Testimony of Foundation for Accountability Before the Hearing on
My name is Dan Perry. I serve as Chairman of the Board of Trustees of the Foundation for Accountability, commonly known as FACCT. FACCT is a four-year old non-profit organization dedicated to helping Americans have reliable information they can use to make better health care decisions. FACCT was created by and continues to be governed by large health care purchasers and consumer organizations. Our Trustees include private sector leaders such as General Motors, AT&T, AARP, the National Coalition for Cancer Survivorship, and the National Alliance for the Mentally Ill as well as public purchasers such as the Federal Employee Health Benefit Program, the Health Care Financing Administration, and several state governments. In my professional life, I also serve as Executive Director of the Alliance for Aging Research here in Washington. Safe health care is the first concern of every patient, and must be recognized as a vital public interest. We applaud the work of the Institute of Medicine and the interested Congressional panels in raising public awareness about the unacceptably high rates of medical errors in our health system. And we are pleased that so many health care leaders have come forward to acknowledge the seriousness of the issue and the need for corrective actions. But we are not confident that the health professions and leading health care institutions are capable of correcting these problems without external pressure - pressure provided by every individual patient and by the public’s collective expectation of improved care. The leaders of U.S. health care – clinical directors, organization executives, policy researchers - have been aware of high medical error rates since at least 1991, but cultural, structural and economic barriers have impeded internally generated solutions. In particular, FACCT believes that the culture of secrecy that has shielded health care performance from public view must be challenged if patient safety is to be improved. The Foundation for Accountability has developed and applied various measures of the quality performance of our health care system. Much of our own work has focused on the quality of care for chronic illnesses and for children’s health. Wherever we look – at health plans, medical groups, integrated health systems – we find inconsistent and inadequate care being delivered to too many people. We also find a general unwillingness to share quality information with the public, and a discomfort with the basic premises of public accountability – that health professionals and organizations must disclose how they're doing. In the managed care industry, for example, only about 50% of eligible HMOs report the industry standard quality measures to the national accrediting body – and one-third of those refuse to make their data public. The nation’s PPOs have been unwilling to collect or publish any quality information. In a recent California initiative to capture simple patient satisfaction data from hospital patients – fully funded by a foundation – only about half of the hospitals were willing to have their patients surveyed. Today, only about one-third of US hospitals have installed computerized medication order systems – and only one per cent require their doctors to use those systems! At the same time, our research and others’ confirms that safe medical care is a central concern of most Americans. A recent survey by the American Society of Health System Pharmacists revealed that 61% were very concerned about being given the wrong medication in the hospital. The AMA found that 42% of Americans believe that they or a family member or friend has been the victim of a medical error. A 1996 AHCPR survey reported that 86% of Americans want information about the quality of their doctor and 83% would like information about the quality of their hospital. Certainly each of us is deeply concerned about quality and wants to have information that would enable us to make good decisions for ourselves and our families. Yet the leading health care organizations often resist most such initiatives. The risk of public embarrassment, the difficulty of creating effective management systems in our highly fragmented health care world, and the cost and uncertainty of investing in computer technology prevent even the best intentions of so many health care professionals from achieving meaningful changes. In considering the tragic proportions of our patient safety problems, Congress should not labor under the presumption that skilled and concerned professionals will suddenly solve problems that have been well-known for many years – particularly when market pressures offer little reward for a commitment to quality care. Louis Brandeis argued – eighty-seven years ago – that "publicity is justly commended as a remedy for social and industrial diseases. Sunlight is said to be the best of disinfectants." The Institute of Medicine bravely embraced this principle in its Recommendation 5.1, favoring a "nationwide, mandatory reporting system … about adverse events that result in death or serious harm." The IOM further stated that "the results of analyses of individual reports should be available to the public," (p. 75) and that "the public also has the right to be informed about unsafe conditions. Requests by providers for confidentiality and protection from liability seem inappropriate in this context." (p. 88) Public disclosure of quality of care problems is important for two reasons – one ethical, one structural.
Our failure to honor these two principles contributes to the persistent alienation of the public from health policy and the continued difficulty the nation faces in improving the performance of its health system. Medical ethics dictates that doctors have a duty to disclose errors to patients and relatives, regardless of liability concerns. Similarly, we should view the advance disclosure of risks, including the risks of error, as an intrinsic part of informed consent. The IOM and others have estimated that on the order of 3-4% of all hospital admissions involve some kind of avoidable error. For a mid-sized community hospital serving 20,000 admissions per year, that represents as many as 800 cases in a year, enough to constitute a measurable index of quality. In states such as Connecticut, mandatory reporting systems have produced as many as 14,000 reports per year in the nursing home system alone – so we know that mandatory reporting can work. Shouldn’t a patient facing a vital health care decision – selecting a hospital for surgery or choosing a nursing home for an ailing parent – be able to factor in the facility’s safety record when making that decision? If any person or agency knows, based on reliable methods, that one hospital or nursing home provides safer care than another, that information should be disclosed to a prospective patient. While we have a moral responsibility to let patients and families know about the risks they may face when entering a health care facility, we should also recognize that the health system will not become accountable until information on institutional performance is public. Entrenched cultural, technical, and management systems permit unsafe systems to prosper and escape scrutiny. So long as health care organizations face no economic consequences or risk of public embarrassment when they fail to address safety problems, they will continue to put safety at the bottom of the priority list. As the Philadelphia Inquirer recently editorialized, "if the counteroffensive against medical mistakes is shrouded in secrecy – as the error rate still is today – that will limit the pressure on hospitals to improve. There’s little doubt that public disclosure increases an institution’s sense of urgency and accountability about a problem… Congress needs to make sure the medical establishment comes clean." [1/25/2000] Finally, the avoidance of public accountability for medical error has damaging, if subtle, consequences for our society. By treating error rates as protected information subject only to professional review and action, we perpetuate the false notion that patients should be passive users of a system that possesses adequate management and professional controls to assure their safety. Patients remain unable to make good decisions, to make trade-offs between various dimensions of risk, benefit, and cost, and they remain unable to exert any pressure on the health system to change. Our health system is insulated from public scrutiny or constructive incentives. No one – doctors, hospitals, HMOs - is recognized or rewarded for achieving better results or providing safer care. Consumers have no useful information to guide them to providers who are likely to give them better care. In the absence of quality information, corporations and consumers continue to favor providers that are cheaper or more convenient, even though we know incredible variations in quality persist. Our personal and collective health is threatened by a system that fails to monitor and disclose its own performance and fails to respond to public concerns. Our health system will not materially improve until the public demands high quality care and evidence that it’s being delivered. Congress should act on the IOM recommendations and establish a mandatory national reporting system for medical error, and ensure that understandable, relevant information about patient safety is available to every American consumer. Back to Witness List |