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The Richard and Hinda Rosenthal Lecture 2011: New Frontiers in Patient Safety (2011)

Chapter: Keynote Presentation--The Honorable Kathleen G. Sebelius, Secretary, U.S. Department of Health and Human Services

« Previous: Welcome--Harvey V. Fineberg
Suggested Citation:"Keynote Presentation--The Honorable Kathleen G. Sebelius, Secretary, U.S. Department of Health and Human Services." Institute of Medicine. 2011. The Richard and Hinda Rosenthal Lecture 2011: New Frontiers in Patient Safety. Washington, DC: The National Academies Press. doi: 10.17226/13217.
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Keynote Presentation

THE HONORABLE KATHLEEN G. SEBELIUS
Secretary, U.S. Department of Health and Human Services

Well, thank you very much, Harvey, for that nice introduction, and also for your incredible leadership here at the IOM. I am delighted to say that the Institute of Medicine continues to be a great partner and colleague with the Department of Health and Human Services (HHS) and continues to inform us, inspire us, and help us do a great job.

I also want to start by recognizing that we have a number of health leaders, some of whom you will hear from, a couple of whom you won’t hear from, but leaders at HHS who are here with me tonight. My great partner, Deputy Secretary Bill Corr, is here. Sherry Glied, our Assistant Secretary for Planning and Evaluation, is here. Dr. Don Berwick, who is the Administrator for the Centers for Medicare and Medicaid Services, who you will hear from. And Dr. Carolyn Clancy, who is the Head of our Agency for Healthcare Research and Quality.

You know, I want to start by recognizing that we’re really here to continue a conversation that the IOM started 12 years ago, with its report To Err Is Human. I think it was an alarm bell that really began to wake up America, maybe didn’t wake them up all the way, but certainly got people’s attention, by describing a system which, at that point, was this snapshot that more Americans were dying every year from the care they received in hospitals, than from all the diseases put together that sent them to the hospital. That’s a fairly frightening fact.

Just as important, the initial report, and the 2001 report that followed, made it clear that the problem wasn’t indifferent or poorly trained health care providers. It is still the case that America has the best trained health care providers in the world. We have the finest hospitals in the world. We have the finest technology in the world.

Suggested Citation:"Keynote Presentation--The Honorable Kathleen G. Sebelius, Secretary, U.S. Department of Health and Human Services." Institute of Medicine. 2011. The Richard and Hinda Rosenthal Lecture 2011: New Frontiers in Patient Safety. Washington, DC: The National Academies Press. doi: 10.17226/13217.
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But there’s no question at all that there are lots of systems where good people get trapped in bad systems, or in systems that malfunction. To improve patient safety, we have to look at the systems and improve those systems.

Over the past 12 years, there are lots of hospitals that have done just that. I have been able to travel across the country and visit a number of those institutions that are really doing quite stunning work in finding ways to re-engineer the patient care system in a way that has backup safety systems in place.

So in February, I was at the Virginia Mason Hospital in Seattle, and they’re using the Toyota engineering system to really make safety a priority. It is something that the leadership understands and that every health leader in that hospital understands, and they do just what is done on the Toyota factory floor to continue to monitor and watch what’s happening. By applying those lessons, they’ve reduced patient falls by 25 percent and bedsores by 75 percent, and those are just some of the outcomes that have been very successful.

In March, I was in Ohio, where a group of The Consortium of Children’s Hospitals and about a dozen adult hospitals have come together, from urban areas and very rural areas, with the business community and with patient advocates to form a partnership to improve patient care. They are now measuring their successes, and they’ve prevented about 3,600 infections and medical complications for Ohio’s children, and they’ve already saved $3 million, and this effort is just under way. They are determined to measure and be very transparent about what is happening.

I know David Pryor is here today from Ascension Health. Over the last seven years, they’ve reduced preventable deaths by more than 1,500 a year. I’ll be at the Seton Medical Center [part of Ascension Health] in Austin this Friday to again help shine a light on the work that they’re doing.

