Hospitals and physicians' offices are supposed to be places that heal.
But for more than 200,000 people in the U.S. every year, they are also the cause of preventable patient deaths.
And in too many cases, providers don't communicate about their mistakes with patients or their families very well, a problem that David Mayer, M.D., executive director of MedStar Health's Institute for Quality and Safety, has sought to change. A decade ago, he helped develop the Communication and Optimal Resolution, or CANDOR, Toolkit with the Agency for Healthcare Research and Quality. It's a tool to help hospitals quickly communicate with and apologize to patients or their families when something has gone wrong—and work to make it right as quickly as possible.
Over the weekend, Mayer was announced as the new CEO of the Patient Safety Movement Foundation, an organization founded by Joe Kiani, the CEO of medical technology company Masimo, who set a goal to reach zero preventable patient deaths in the U.S. by 2020. I caught up with Mayer at the foundation’s summit in California to talk about his goals for the organization—despite figures which show hospitals will likely fall far short of the goal—and how hospitals can reap a return on their safety investment.
FierceHealthcare: What are your goals moving forward even as it looks like that zero goal won't be met in the next year?
David Mayer: When Joe Kiani put out in 2015 that we would achieve zero preventable harm in 2020, it was a really bold goal. Some people said it was crazy. But I think it created an urgency that had been lacking on the patient safety side of quality and safety. … Those numbers he shared [of more than 90,000 people saved in 2018] came from commitments of people trying to save 15 patients here, 20 patients there. Dignity Health saved 2,300 patients in the last year. If you don’t put that stake in the ground and keep asking for the commitments, I don’t think we’d be a third of where we are today. If we could save 150,000 lives next year, what an amazing thing. Think about the people who would be home for Christmas with their grandkids or with their spouses who wouldn’t have been..
FH: Yet we still hear so many stories of patients harmed and of hospitals not admitting when a mistake is made. How do you get this message to those organizations?
DM: Part of it is getting CANDOR out to other organizations. … And people hate when I say it, but part of it is about regulations and legislation. I’ve had some CEOs of hospitals tell me, especially in states where there is sort of a cap on medical malpractice, “We have 60 horrific events every year, it costs us $250,000 per medical malpractice claim to pay it off, so that’s $15 million. We just build it into the cost of doing business and we focus in on generating more revenue.” It makes no sense to me.
FH: So how did MedStar make the calculation that patient safety was worth prioritizing?
DM: The reason we’ve been so motivated at MedStar is because of leadership. When I first came to MedStar, I said to Ken Samet, our CEO, “Why would you want someone like me?” And he said: “Dave, because I’m tired of apologizing for bad care.” And you could see it in his face and in his gut that, for a CEO, it was one of the worst feelings to know your health system hurt someone. He told me two things: He wanted to improve and he used the word apology. There are some places that say “Eh, stuff happens. It’s part of doing business” and move on. If the CEO of every health system had to be in the room with a patient or family to do an apology, life would be different.
FH: What legislation or regulations do we need?
DM: Joe talks about that if your hospital is involved in a case where the care was bad and you didn’t have [best practice models] in place, and didn’t have a process where you apologized, you didn’t get paid for that care. And today, we still pay for too much bad care and too many infections. What we’ve proposed in Maryland would be an audit committee made up of plaintiffs' attorneys, defense attorneys, patient and family advocates and quality/safety leaders that would audit hospitals the way the joint commission does. Because hospitals will say “Oh yeah, we do this.” No, they don’t. There would be an audit process to ensure that hospitals that are doing it the right way receive certain benefits and hospitals that weren’t would get certain penalties.
FH: What is a tangible, simple thing that a hospital CEO could do to start getting traction right away when it comes to impacting patient safety?
DM: There’s got to be a tie that connects the event with process and systems improvement that results, with an audit to make sure changes were put in place. It’s one thing to say “Oh yeah, we’re going to put in these new monitors here.” But six months later, the monitors are still in the order process. Where is the urgency? From the CEO standpoint, I think certain CEOs get it. And some don’t. A CEO’s survival really comes to “At the end of this 12-month period, how did we do financially? Did I hit the budget, did I make the numbers?” Many CEOs, in this day where revenues are tight, healthcare is being cut, they are really afraid to invest in something that is longer term and may show results two, three, four years later.
FH: Beyond the impact on patients and their families, can investments on safety reap a return?
DM: The results we’ve seen at MedStar weren’t seen in the first year or the second year. It was like the end of the second year to the beginning of the third year where we saw our medical malpractice totally drop. The first year it dropped $7 million. Then it dropped $20 million. It has consistently dropped over $20 million in the last four years. … They invested a couple million dollars to train people in high reliability and resilience training, they invested in a human factors engineering center.
It was a huge investment for an organization. A single hospital couldn’t do this sort of investment. But as a large health system, we’re able to spread the costs out. All those things we knew wouldn’t contribute to our bottom line that year or even the next year. But our chief financial officer and our CEO said, “We’re going to get better and we’re going to invest in these things.” And now all that money we’ve saved has added up to $100 million in the last four years.