursing in older nurses are working longer but this is insufficient to meet projected demands. Turning away a least 80,000 qualified applicants in 2012 due to inadequate resources. For Research Shows reregister curses with the minimum of a baccalaureate degree and adequate staffing level which has been shown to decrease patient mortality. However only 50 percent of nurses have a baccalaureate or higher in this country so we need the added with number with a minimum there actively involved to make decisions with a safe level of staffing. The second recommendation may must engage the patients family as full partners in care. As they noted practice around what is most convenient for the providers and not the patient but yet we know Better Outcomes can be achieved at lowercost when a partner with care providers and assume responsibility to manage their own health care. Him well clinicians have the medical expertise the patient and the family knows what works for him or her. And as committed to safety this might be obvious are all hospitals concerned about safety . Of course, they are. We much shift from the bureaucratic model from autonomy to one that is interdependence and of focus on safety. Emperor fat we are advocates and what process improvement and leaders who know what they dont know to invite others to help solve problems. This is the enormous change would be easier if we just threw money at it. This encourages organization to adopt higher liability where everyone has a laser focus on safety where there are systems in place where everyone including patients and families is encouraged to speak up to report errors and unsafe conditions to make sure they get visibility and. Thank you. Our next panelist was the direct the coin dash director of save nation project a policy action of Consumer Reports to direct a multistate campaign that was passed in 27 states and washington d. C. To raise medical vernets on harm. And with the cdc Health Care Advisory committee as a consumer representative for the Health Care Associated steering committee. Prior to joining he worked for the Texas Senate Committee and hhs. Thank you for being with us. Thanks for holding this hearing and for being here. I will not go over statistics because they are covered but the response that comes close is the focus of the hearing as a understand it. To talk about the patients the impact varies and can be anywhere from minor harm will regard this from the scope or the impact of medical error. Most peoples lives are affected beyond the health care or the physical response. People who were harmed lose their jobs and homes and Health Insurance and many go bankrupt trying to pay medical bills they would not have had if they were not harmed by the health care provider. These are very real consequences of the failure to take action to eliminate medical errors our sisters and brothers in they are disabled and many are dead because of these defense. Patients have been to trade by the system that day place their trust they dont expect perfection but they will use the best knowledge and diligence and the adherence to the best practices Pay Attention to what we ask it when we pay for services we expect it will include doing all they can to keep us safe from harm. When they make a mistake they will realize and correct its. For said years my a project as the National Campaign to limit hospital infections and a major strategy is reaching of goal to improve transparency. In 2003 we default develop legislation to create hospital acquired infections reporting and took it across the country recruiting people who have been hard to help pass bill now 31 states have these laws and a federal Program Requires reporting of infections. The creation of the cdcs Safety Network was essential to making this happen. That was created around the time we went across country and the states adopted that. So it is true for a standardized system to collect information about more infections as well as medical errors and that is essential to move us forward. Public disclosure is a critical element to prevent these events from happening because it shows about the outcome to motivate more to prevent errors. Our work also includes working with people who have been harmed and i am grateful for all they have taught me. I know many of them are watching in many sent letters to Congress Last week urging them to urge a national Patient Safety board to take up this crisis. I would like to touch on transparency and oversight and accountability. We have an infrastructure provided by have hospitals and physicians but it doesnt work very well for consumers seeking reliable information or for patients stressing oversight agencies will respond promptly with the standards of care not followed. We are talking about the transparency of the events but our system is secretive and it needs to change. The government hold lots of information that is not readily available to make it more easily available the oversight system does not work at the state and federal level it is not responsive. It is also rife with dishonesty and stonewalling with patients are charged. And had to fight in court to get his heart back we could have revealed to do for a medications given in the hospital or surviving infections after routine surgery discover photos from hospital records were not submitted to the medical board when asked and the wreckage of a choose to spend their money on things that bring profits rather than activities that improve the safety of patients we need someone on our side and that is why we ask for the independent National Patients safety board we need someone to offer insights for what needs to be done i would be happy to talk more through question and answer. Thank you for your testimony. It is excellent testaverde let me begin the questioning. Working for the of v. A. Occasionally and i am on the committee for Veterans Affairs and we have heard a lot about problems with the v. A. And their legitimate and we will deal with them but as many panelists have indicated we have heard