Statement of the American Academy of Family Physicians, Leawood, Kansas
Introduction
This statement, submitted to the Ways and Means Health Subcommittee regarding patient safety and health care quality is offered on behalf of the 93,500 members of the American Academy of Family Physicians (AAFP).
The Academy Finds the Creation of a Non-Punitive Environment a Mandate for Safety Reporting
The Institute of Medicine’s report, To Err is Human, released in December 1999, highlighted the unacceptable frequency of health care errors. All patients need to know they can rely on their physicians to do the utmost to bring about the best possible medical outcome. Such assurance requires that patients are as free as possible from harm due to medical errors, regardless of the setting. Unfortunately, the IOM study makes clear that adverse events occur with unacceptable frequency. It is timely and appropriate for this aspect of quality in the delivery of health care to become the focus of nationwide attention and efforts for improvement. Today’s hearing focuses on how Congress can help initiate a patient safety reporting system to promote quality health care.
In the US, most healthcare contacts are made in office settings; most office-based care is primary healthcare; and family physicians provide more primary healthcare than any other specialty. In 1998 in the US, there were 39 million hospital discharges and 829 million outpatient visits, suggesting that ambulatory care may hold an even more important opportunity for improving patient safety. A recent study of the ecology of medical care confirms this large, relative difference in exposure to outpatient and inpatient care. This study, based on data from the Medical Expenditure Panel Survey (a nationally representative, longitudinal survey sponsored by the Agency for Healthcare Research and Quality), found that for every one thousand patients in a month, 217 would be seen for a medical condition in the outpatient setting and only eight to nine individuals would be hospitalized.
Three years ago, the AAFP made a $13 million commitment to improving the research infrastructure for primary care ($7.7 million for three Centers, and $5.3 million for the Robert Graham Center for Policy Studies in Family Practice and Primary Care). In the last year, that investment contributed the first US study of errors in ambulatory care. The Robert Graham Center and the AAFP National Research Network learned from 43 practices across this country what physician-reported errors look like. These findings are currently in peer-review at the international journal, Quality and Safety in Health Care. The Academy recently launched a six-country study to look at errors in similar clinical settings in the U.S., New Zealand, Canada, the Netherlands, Australia and England so that patient safety and quality improvement projects could benefit from comparison with other countries.
The Academy has been awarded an innovation grant from the Agency for Healthcare Research and Quality (AHRQ) to develop a Center of Excellence that will identify, test, and disseminate strategies for making primary health care safer. One strategy already in use is a computer web-based anonymous error reporting system that has so far proved effective not only in identifying threats to patient safety but also in improving more general aspects of primary health care quality. The success of the Academy’s error reporting system beyond initial testing stages will depend upon Congressional efforts to ensure that information reported remains confidential, is protected from use in legal actions and will not be used in separate punitive actions as a result of a report having been filed.
Finally, the Academy believes that there is a need for error-reporting systems that are "open, discussible and without blame," in the words of Dr. Donald Berwick, one of the IOM study authors, and an invited guest of the Subcommittee. Only by researching the underlying cause of medical errors, creating effective interventions and addressing future prevention, can the IOM's call for a 50 percent reduction in the rate of medical errors over the next five years be realized.
The Academy supports the following principles as integral to creating a learning culture that actively seeks to improve the delivery of health care.
Analysis and Feedback
Reporting systems cannot become warehouses of data. Information submitted to reporting systems must be the basis for conducting analysis that results in changes being made to practice. When effective procedures are developed to respond to the underlying cause of patient safety events, they should be compiled and widely disseminated to all healthcare professionals and organizations.
Confidentiality
Confidentiality protections are absolutely necessary for both healthcare professionals and healthcare organizations to trust that reported information will not be used in a punitive fashion. Without such an assurance, individuals will continue to make independent assessments about the utility of reporting their observations to outside entities. Reporting systems should protect the identity of individual patients and abide by all relevant confidentiality laws and regulations. The identities of healthcare professionals and organizations involved in errors should not be disclosed outside a reporting system without consent. This vital protection ensures that reporting systems, such as the ground-breaking system developed by the Academy, have a far greater likelihood of being successful facilitators for improving patient safety.
Information Sharing
While maintaining the confidentiality measures highlighted above, sharing information is fundamental to a reporting system’s ability to achieve widespread improvements in patient safety and to instill a confidence in the public that safety issues are being addressed. The causes of errors and their solutions must be widely shared so that all healthcare organizations can learn from the experiences of others.
Legal Status of Reporting System Information
Congress should create new federal protections for information submitted to patient safety reporting systems. Informationdeveloped in connection with reporting systems should be privileged for purposes of federal and state judicial proceedings in civil matters, and for purposes of federal and state administrative proceedings, including with respect to discovery, subpoenas, testimony, or any other form of disclosure. This new privilege should not interfere with the availability of records that would be otherwise attainable, including patient access to their own medical record.
Conclusion
The Academy appreciates this opportunity to submit a statement to the subcommittee and looks forward to working with Congress to develop effective patient safety legislation. This is a matter of continued interest to AAFP and we thank the Ways and Means Health Subcommittee for its interest in the topic.