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Patient Safety: Achieving a New Standard for Care
ACCOUNTABILITY VERSUS LEARNING: UNDERSTANDING THE CONTINUUM
There are clearly many important applications of patient safety data and many different users. When called upon to respond to the most egregious performance failures, legal and regulatory programs appropriately aim to bar substandard providers from practice and to provide compensation to the injured. Incentive-based approaches aim to create an environment that rewards safety and quality and, in so doing, to encourage providers to pursue system redesign.
Although the three broad categories of applications—accountability, incentives, and system redesign—have quite different immediate aims and operate independently, they are intertwined in several important ways. First, depending upon how well they are crafted, the approaches pursued by legal and regulatory bodies and by purchasers and consumers in the marketplace can have either a positive or a negative effect on the efforts of providers to create a learning environment. Second, applications in all three categories rely to a great extent on the same underlying safety data systems and will do so increasingly in the future. Finally, all three consume scarce health care resources (e.g., dollars, provider time and attention), making an appropriate balance of activities imperative. This section presents a case study involving the use of mortality reports for accountability purposes and then uses this case study to illustrate key points related to issues surrounding the use of patient safety data, including the selection of measures, the risk that the use of performance data will instill fear and provoke defensive behavior on the part of providers, and the concept of preventability. The section ends with a discussion of the implications of the range of applications for patient safety data systems.
Between 1986 and 1992, the Health Care Financing Administration (HCFA) released a series of annual reports assessing mortality outcomes across approximately 5,500 hospitals that treated Medicare patients in the United States (Health Care Financing Administration, 1987). A team of HCFA researchers and statisticians developed risk adjustment models for mortality following hospital discharge and improved and refined those tools over time. Within the reports, the highest 5 percent of hospitals in terms of risk-adjusted death rates were labeled “high mortality outliers,” while the bottom 5 percent were labeled “low mortality outliers.” The news media distributed the result