Let’s face it, providing medical care in an era of advanced technology is both a prohibitively expensive as well as an error-prone proposition. For example, the Leapfrog Group, comprised of 150 public and private organizations organized from the Business Roundtable, an association of Fortune 500 companies, has defined some statistics directly related to the cost and safety of medical care.[1] The benefit packages of these organizations include providing healthcare services to 34 million Americans at a cost of $62 billion dollars a year. Since the Leapfrog members pay that bill, they want to have some say in what their constituencies receive for the considerable monies spent. The Leapfrog group is not alone in this regard. They have been joined by a host of significant others including the Institute of Medicine, the Institute for Healthcare Improvement (IHI), the Center for Medicare Services, and another consortium called Bridges to Excellence, to name a few from a rapidly growing number. Lest one think that this is solely a business venture, the concern is not just dollars and cents. Did you know that if the airline industry committed as many errors as healthcare does, the equivalence in lives lost would equal a passenger jet crashing every one to two days? Contemporary medicine is in a fine mess. How should it go about fixing these potentially fatal problems?
A number of evidence-based solutions have been recommended. Two examples will be provided. Adverse drug events are a major quality and safety problem. Both the IHI and Leapfrog have prescribed computerized physician order entry and other safety measures, none of which have been uniformly implemented. Leapfrog has also suggested something called “Evidence-Based Hospital Referral.” Their hypothesis is that if hospitals increased volume for complicated procedures, specific hospitals would acquire optimal expertise, and as a result, better outcomes than referral centers that don’t perform a requisite number. In fact, it has been estimated that mortality may be decreased by as much as 30% if this specific recommendation was enforced.[2] A recent report suggests, however, that contemporary medical and surgical practice still has a long way to go with this particular safety recommendation.
An article in the Los Angeles Times has collected disturbing data that says, “Medicare allows 20% of the 236 transplant programs in the U.S. to stay in business despite performing too few operations or having low survival rates.”[3] To put the conclusion in human terms, between 2003-2004, nine lung-transplant programs accounted for 21 more deaths than expected. Thirty-six heart-transplant programs also accounted for 43 more deaths than expected. Many more centers are well below minimum numbers required for competency, so this lethal trend may continue. There seems to be a disconnect between recommended safety standards, such as the Evidence-Based Hospital Referral, and individual center compliance as well as appropriate regulatory oversights (in this case, Medicare).
The scariest part of the article in the Los Angeles Times is that transplantation is only a small part of the much larger safety problem. Similar chilling statistics can be applied to almost every other aspect of healthcare. For those interested, either Atul Gawande’s book Complications: A Surgeon's Notes on an Imperfect Science, or Wachter’s and Shojania’s, Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes will bring the magnitude of this critical issue into focus. The prestigious Institute of Medicine has stated categorically, “Serious and widespread quality problems exist throughout American medicine . . . Between the healthcare we have and the care we could have lies not just a gap, but a chasm.”[4] What is required is a substantive overhaul of the entire healthcare system. Rectifying the transplantation safety shortfall should become a reigning paradigm. Every contributor to patient care has to practice as well as inhabit a holistic “Culture of Safety.”
Graduate Medical Education has begun to ensure the next generation of physicians becomes the dynamic for necessary culture change. Two of their six competencies established for physicians-in-training are Performance Improvement (establishing individual, measurable quality habits) and Systems-Based Practice (ensuring that the systems of care have built in redundancies for the sake of safety). Simulation-based training using real emergencies is on the rise and may provide a structured environment in which teamwork and safety are prioritized.
The entire system and all its component parts have to listen to Leapfrog and a host of other organizations. They are on target in their admirable goals and not just talking in an effort to protect their member businesses’ bottom lines. Many lives are at stake and healthcare workers have to emulate the airline industry. Pilots have been making safety job number one (they have been leaders in simulation), and their outcomes have been no less than remarkable. Healthcare workers need to jump on that learning curve immediately, not only with transplantation, but with everything that they practice, from the simplicity of regularly washing their hands to decrease infections to the complexity of transplantation surgery. Their patients deserve nothing less.
[1] Walter G. Maurer and Christopher J. Hebert, “Quality Measurement: Who is Measuring Outcomes and What are Patients Being Told?” Cleveland Clinic Journal of Medicine 73 (March 2006): S30-S35. http://www.ccjm.org/PDFFILES/Maurersuppl1_06.pdf
[2] Ibid.
[3] Tracy Weber and Charles Ornstein, “20% of U.S. Transplant Centers Are Found to Be Substandard,” Los Angeles Times, June 29, 2006, http://www.latimes.com/news/local/la-me-transplant29jun29,0,2730832.story?coll
[4] Committee on Quality of Health Care in America, Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st Century (Washington, DC: National Academies Press, 2001). http://www.iom.edu/?id=12736
