[Senate Hearing 112-554]
[From the U.S. Government Publishing Office]
S. Hrg. 112-554
NEXT STEPS FOR PATIENT SAFETY: ASSURING HIGH VALUE HEALTH CARE ACROSS
ALL SITES OF CARE
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FIELD HEARING
BEFORE THE
SPECIAL COMMITTEE ON AGING
UNITED STATES SENATE
ONE HUNDRED TWELFTH CONGRESS
SECOND SESSION
__________
HARTFORD, CT
__________
JULY 2, 2012
__________
Serial No. 112-19
Printed for the use of the Special Committee on Aging
Available via the World Wide Web: http://www.fdsys.gov
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SPECIAL COMMITTEE ON AGING
HERB KOHL, Wisconsin, Chairman
RON WYDEN, Oregon BOB CORKER, Tennessee
BILL NELSON, Florida SUSAN COLLINS, Maine
BOB CASEY, Pennsylvania ORRIN HATCH, Utah
CLAIRE McCASKILL, Missouri MARK KIRK III, Illinois
SHELDON WHITEHOUSE, Rhode Island DEAN HELLER, Nevada
MARK UDALL, Colorado JERRY MORAN, Kansas
MICHAEL BENNET, Colorado RONALD H. JOHNSON, Wisconsin
KIRSTEN GILLIBRAND, New York RICHARD SHELBY, Alabama
JOE MANCHIN III, West Virginia LINDSEY GRAHAM, South Carolina
RICHARD BLUMENTHAL, Connecticut SAXBY CHAMBLISS, Georgia
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Chad Metzler, Majority Staff Director
Michael Bassett, Ranking Member Staff Director
CONTENTS
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Page
Opening Statement of Senator Richard Blumenthal.................. 1
PANEL OF WITNESSES
Statement of Alice Bonner, Director, Division of Nursing Homes,
Survey and Certification Group, Centers for Medicare & Medicaid
Services, U.S. Department of Health and Human Services,
Baltimore, MD.................................................. 3
Statement of Jean Rexford, Executive Director, Connecticut Center
for Patient Safety, Redding, CT................................ 14
Statement of David Blumenthal, Chief Health Information and
Innovation Officer, Partners HealthCare System, Boston, MA..... 17
Statement of Susan Davis, Chief Executive Officer, St. Vincent's
Medical Center, Bridgeport, CT................................. 22
Statement of Jamesina Henderson, Chief Executive Officer,
Cornell-Scott Hill Health Center, Hartford, CT................. 25
Statement of Scott Ellner, Director of Surgical Quality, Saint
Francis Hospital and Medical Center, Hartford, CT.............. 28
APPENDIX
Witness Statements for the Record
Alice Bonner, PhD, RN, Director, Division of Nursing Homes,
Survey and Certification Group, Centers for Medicare & Medicaid
Services, U.S. Department of Health and Human Services,
Baltimore, MD.................................................. 38
Jean Rexford, Executive Director, Connecticut Center for Patient
Safety, Redding, CT............................................ 51
David Blumenthal, MD, MPP, Chief Health Information and
Innovation Officer, Partners HealthCare System, Boston, MA..... 54
Susan Davis, Chief Executive Officer, St. Vincent's Medical
Center, Bridgeport, CT......................................... 60
Jamesina Henderson, Chief Executive Officer, Cornell-Scott Hill
Health Center, Hartford, CT.................................... 64
Scott Ellner, Director of Surgical Quality, Saint Francis
Hospital and Medical Center, Hartford, CT...................... 68
Additional Statements Submitted for the Record
American Society of Consultant Pharmacists, Alexandria, VA....... 70
Gail R. Simon, East Haven, CT.................................... 81
NEXT STEPS FOR PATIENT SAFETY: ASSURING HIGH VALUE HEALTH CARE ACROSS
ALL SITES OF CARE
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MONDAY, JULY 2, 2012
U.S. Senate,
Special Committee on Aging,
Hartford, CT.
The Committee met, pursuant to notice, at 1:06 p.m. in the
Legislative Office Building, 300 Capitol Ave., Hon. Richard
Blumenthal, presiding.
Present: Senator Blumenthal [presiding].
OPENING STATEMENT OF SENATOR RICHARD BLUMENTHAL
Senator Blumenthal. Good afternoon. I have the great
pleasure and honor of convening this special field hearing of
the Committee on Aging, and I want to welcome everyone here,
all of the advocates, the experts, the citizens and elected
officials. I see one here, Senator Edith Prague. Thank you for
being with us today.