a lot. And said to have to a larger airplanes political is a lot of people. My first question is how come this story isnt on the front page every single day . Somebody dying at v. A. Hospital but a 500 people die every day is also a big story. That is one question. Lets start with that. Why doesnt it get the kind of attention it deserves . Two quick points to that question, people go to the hospital they are sick and it is very easy to confuse the fact that somebody might have died because of a natural consequence of disease or a complication from medical error. The bottom line is that to prove to all of us they are not a natural consequence of the underlying disease. Purely failures of the system to address the problem. That is a wakeup call for clinicians and physicians andersens a and nurses to do better. But the first is we have labeled so much harm as inevitable that we now know it is preventable but the difference in hard estimates between the report of 1989 and today is not that care got worse for all the other deaths play in the inevitable but it moved to preventable and there are probably even more we should move. Second is the death occurs alone one of the time and silently does not get the media attention. Compared to mining but lets get the media attention. It is disease Advocacy Groups the bench the Breast Cancer groups there is an Advocacy Group with power for Patient Safety because there are many different diseases and nih funding is you have to answer to those constituents but we lack an that and we need that. Leslie pick up the point. If i go to a hospital is about the level of infection that other preventable deaths . We are beginning to have information. They dont know if the whole hospital is say if and when theyre treated bet with surgery it depends on what state you are in a fit will be published in washington state. As a you are in luck but not in texas in the federal government does not require that yet. And we really are getting a small piece. A wife has an operation and clearly there is a problem. May be the threat of a lawsuit. Is it true the settlements will not be made public . We dont know how many types is that an accurate statement . For someone going in for surgery there is so many other pieces of information they need to know aba to see a primarycare doctor. But with patience is is minimal but on transparency there is a couple of Different Levels first with patients as we were talking about with the data errors and why we do care redo. And it is a huge lost opportunity. But then my hospital fix is it and how to solve it does not naturally leave the floor and walls of my hospital so things are reinvented and things are happening constantly so we need better mechanisms to insure that sharing is that they do ocher. Senator warren . In mecca according to the cdc 75,000 die annually from infections. Now we already know a lot about how to reduce these deaths. The simplest things like better hand washing, room cleaning led to reduce these infections. Boston Childrens Hospital which treats some of the sickest children in the world has had terrific success to implement steps like these. Boston childrens has not had one single case of ventilator associated ammonia in the cardiac ico in nearly i see with nearly two years and not as simple catheter ut i in the medical icu for over two years. Knowing how to make patients safer unfortunately it is not happening everywhere we need a system in place. So my question is this. Knu help us understand why Certain Health care entities have not yet adopted straightforward proven techniques to reduce these infections . Fundamentally that question in front of us is how we have an industry where we have cheap and easy interventions that save lives, save money and not every Single Person uses every single day . There is a disconnect. It strikes me looking at boston childrens and hopkins it is driven by passion and leaders to care deeply despite those who dont give them any rewards. If they have a system that relies on heroes and great leaders to solve all the problems i would love to clone him but this is the policy solution for the problem way have. Looking at hospital ceos and what determines co pay the organizations of the nonprofit status quality outcome Patient Safety net of those are influenced until they get to the point the ceo lies awake at night worrying about patients safety we will not move the needle the matter what his sentence we played in front of them. Is also critical for the board of directors to be better educated there much more focused on the financial aspect i am interested in these are hard Financial Times the having a board of directors to understand this issue is key step in if there are simple procedures it seems like we should say wash your hands even with that simple basic that we know is the number one preventative action becomes complex social leaders say we are as concerned bayou need resources in place even washing your hands in equipment, a sinks available, housekeeping making sure soap dispensers are filled, where do they put that down . On the floor . I dont think so it is a Ripple Effect you need equipment and people to understand. Mentioning about transparency staff have to understand the metrics we can do National Promoting and information among hospitals but here is our inspection rate so all of those go into something as simple as he and washing. Senator you should have been on our research team. With precarious would allow a hospital to get at zero . We borrowed peer to peer review developed after three mile island. We went into hospitals to understand. What we found is there was no magic bullet but there was the clear chain of accountability so if the ceo said 00 they looked at the rates and they knew it to enable support structures the fdic you and director on the problem to say what is your rate . If they had a culture where nurses could open the question for not using the checklist that was well received if the frontline staff investigated as a defect if he it did one of them. But can