Statement of Mark R. Grealy, Healthcare Leadership Council

The Healthcare Leadership Council (HLC) is a coalition of chief executives of the nation’s leading health care companies and organizations representing all sectors of health care. Our members are committed to advancing a market-based health care system that values innovation and provides affordable, high-quality health care. HLC would like to thank the committee for focusing today on health quality and patient safety and for the opportunity to submit this statement.

While Congress considers how to enhance the safety of the nation’s health care system through legislation, we ask you to consider also the numerous steps the health care industry has initiated to reduce error rates and to continually increase the quality of the care it delivers. Many health care providers are reducing human error by upgrading their systems technologies through the use of computerized physician-order entry, computerized on-floor pharmacies, and scanning bar-codes at the patient bedside. Manufacturers are changing their packaging to dose-by-dose packages, improving dosage and interaction instructions, and eliminating look-alike packages and names. Hospitals are removing high-error medicines from patient floors. Many hospitals are also voluntarily submitting error data to organizations like the Joint Commission on Accreditation of Health Organizations and U.S. Pharmacopia, where they receive analysis and feedback of how to avoid similar errors in the future. These are just a few of the many examples of some of the activities underway within our membership.

In an effort to increase safe practices and to cross-educate health organizations, HLC has launched its own effort and formed a Chief Executive Task Force on Patient Safety. Our goal is for the various sectors of the health care industry to work together to help elevate public confidence in the safety of the nation’s health care system. We are accomplishing this by uniting behind a self-initiated protocol for addressing patient safety in the health care system responsibly, positively, and tangibly.

The HLC task force is guided by the following eight principles which we offer for the committee’s consideration as it evaluates potential patient safety legislation:

1. Solutions should be developed collaboratively and with executive responsibility and leadership. A zero error medical environment will require devoted, thoughtful and creative collaboration of ALL STAKEHOLDERS. For example, all care givers must increase awareness of the potential for errors, administrators must facilitate systems of improvement, patients must be committed to complying with treatment programs, industry executives must make patient safety improvement a declared and serious aim by establishing programs with defined executive responsibility, and lawmakers and regulators must resist mandates that could stifle innovative problem solving.
2. A holistic quality assessment system must be developed and adopted for use in health care. Individuals are not the true source of errors in health care or any other industry. Systemic review of processes, practices and policies to uncover sources of error so the source of those errors can be eliminated is essential for improving safety in the health system. The health care system should incorporate the lessons learned in other industries that have greatly reduced their error rates.
3. Safe practice standards should be evidence-based, flexible and feasible. Nationally recognized safe-practice standards should be developed only through analysis of conclusive data on broad-based effectiveness and feasibility, and should consider evolving science. In addition to recognizing broad-based safe practices, health care organizations should be encouraged to and should be recognized for adopting tailored safe practice programs unique to their specific risk points, specialties, and patient populations.
4. Healthcare organizations, lawmakers, and other policy officials should support the automation of patient safety systems to the greatest extent possible. The Institute of Medicine is urging a new generation of patient safety systems that are automated, information system-based, and technologically driven. A voluntary health system information technology infrastructure should be encouraged and facilitated as broadly and rapidly as possible to help reduce incidence of human error in the practice of medicine.
5. Establish a culture of awareness–NOT blame–to drive health care errors into the open. Improving patient safety depends heavily on the ability to collect and analyze patient safety data, and to use that information to develop safer systems. Laws that perpetuate litigation are antithetical to the goal of transforming medical adverse events and "near misses" to permanent and pervasive systems improvements. Lawmakers should carefully consider any new laws or regulations that could actually do damage to the current health care system by making errors and "near misses" even harder to identify. Peer review protections should be instituted to protect organizations from the fear of litigation which will prevent the sharing of information.
6. A system of incentives is the key to patient safety. Using positive incentives to encourage health care organizations and all care providers to swiftly report health care delivery problems and to develop processes and procedures to prevent further errors in the area is the key to improving the safety of health care system.
7. Focus on prevention instead of errors. Instead of devoting major efforts to medical errors after the fact, develop a system focused on studying near misses, to prevent adverse events in the first place. This focus should be firmly impressed early on in graduate medical education programs as well as training programs for all types of health care professionals.
8. Consider the larger context. The cause of -- and solutions for -- adverse medical events must be considered in full context beyond the individual incidents that result in medical errors:

• A hyper-regulated health care environment is not conducive to patient safety. Coping with more than 111,000 pages of complex Medicare rules, guidelines and instructions reduces the amount of time and attention left for providers to focus on their patients.
• A litigious health care environment is not conducive to the promotion of awareness and information sharing necessary to understand and avoid medical errors.
• A price-controlled health care environment reduces the ability for health care organizations and systems to implement the necessary technology that can positively affect patient safety.

There is no question that the health care industry as a whole must continue working toward a zero-error environment. Such an environment will require the devoted, thoughtful collaboration of everyone, including lawmakers, providers, health systems and patients. Numerous solutions should be considered before implementing any that could hinder the creation of a safer health care environment. HLC is committed to working with Congress to ensure the highest standards for health care for all Americans. We look forward to working on this important health policy issue in the coming months.