[Applause.]
Certainly one of the experts, advocates, and great citizens
of our state on this issue and so many others.
We are going to begin with a video that the Hamilton family
very, very graciously has helped us put together, and then I'll
make an opening statement. We're then going to ask Alice Bonner
of the Department of Health and Human Services to speak to us,
and then take a second panel consisting of some experts whom I
will introduce at the time.
So why don't we begin with the video?
[Videotape played.]
I thank the Hamilton family again for sharing that story
with us. Anybody who knows about T. Stewart Hamilton knows that
his granddaughter was actually quite modest about his
achievements and his stature in the community. For many, many
years he was well known as a leader in the profession and an
advocate for better health care in all of Connecticut, as well
as an administrator at the Hartford Hospital, and I want to
thank his family for so graciously sharing the story of their
grandfather, T. Stewart Hamilton, who leaves a legacy and a
story. I think he would have supported and approved of what
we're going to do and what we're going to hear today.
I want to thank Alice Bonner for making the trip, as well
as my brother, David Blumenthal, who are from outside of
Connecticut. But the reason for having this hearing in
Connecticut is that our hospitals and our providers really have
been at the forefront of caring about this issue of patient
safety. As you'll hear from Susan Davis and others, our
hospitals and our providers have made patient safety a
priority. So I can think of no better place to have this
hearing, and I'm very proud to do it here.
At the same time, one of the reasons we're doing it here
and one of the reasons that Connecticut hospitals and providers
and doctors have been so foresighted and vigorous in this
effort is that we have so far to go. We have a lot of work to
do. Some of the statistics nationally are absolutely
staggering.
Today, an estimated 100,000 people die every year from
hospital-acquired infections, at an estimated cost of $28.4 to
$45 billion. That's billion, with a B. Medication errors alone
harm an estimated 1.5 million people every single year, costing
$3.5 billion in extra medical expenses. One in four seniors
will be discharged to a nursing home and then readmitted to a
hospital within 30 days, costing Medicare more than $4 billion
every year, and 50 percent of all those readmissions are
avoidable. The costs can be saved.
The Office of the Inspector General of the U.S. Department
of Health and Human Services found in 2010 that one in seven
Medicare patients are injured during hospital stays. One in
seven Medicare patients nationwide are injured in hospital
stays. That's a staggering number. An average of one in five
Americans, 22 percent, report that they or a family member have
experienced a medical error of some kind.
When we're talking about patient safety, we're talking
about a problem that affects every family, literally every
person in Connecticut and the country, and the work ahead
should have the kind of priority that Connecticut providers and
hospitals are giving it. Those kinds of numbers do not capture
what you've just seen about a single man, a single person, a
family that bears the burden and the grief and struggle of
patient safety problems.
It really isn't about numbers; it's personal. It's not only
about statistics. It's individual lives lost and suffering
created. It was personal to T. Stewart Hamilton's
granddaughter, as you've seen, who was brave enough to share
her story. It was personal to Lorraine Purowski of South
Windsor, whose husband underwent successful surgery for cancer,
only to later pass away from an infection acquired afterwards.
He had successful surgery for cancer. He passed away from the
hospital-acquired infection afterwards. And it was personal to
Marilyn Jasmine, an insulin-dependent diabetic who acquired a
treatable infection after surgery, but the nursing home
misplaced doctor's orders for antibiotics. She lives with the
consequences of an infection that spread out of control before
the mistake was realized, and she was severely hurt as a
result.
We all have a stake in this problem. The Affordable Care
Act and the HITECH Act are two measures designed to help
address these issues, and the witnesses today who will have
speak to us can speak not only to the problem but also to the
solutions, because there are things we can do that will make a
difference.
Every single hospital in the State of Connecticut is now
part of an initiative begun by the Administration in April
called the Partnership for Patients, which commits to dramatic
reductions in hospital infections and readmissions. They
believe that the Partnership's efforts alone will save 60,000
lives and 10 billion in Medicare dollars in the next three
years, and more than 50 million Medicare dollars over the next
10 years.
So these problems, those savings of 50 billion--not 50
million--50 billion Medicare dollars are achievable. The kinds
of efforts that we can document in this state that we can
achieve can be a model for the country. Again I want to thank
the experts who are here today to talk about them, beginning
with Alice Bonner, who is Director of Survey and Certification
for Nursing Homes at the Center for Medical and Medicaid
Services. She will open our discussion on an area that is
particularly relevant to our Baby Boomers. She has a background
in this area, a distinguished resume, and a background
including expert work in many of the areas that are relevant
here.