we just follow . What would you change the several state requirements and policies to go that direction . It is not the part about those magical things but washing your hands to drive down the rate of death and infection. Estimate there are a lot of things to make these pavement incentives more meaningful. Like hospital acquired payment program. The disincentive is simply to not pay for the of hospitalization of which the event occurred. But that person on medicare has to have wound care, a doctor visits, medication is , all kinds of expenses that medicare pays for and that hospitals should be responsible for the zero hold rating of a whole range of things. I am overdue this squad quickly. Dr. Disch . Web minnesota is doing is networks to bring together the sea of to look at what were doing to have a conversation across institutions that how come your sister doing better than ours and talk among themselves. I said to them how many ceos do you think are changing natalie concerned about finance but also the bottom line . She said it is changing the dial when they sit down and talk to share stories. It is the senior team like medical leadership and that comparison is happening at the state level. Senator warren we have reduced these dramatically the several hundred hospitals have 10 times the National Average with no accountability outside the public reporting their fully accredited and we know they can get at zero. Of above to see them start with the infection rates but we have a good measure if he were not download there is no excuses. If your hospital is five there should be a greater sanction. Let me pick up on a point you know, that there are some hospitals and had the infection rates 10 times higher than other hospitals . To the American People know those . I know of those because of the work of Consumers Union in some states require public reporting chicago, baltimore that write newspaper articles that list those hospitals but outside of that liberal the there is no followup. Said you are accredited which is great but people are dying. Who is responsible to say that is not appropriate . We know you cant fix it. What would you do . What is the next at . We have the consumers have taken on this but what do you do next . To begin a federal level or the joint commission i would start with this one measure because we know the measure is good and the evidence is good. If your rates are above the National Average you are told we know the infection rates plummet immediately within months. From the accreditation you will be sanctioned. I apologize. Senator whitehouse. Thank you chairman. The clear accountability that everybody agrees is a very important signal is hard to develop without clear data. I am concerned there is a tower of babel problem that the provider has to report through multiple means of reporting to the federal government. Every state through those means syria ever reporting mechanisms the individual insurers they do business with is built into their system and and through whenever local systems might have been set up and potentially through the process and by the time you have loaded up the reporting one the reporting begins to eat up the actual repair it and to the new ways overtakes the signal if the hospital gets a bad report the first thing i hear them say is that is not a good look at this it does better over here. So with robust reporting weld the rest is a moving target to what extent we should focus to simplify and direct attention to a few clear agreed measures that can then become a barometer for the system behind them this is up problem you will solve it by reid calibrating the culture of the system smith said is an excellent point to start with i can indicate because there is one institution that tracks 1800s indicators. How could you possibly give a signal out of that . They will save flavor of the month so the words that the staff use so getting a line or orator is immensely helpful. A lot of those are process measures because this is what we need to do in hospitals have to track that but for public reporting we need outcome measures. Most of the report now is a process measure the doesnt tell us if a patient got an infection or was harmed. Civic we reported Johns Hopkins well over 300 measures in most outcomes are using billing data and their near worthless. We spend a ton of money but we spent money with coding and not improving care we know those top five causes like infections to develop measures to focus on those where people are dying. Outside of Health Care Acquired Infections i do not believe we have a system for valid measures for any of other harms in a changing the topic. I think we all agree so far. If you were to pick some core quality measures to become much more visible and clear, that that will lead defect the system operations and the type of culture that is repeated the talk about and would tend to propagate other areas or do you have to fight infection by infection or issue by issue . I completely agree of the metric overload. The one considered i have is that there is the whole lot of other stuff that does not get tackled. I think part of the court metrics. Isnt there one way instead of not making progress . Because then you dont make significant progress but it is important to think about infrastructure and foundational things so we talk about incentives to use cl if you have a culture where people are afraid to speak up you will i get very far. So we have measures. The biggest ford plant that makes the vast majority of their trucks in michigan any person on the line can stop the blind and they are protected if they see any flaw. You are exactly right. That is a good process senate they implemented the same strategies. So how do we measure that and incentivize . And with infrastructure cannot have leaders telling people try harder next time. People have to understand safety scion sam principles how to improve things things are happening all over the place. Dr. James . Directed good news is we have a mature programs to identify a few key