A Toolkit for Action:
Ensuring Patient Safety Across Health Care
Introduction
There are approximately 40 million discharges from U.S. hospitals every year, at a national cost approaching $900 billion. Even a small percentage of cases involving harm affects very large numbers of patients and incurs enormous costs. For example, hospital-acquired infections kill 90,000 U.S. patients per year, amounting to more than $30 billion in avoidable costs.
According to Donald Berwick, M.D., and Lucian Leape, M.D., "we will not become safe until we choose to become safe." Hospitals and their teams of physicians, nurses, pharmacists and other health professionals must lead the way. However, employers, who shoulder a large portion of health care expenses, and employees, who consume health care services, also have important roles to play.
The Board of Directors of the National Business Group on Health adopted a position statement on patient safety in November 2006, Recommendations to Employers on Essential Actions to Improve the Quality and Safety of Health Care. To reinforce its commitment to the issue, the Business Group has developed A Toolkit for Action: Ensuring Patient Safety Across Health Care specifically for employers. Many organizations and individuals provided input for this product. We especially acknowledge the Institute for Healthcare Improvement (IHI) for their guidance and intellectual leadership.
Toolkit Components
Promoting Patient Safety: The Business Perspective  —The cost and productivity impact of avoidable harm occurring in our nation's hospitals make a compelling business case for employer action. Employers should use all available levers to promote a patient safety agenda.
Employers as Hospital Board Members & Community Leaders: A Key Role in Ensuring Safe Hospital Care —According to experts, such as the IHI leadership team, the most important ingredient for safe care is a culture of safety within the hospital. Building such a culture requires leadership from the top. "Board on Board" initiatives are working to achieve this goal.
Achieving Preferred Hospital or Center of Excellence Status —Employers must not reward hospitals for harm-producing care, which typically results in much greater costs to payers and needless suffering for patients. The Centers for Medicare and Medicaid Services (CMS) recently took the lead in denying payment for avoidable harm in certain situations, and private payers should support and extend this position. This component includes suggested requirements to be met for a hospital to gain Preferred Hospital or Center of Excellence status.
State Patient Safety Rules and Regulations (Reporting and Disclosure) —This chart (updated as of August 2007) displays actual and proposed state actions on patient safety reporting (voluntary or mandatory) and on hospital disclosure of incidents to affected patients/families. More and more states have passed such laws.
Employee Education —A collection of online resources from authoritative sources to help employees and their family members choose and receive safer hospital care.
Ensuring Patient Safety Across Health Care (Presentation) —This presentation is for Business Group members to use and adapt for their own presentations to educate and inform their colleagues, management team and employees.
Next Steps
The National Business Group on Health is planning to pilot A Toolkit for Action: Ensuring Patient Safety Across Health Care in a few locations in 2008. We are seeking employers with executives on key hospital boards who are in a position to influence hospital governance, preferably in states with some patient safety infrastructure in place. An example of this infrastructure is a hospital's collaboration with IHI and/or state reporting requirements. If you are interested in participating in the pilot or would like more information on the Business Group's patient safety initiative, please contact heinen@businessgrouphealth.org or darling@businessgrouphealth.org.
Expert Work Group on Patient Safety
Troy Brennan, M.D., J.D., Aetna; Jim Conway, IHI; Bruce Bradley, General Motors; Ilina Chaudhuri, University of Minnesota; Helen Darling, National Business Group on Health; LuAnn Heinen, National Business Group on Health; Pamela Hymel, M.D., Cisco Systems; Karen Ickes, Wendy's; Clarion Johnson, M.D.; Exxon Mobil; Jeff Kang, M.D., CIGNA; Allen Karp, Aetna; Vince Kerr, M.D., UnitedHealth Group; Brian Marcotte, Honeywell; Joe McCannon, IHI; Harry Spencer, Time Warner; Bonnie Zell, M.D., CDC/IHI
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