So every day, those hospitals and many others around the country are proving that safer, better, and more affordable care is indeed possible, because that’s what they’re driving toward.

In the past, there have been real questions about whether the results of some of these great hospitals could be brought to scale. They wondered whether providing high-quality care was like playing in the NBA, limited to only a select few, those exceptional athletes with remarkable ability. So while all kids can play basketball, only a few will ever be drafted by the NBA.

Suggested Citation:"Keynote Presentation--The Honorable Kathleen G. Sebelius, Secretary, U.S. Department of Health and Human Services." Institute of Medicine. 2011. The Richard and Hinda Rosenthal Lecture 2011: New Frontiers in Patient Safety. Washington, DC: The National Academies Press. doi: 10.17226/13217.
×

But I think what we’re talking about is creating systems where it’s more like shooting a free throw. Anyone can do it with the right commitment, the right practice, and the right support. You don’t have to be an NBA draftee to actually score two points from the foul line. Now, the reason we know this is because we’re beginning to see some of these pockets of excellence spread.

A great example is central line infections in intensive care units. First, the researchers, as you all know, developed a check list that significantly reduced the occurrence of those infections. Then, they piloted the checklist in Michigan, where they spread it to a series of hospitals, saving 1,500 lives, and reducing health costs by more than $200 million in just the first 18 months. Today, with the support of our Department, those best practices are indeed being spread around the country.

Between 2001 and 2009, ICU central line infections fell 63 percent nationwide, so it is indeed able to be taken to scale. Now, that’s an incredible accomplishment, and because of that effort, thousands of Americans are still living happy lives, going to work, and playing with their grandchildren. Everyone who played a part in that effort should be incredibly proud.

But I want you to consider exactly how limited that achievement is. This wasn’t all health care-associated infections; it was only infections associated with one procedure in the hospital. It was not even all central line infections; it was just in ICUs that those statistics were measured. And it was not a 100 percent reduction, or even an 80 percent reduction, it was just over a 60 percent reduction.

So the truth is, despite the successes around the country, injuries from care are still way too prevalent. In fact, a recent study found that as many as one in three hospital patients are being harmed by their care right now in hospitals around the country. So as we look back over the last 12 years, we can say two things: we have made some progress, but it’s not nearly enough.

Let me put it in even stronger terms. If we only improve care as much in the next decade as we have in the last, we are failing the American public. The good news is that bigger and faster improvements are well within our reach. Not only do hospitals that want to improve care today have more examples to follow, they also have access to better research on quality and better metrics for measuring that quality.

Even more important, there’s a growing urgency behind improving care. Medicare alone is expected to rise, in terms of cost of Medicare, 91 percent over the next decade. Let me say that again. The costs of Medi-

Suggested Citation:"Keynote Presentation--The Honorable Kathleen G. Sebelius, Secretary, U.S. Department of Health and Human Services." Institute of Medicine. 2011. The Richard and Hinda Rosenthal Lecture 2011: New Frontiers in Patient Safety. Washington, DC: The National Academies Press. doi: 10.17226/13217.
×

care are on a trend to rise 91 percent over the next decade, unless we do something about that cost trajectory. Families and businesses are expected to see similar increases.

Now, people are realizing that we’ll be forced to slow health care spending somehow and we really only have two choices. We can spend less overall on health care and just cut benefits, or we can provide better care and lower the cost that way. If we want to improve the care, we’re already behind the curve, so we have got to start now.

Now, I saw this urgency last month when the administration helped launch a new patient safety coalition we call, as Harvey told you, “The Partnership for Patients.” We recruited doctors, nurses, pharmacists, hospital leaders, health plans, employers, patient advocates, and patients themselves to work with us on achieving two ambitious goals for the next three years.

We want to reduce preventable injuries in hospitals by 40 percent. We want to reduce hospital readmissions by 20 percent by targeting those that should have never happened in the first place. Today, I am proud to say that within a short period of time after launching this exciting new initiative, we have 2,500 partners who have already signed on, including more than 1,200 hospitals around the country.