metrics to get everyone on board this is the problems the cdc is a natural bowl to be. If we could go after to measure am put in incentives because culture comes from leadership in that response to incentives then we have the right coulter a culture. Weaver doing this that nasa as i was leaving called 360degree reviews if you talk to doctors and nurses and hospitals they know whos doing a right and performing well but they are afraid to do so. There is something wrong with their colleagues or boss. That 360degree view works well is anonymous but you get feedback so for the first couple of years you get feedback on what you need to fix i got interesting feedback on one id do to fix but after a couple of years if the physician is not fixing according to the feedback and the administrators take action. But within hospitals it is known what is going only have to find a way to pull all that information to get it available to the public. I will continue the questioning. Talking about the end of the day talking about patients. In the course of this discussion we have several observations. Dr. Gandhi mention doctors prescribe to there. Data for patients cannot afford to buy the a drug what type of insanity to go through the insanity to diagnose with that there be but too bad you cannot afford the drug . Dr. James talked about the tragedy in his life after the treatment his son received to go through athletics so there was a lack of communication. I knew as part of the hearings that we have medicare will spend money doing surgery than resend them home then they dont have enough food in the house or it isnt warm enough in the winter sleighs and 50,000 on surgery but not 500 on the social worker so that speaks to a system in general with the profit oriented rather than patient centered. Who would like to comment . I think it is true we do not do enough to ensure patients are educated and partnering with us that they have the resources is when they go home to do what we ask them and the incentives are not aligned with that. Caring for populations as opposed to these distinct episodes i think will help. In terms of cost if we do a major surgery that is not infrequent people will come back because they dont have the right medication or the food. And the Current System they are paid again for that readmission so in the old system did not have the incentive to ensure that everything went great. That is the real challenge or to sustain a primarycare practice a pharmacist to talk to patients and explains things that would help the had to pay for that person with the incentive is not there . Limit that is a serious problem. Those on a multiple medications it could be side effects, not understanding why they need to take a and a primary care doctor will have a hard time spending one hour to explain. And we pay for that lack of information and later. Exactly. With your experience which is a different type of system what does it do better or worse . It takes the leadership role under the Clinton Administration to make Patient Safety a priority before the report to put together center for Patient Safety they had done leading work in this area to track down adverse events they have ben phenomenal but may concern is over the last few years there has been less focus on Patient Safety in the v. A. Destruction with other issues but the v. A. Represents the same problems we have heard about hundreds and hundreds of metrics to lose the focus of what matters to veterans and because of that we have not see the gains we would have liked to have seen because the emperor structure and the covenant is there to make it a safe organization. I do think the v. A. Is a good example. A number of years ago they started to scream patients for the antibiotic resistance above people pay carry on their skin so the infections have gone down as a dividend the. Of the v. A. Put out a directive we will do this all over the country. In the private sector the only way to do it is through medicare. They make things happen so i would say one of the most important things to keep pushing on these incentives and there are ways they could standardize and coordinate better but this needs to keep building and you will hear from hospitals that say stop the from the consumer perspective we want to see accountability for these events and pavement incentives are what a way to do it. Dr. Pronovost some have rates that are higher if you give them a boarding to you get your act together . What is the or else . Our regulators have wellestablished policy is how to do this. Largely implemented a complaint so if a patient has a complaint they review if the policy is here they could withhold medicare funding if they have a great power of sanction. But that is for rates of infections so oftentimes for individuals they have not focused. If you dont get the infection rate down . They have a policy for issuing sanctions that have not pulled that trigger for outcomes what they do that measures are valid. They have been reduced dramatically the signal is could ian swayed accountability. I want to reiterate that the m1 measure certainly becomes the focus for the organization and it is done. To really change the culture of what it is working on is so critical. So this accountability is critical to be at a higher level than a single measure civic have wanted go back to a point that patients safety cannot stop when they leave hospital. Many people come home with the prescription or in some cases with several. And they have to manage them on their own but something as basic as aspirin almost none of these prescriptions come with standardized consumer friendly instruction this is a huge hole it has real consequences and in 2010 alone cdc found 50,000 people died from unintentional Prescription Drug overdoses that is entirely preventable and unacceptable. Can we assume some of the overdoses archivist by people who dont understand how properly to take their medications . That is a valid assumption. Would you conclude to those that died from an intentional overdose there