10 th Anniversary of To Err is Human The Commonwealth Fund and Alliance for Health Reform

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

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

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.

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

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

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

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

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

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

11. Pressure Ulcer

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

13. Palmetto Hospital Mortality Rates(South Carolina)

14. Does Improving Safety Save Money? 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

16. How Government Can Help:“Will, Ideas, and Execution”

17. “20th 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%

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

19. $10,250 to 17,184 (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 How Do They Do That?High-Performing Communities in American Health Care La Crosse, WI Everett, WA Cedar Rapids, IA Portland, ME Sayre, PA Richmond, VA Asheville, NC Sacramento, CA Tallahassee, FL Temple, TX

20. What Are They Doing? Per-Capita Spending – and Spending Growth – Are Lower. Potential Annual Savings: 12.7% - 16.2%