What really sets this partnership apart from previous efforts is how eager they were to join. There was no negotiating or arm twisting. When we reached out, the typical response was, “Where can we sign up? How can we be part of this effort?”

If we’re going to bring excellence to scale in our health system, we need all of those partners to play a part. But we know that government has a particularly important role to play. When it came to eliminating the central line ICU infections, for example, many hospitals only got serious when Medicare added them to the no-pay list.

But for far too long, that kind of leadership from Medicare was an exception. I’ve talked to lots of employers, and frankly lots of hospital administrators over the years, who felt that when it came to improving care, Medicare was actually dragging behind what private employers and others were trying to do. We knew that needed to change.

So the first thing we did was to encourage the President, who was eager to find the best possible talent, to nominate Don Berwick, who helped write the IOM report and who I met in the mid-1990s when we served together on the Clinton Commission on Patient Quality and Patient Care, to come to head the Centers for Medicare and Medicaid Services and work with Carolyn Clancy and our other leaders to figure out

Suggested Citation:"Keynote Presentation--The Honorable Kathleen G. Sebelius, Secretary, U.S. Department of Health and Human Services." Institute of Medicine. 2011. The Richard and Hinda Rosenthal Lecture 2011: New Frontiers in Patient Safety. Washington, DC: The National Academies Press. doi: 10.17226/13217.
×

how we can use the world’s biggest insurance company to help leverage the kind of changes we need to see in the system.

Next, we started putting the unprecedented tools and resources we got in the Affordable Care Act to work. For example, we have a billion dollars to back up this new initiative on these two ambitious goals; to support local efforts, to do technical outreach, to do training, and help leading hospitals spread their efforts and take them to the next level.

We also recently launched an initiative that ties payments to quality for 3,500 hospitals across the country beginning in 2012. Over time, even more money will be paid out on the basis of quality, creating powerful incentives for improvement. Medicare will no longer be pay-for-volume, it will be a pay-for-value program, and that’s a huge change in the financing system.

Referring to some of these changes, one Georgia hospital CEO said recently, “It’s not just a good thing to do quality. It’s going to be a necessary thing to do quality.” We hope his attitude is understood across the country.

We have also provided some guidance to help doctors and hospitals form accountable care organizations, where they will be able to share the savings if they keep their patients healthy in the first place. We’ve established a new Innovation Center in Medicare and Medicaid that will test new approaches for improving care. The best hospitals have already adopted philosophies of continuous improvement.

With the Innovation Center, we’re setting the same goals in Medicare and Medicaid, again unprecedented. By preventing injuries and the unnecessary care that goes with them, the reform frees up critical resources. We estimate that with the Partnership for Patients alone, we can reduce costs by a minimum of $50 billion in Medicare over the next decade. And those reforms will have a bigger impact when they’re adopted and implemented by other payers, creating powerful incentives for improving health care across the entire system.

So my pledge to you today is that we want to continue to be active partners in improving care, but ultimately, the transformation happens one hospital and one health system and one community at a time. We can provide support, we can establish incentives, but you are the ones who have to do the hard work of putting better systems into practice.

Now, many of you in this room are already national leaders in the effort, but today I want to ask you to go even further. Shortly after I was sworn in, I got a letter from a woman in Maine. Her father had gone to the hospital with a fractured ankle and a mild urinary tract infection, and

Suggested Citation:"Keynote Presentation--The Honorable Kathleen G. Sebelius, Secretary, U.S. Department of Health and Human Services." Institute of Medicine. 2011. The Richard and Hinda Rosenthal Lecture 2011: New Frontiers in Patient Safety. Washington, DC: The National Academies Press. doi: 10.17226/13217.
×

while he was there, he was infected with MRSA (methicillin-resistant Staphylococcus aureus) and pneumonia. A day-and-a-half after he came home, he collapsed and never walked again. He lost 50 pounds and eventually got so weak he couldn’t sip water through a straw. A few months later, he was dead.