are many more who take medication improperly because they dont understand the instructions . I think its something that congress can do something about. Dr. James. Knew two parent who lost young Adult Children to overdose of medication. Often these are opiodes are very addictive and doctors dont under the power of the prescriptions so they go to another pain mill and get these. And so theres kind of the system needs to be fixed so that cannot happen so young adults dont die. Dr. Dish . This is another good example of an issue that requires patients and family conversations about the drugs, not just prescribing and saying, heres what were going to put you on, because there may be information that the patient or family has that this isnt a good drug or ive taken it before, or theres a story where a patient was ordered to change his diuretic and weigh himself and come back if the gained more than three pounds. Great education but the patient was homeless and didnt have a scale. So the discussion about, is this going to work for you and personalizing something that seems as straightforward as a medication prescription really requires talking with the person and not just prescribing for. So, we have seen this happening in lots of other areas where we now have we change the way we label food. If the data is confusing its worse than no informing at all, so we have seen progress in this. Theres ban lot of very good work to start pointing to what is the kind of information you need to show patients, how do you present it in a way that people can understand. This is not rocket science. This is a place where i think the fda this is a little beyond my disports of who does the regulating but it seems this is something we have a clear role on to make the information much more consumerfriendly so normal people can understand it. And dr. Gandhi. , so i want to reiterate what dr. Disch said. Label alone will not solve the problem. Its really having the really good conversations with patients about medications. But the other piece, too is giving providersed the tools to have those good conversations. So, these patientfriendly tools, Electronic Medical records, for example, could really help to provide a nice calendar to a patient of, heres what you take and why and what days and so on. So i think theres tools we need to give to providers to help these conversations really go well. Well, i very much appreciate your point on this. I want to summarize it by saying its clear there are dangerous associated with improper medications. Its also clear that we have consumer friendly labels for over the counter drugs, tylenol, cough syrup, but not on Prescription Drugs. What im hearing the panel say we wont solve everything by Getting Better labels but if we had more consumer friendly labels on Prescription Drugs, this is one of those like wash can hands, at least a lowcost, simple, direct way to make an improvement in Patient Safety that could save lives and certainly save people who have suffered. I just want to say on this one, the food and Drug Administration has been working on getting consumer friendly labels for more than 30 years, and we still dont have them. So, this is an area where i think we should continue to push and particularly continue to push the food and Drug Administration. They have the authority to do this. We need to have patientfriendly labels on Prescription Drugs. Thank you, mr. Chairman. Thank you, senator warren. Thank you, chairman. While senator warren is here and senator murphy was here also, want to thank both of them. Were working together along with a few other senators on a piece of legislation to address the problem of hospitalacquired infections. Were looking at trying to improve the meaningfulness, if thats a word, of the data collection, and the distribution of that data, its transparency. Were looking at trying to reinforce the statebasedded infection reduction efforts because some of this has come out of so many local initiatives. Were looking at improveing antibiotic stewardship and also looking at trying to improve the data across handofs, and that is the question i want to ask all of you now. We have, i think, fairly good sense of the four or five elements that combine together to solve 0 solve a lot of these infection problems. The fight uphill against incentives that cost the hospital often money, cost them money to implement the program, and they lose the revenues they got for treating the hospitalacquired infection they caused. So, its a kind of a doublehit to them. And in that environment, where there is actual control, you have a ceo of the hospital and the hospital. Even then we see these problems. So when youre dealing with a handoff for a patient who, say, is going from a hospital setting to a nursing home, and very likely back to the hospital and back to the nursing home more than once. What should we be optimistic about our ability to tackle that problem while were still having so much trouble with the first problem . And what kind of reporting do you think would be most helpful . Let me ask first, dr. Gandhi. This is your expertise. What should we be doing about expanding this beyond an intracorporate setting within one organization to try to reach to the handoffs between organizations . So, first i think there need to be standards how these handoffs should happen. Honestly, if you have seen one hospital do handoff, you have seen it once. What are the key critical pieces of information that need to get communicated. What time frame do they need to be communicated in theres still hospitals that say a discharge summary can be done within 30 dives discharge. Patients going to see their primary care doctor tomorrow and were saying its okay there can be 30 days for a hospital discharge to get done. So timeliness and content of communications is key. Electronic medical records can help and theres work going on there, but theres also a really critical human component, and its the term we have been using is warm handoffs. If a patient is sick enough to go from hospital