OAKBROOK TERRACE, Ill. -- The most powerful
incentive for reducing medical errors is to align payments for service
with the successful provision of safe, high quality care, the president of
the nation's leading advocate for health care quality and safety told a
Senate Committee today.
Testifying before the Senate Committee on Governmental Affairs,
Joint Commission President Dennis S. O'Leary, MD, outlined six crucial
strategies for the creation of a true culture of safety within healthcare
"The Joint Commission, like others, is deeply concerned that the
number of serious medical errors remains unacceptably high, despite the
focus of significant national attention on patient safety in recent
years," says O'Leary.
To overcome the barriers preventing health care organizations from
truly embracing patient safety, O'Leary emphasized that Congress, health
care providers and purchasers need to work together to:
Create a blame-free, protected environment that encourages the systematic
surfacing and reporting of serious adverse events.
Reinforce the "systems approach" to preventing medical errors, whereby
health care organizations assess the weak points in their systems of care
and re-design care processes by putting safeguards into place to keep
mistakes from reaching the patient.
Reform the professional educational system to produce healthcare
professionals who are proficient in executing a "systems approach" to
patient safety and are trained in team approaches to patient care.
Joint Commission president testifies before Senate
Invest in the information infrastructure of health care organizations in
order to make critical patient information available on a timely basis and
thereby support the safe and appropriate delivery of medical care to
Establish performance incentives for achieving safety objectives through
federal adoption of the Joint Commission's National Patient Safety Goals,
and align reimbursement for healthcare services with the provision of
safe, high-quality care.
Enact patient safety legislation that that would encourage the voluntary
reporting of healthcare errors and their causes by affording
confidentiality protections for such reports.
"Healthcare professionals, who work under continuous high stress,
will make errors," says O'Leary. "The goal is to prevent those errors
from reaching or affecting the patient."
The Joint Commission maintains one of the nation's most
comprehensive databases of serious adverse events and their underlying
causes. Information from this database is regularly shared with accredited
organizations to help them take appropriate preventive steps. It is also
used to establish the National Patient Safety Goals. It is believed that
the sharing of this information has already saved countless lives.
The Joint Commission's National Patient Safety Goals, implemented
in January 2003, set forth clear, evidence-based recommendations to focus
health care organizations on significant documented safety problems.
Accredited healthcare organizations that provide care relevant to the
goals are evaluated for compliance with these goals.
"There are considerable barriers to be overcome if we are to be
successful in persuading healthcare organizations and practitioners to
fully embrace state-of-the-art patient safety and health care quality
practices," says O'Leary. "The knowledge of what to do differently and how
to do it exists and progress is being made. However, more needs to be done
by all of us, including the Congress, if we are to succeed."