And if you asked his daughter what an acceptable rate of preventable injuries was, she would say zero, and she would be right. If you asked any of us what rate of injury we would accept for our own parents or our children or our spouses, we’d give the same answer. And that needs to be our goal. We must do no harm and harm no patient. It should not be reducing by 20 percent or 30 percent or 50 percent or 70 percent. It should be the goal of taking harm rates to zero.

We have to strive to reduce all types of harm, including harm to those who provide care. Today, a nurse in Maine is more likely to miss a day of work because of an injury than a logger is in Maine. So that’s an area that also needs more of our attention. In its 1999 report, the IOM sought to, and I quote, “break the cycle of inaction.” Today, we’ve broken that cycle.

We are moving forward, but we’re not going nearly fast enough. Every day, new treatments and therapies are introduced, bringing benefits for patients but also adding more to the complexity that breeds medical errors. If we want a safer health care system, we need to speed up the rate of improvement, and we need the leaders in this room to actually continue to lead the way.

I want to thank you for the hard work that you all have done so far, and for your courageous leadership over the past 12 years. We wouldn’t have gotten where we are today without the work that’s been done across the country. But we need to cross that next frontier, to commit ourselves to the goal of elimination of harm and complication. That, once again, lies in your hands.

We are poised to take a great leap toward the day when every American who walks into the doctor’s office or hospital receives the right care at the right time. I look forward to working with you as a great partner to make that happen. Thank you so much.

DR. FINEBERG: Secretary Sebelius, I just want you to know how much we value and appreciate your words, your inspirational goals, and your encouragement, and I want to assure you that we will do our best, every one of us, to work with you and to achieve those goals for America and for the American people. Thank you very much. Thank you very much, Secretary.

Suggested Citation:"Keynote Presentation--The Honorable Kathleen G. Sebelius, Secretary, U.S. Department of Health and Human Services." Institute of Medicine. 2011. The Richard and Hinda Rosenthal Lecture 2011: New Frontiers in Patient Safety. Washington, DC: The National Academies Press. doi: 10.17226/13217.
×
Page 3
Suggested Citation:"Keynote Presentation--The Honorable Kathleen G. Sebelius, Secretary, U.S. Department of Health and Human Services." Institute of Medicine. 2011. The Richard and Hinda Rosenthal Lecture 2011: New Frontiers in Patient Safety. Washington, DC: The National Academies Press. doi: 10.17226/13217.
×
Page 4
Suggested Citation:"Keynote Presentation--The Honorable Kathleen G. Sebelius, Secretary, U.S. Department of Health and Human Services." Institute of Medicine. 2011. The Richard and Hinda Rosenthal Lecture 2011: New Frontiers in Patient Safety. Washington, DC: The National Academies Press. doi: 10.17226/13217.
×
Page 5
Suggested Citation:"Keynote Presentation--The Honorable Kathleen G. Sebelius, Secretary, U.S. Department of Health and Human Services." Institute of Medicine. 2011. The Richard and Hinda Rosenthal Lecture 2011: New Frontiers in Patient Safety. Washington, DC: The National Academies Press. doi: 10.17226/13217.
×
Page 6
Suggested Citation:"Keynote Presentation--The Honorable Kathleen G. Sebelius, Secretary, U.S. Department of Health and Human Services." Institute of Medicine. 2011. The Richard and Hinda Rosenthal Lecture 2011: New Frontiers in Patient Safety. Washington, DC: The National Academies Press. doi: 10.17226/13217.
×
Page 7
Suggested Citation:"Keynote Presentation--The Honorable Kathleen G. Sebelius, Secretary, U.S. Department of Health and Human Services." Institute of Medicine. 2011. The Richard and Hinda Rosenthal Lecture 2011: New Frontiers in Patient Safety. Washington, DC: The National Academies Press. doi: 10.17226/13217.
×
Page 8
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More than 10 years ago, the IOM released its landmark report on patient safety, To Err is Human: Building a Safer Health System. The 2011 Rosenthal Lecture featured the Honorable Kathleen G. Sebelius, Secretary of the U.S. Department of Health and Human Services, who presented the new steps that HHS is taking to improve patient safety. A panel of leaders in patient safety followed to discuss patient safety progress and opportunities.

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