to rehab,ing the not going home. Theres going to another facility, and the norm is that nobody from the hospital is actually talking to someone in that receiving facility. The patient gets on a stretcher with the chart and goes off with no communication verbally, and we have seen that when you do that verbal communication, really Important Information gets conveyed. So standardizing that process, content, timeliness, and when do you need the persontoperson dialogue is fundamental, and were just starting on this. I dont think we can wait to say, hospitals fix yourselves, because this care across the continuum cant just be put aside until later. And assuming, as you said, there are process measures that could be checklisted for that handoff, where do you think in the oversight universe the responsibility for overseeing that checklift checklist issue. We could create measures im not sure what the right i dont know if its medicare or who but just as an example, was at Partners Health care and we created a measure and said these ten things need to be in a discharge sister and if you have nine out of ten, you get a zero, and we could measure and it improve it because we can measure it. There needs to be a measure and that can be tracked. I think medicare can certainly be part of this. These are sometimes not easy to abstract from records but we can figure out how to do it. So i think that somebody like medicare would make sense. Dr. Jha and then dr. Disch. One important problem here is you look at the hightech act, which you know well, senator, and we are providing incentives for doctors and hospitals to put in Electronic Health records and its going well. Dont get me started on this one. I know this is a topic near and dear to your heart, no. Just for everybody Nursing Homes and Health Providers so theyre not part of the Meaningful Use Program i told you not get started. My apologies, senator, for egging him on. I know this is an issue near and dear to your heard but its exactly the problem were talking about. The sickest, most expensive patients leave the hospital and go to Nursing Homes, to rehab facilities. Those place does not have Electronic Health records. We have tracked their data and theyre lagging behind, and so you can have a great Electronic Health record and an electronic summary and you have to print it out and fax it, and that is no way to do business in 2014. Understood. Dr. Disch. I think we have to do a little both and thinking here because its seductive to think we talked about a couple of specific issues, labeling, infections, handoffs, and do a deep dive on those, but we also have to step back and say, if we are trying to change preventible deaths, make like the Aviation Industry we have to think about high reliable oranges where the whole organization aligned. People do not tolerate deception or theyre preoccupied in a good seasons of fail other. We have leaders that are excited. Its we have to do both. We have to work on the initial issues but i wore well focus on fixing the problem of the moment. The Aviation Industry had to restructure how they did business and that that be on our radar screen. Thank you. Dr. Jha. Very quickly. Thats goes back to what dr. Jha said there needs to be a standard for medical records. Theres a number of different systems and they dont communicate well. Ive heard that from doctors. Im not a doctor. But that needs to be fixed at the federal level in my opinion. Thank you, chairman. This is far and away the most important hearing happening today in washington, dc, because of the importance of this issue and your attention to and it this incredible panel you brought together has been terrific. Thank you, senator whitehouse, and i want to concur with what senator whitehouse just said. We dont know the exact number but were talking probably hundreds of thousands of people a year dying from preventible problems in hospitals and god knows how many outside of hospitals. We know this issue has not gotten the attention that it deserves, and i hope that today is the beginning of an effort to focus more light on it. You guys i want to thank all of you and echo what senator whitehouse said. You have given us ideas not only in terms of what the problems are but where we have to go. The federal governments role in terms of the cdc, the fda, medicare, medicaid. So, we have a lot to work with. I just again want to thank you for all the work you have done in your powerful presentations today. Thank you very much. This hearing is adjourned. I did want to add, senator boxer wanted to put in some work on Patient Safety issues into the record, with unanimous consent well do that. Thank you all very much. [inaudible conversations] a look now at primetime programming tonight across the cspan2 networks. On cspan at 8 00, an American History tour. Well bring you a look at native americans, including the battle of little big horn. On cspan2, more booktv, a recent indepartment program with ron paul. And on cspan3, American History tv will feature our real america series which brings you archival footage. Tonight we have films on apollo 11, hoover dam, and conversations with herbert hoover, starting at 8 00 eastern. 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Nick hanauer is shawneing us from seattle, and we are looking at your piece, but before we start, can you tell us about your background and, frankly, about your wealth . Guest well, you know, i grew up in a family business, manufacturing business, but when i was in any early 20s i started starting other companies, and ive started ive either founded or helped finance and get off the ground, i think, now 35 Companies Across a range of industries, and i had a series of very fortunate things happen to. My was i had a very early interest in the innet and had a friend who shared the interest, named jeff bezos, and i became the first nonfamily investor in amazon. Com. He came to my house in seattle and started that here, and then i also founded a company that became essentially the largest independent internet