Her work now is to oversee certification and review of all
Medicare-participating nursing homes in the United States. She
has also been a geriatric nurse practitioner for the past 20
years, and she has focused her research efforts on both nursing
home quality and development of patient safety culture in
health care organizations.
Thank you very much for being with us.
[Applause.]
STATEMENT OF ALICE BONNER, DIRECTOR, DIVISION OF NURSING HOMES,
SURVEY AND CERTIFICATION GROUP, CENTERS FOR MEDICARE & MEDICAID
SERVICES, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES,
BALTIMORE, MD
Ms. Bonner. I brought with me some photos that are 30 years
old, from when I was a nursing assistant, which is how I got
started working in nursing homes. So when you say it's
personal, even though I'm representing CMS today, I want you to
know that this is very personal for me as well in my 30-year
journey in nursing and nursing homes.
So thank you, Senator Blumenthal, for the opportunity to
appear today to discuss CMS' efforts to improve patient safety
in nursing home residents. Nursing homes play an important role
in health care today. More than 3 million Americans rely on
services provided by nursing homes at some point during the
year, and 1.4 million Americans reside in the nation's 15,800
nursing homes on any given day. Those individuals and an even
larger number of their families and friends must be able to
count on nursing homes to provide safe, reliable, high-quality
care.
To ensure that nursing homes meet both Federal and state
standards, CMS conducts initial and ongoing inspections of all
facilities participating in the Medicare and Medicaid programs.
The survey and certification process plays a critical role in
ensuring basic levels of quality and safety for Medicare and
Medicaid beneficiaries by monitoring nursing home compliance
with Federal and state requirements.
Within the survey and certification group, the Division of
Nursing Homes focuses on optimizing the health, safety, and
quality of life for people living in nursing homes through
close collaboration with other divisions as well, and over
5,000 Federal and state surveyors conduct on-site surveys of
certified nursing homes each year to assure basic levels of
quality and safety for beneficiaries.
So prior to becoming the Director of the Division of
Nursing Homes, I did work as a nurse practitioner in clinical
practice in the State of Massachusetts for 20 years, and I'm
very well aware of the importance of interdisciplinary
partnerships in nursing home care where safe, reliable care
depends on these close collaborations among nurses, nursing
assistants, physicians, therapists, pharmacists, really the
entire interdisciplinary team, most importantly the residents
and families at the center of that care.
I've also seen firsthand the importance of balancing safety
with autonomy and choice, and an ability for residents to
really have a say in their daily routines and basic human
rights.
So CMS encourages facilities to examine their
organizations' values and structures and practices so that, as
a nation, we can transform these very institutional settings
that they've been for so long into person-centered environments
where individuals are really recognized and respected. We know
that that will improve the resident's and family's experience
of care, and may also reduce staff turnover and improve care
practices as well.
So today I'd like to highlight some recent specific
activities that CMS has undertaken to improve quality and
safety for nursing home residents in the areas of dementia care
and anti-psychotic medication use, managing fall risk, nursing
home oversight of special focus facilities, quality assurance
and performance improvement, and care transitions.
So in terms of dementia care and anti-psychotic use, CMS
has implemented substantial improvements to the survey and
certification process to help address concerns about over-
utilization of anti-psychotic medications. CMS revised
guidelines in 2006 clarifying a number of aspects of medication
management and emphasizing that residents have the right to be
free from being prescribed unnecessary medications.
Current work on surveyor training focuses survey teams on a
number of key processes, including the requirement that
providers must try non-pharmacologic interventions first in
order to manage behaviors before using medications to address
them.
On May 30th, CMS announced the CMS National Partnership to
Improve Dementia Care: Rethink, Reconnect, Restore. So rethink
means rethinking how we approach dementia residents in nursing
homes; reconnect means connecting with them as an individual,
as a person, so you know enough about them to prevent some of
these behaviors; and restore means restoring quality of life.
This initiative includes raising public awareness,
strengthening regulatory oversight, providing technical
assistance and training to nursing homes and prescribers,
improving public reporting to increase transparency, and
conducting research. And we've set a national goal to reduce
the use of anti-psychotic medications in long-stay residents
with dementia by 15 percent by the end of December 2012.
In terms of managing fall risk, CMS is attempting to reduce
the number of injurious falls sustained by nursing home
residents. A new quality measure on nursing homes this summer
will report the percentage of falls with serious injury in
nursing home residents by facility. These data will enable
professional associations, culture change coalitions, quality
improvement organizations and others to target technical
assistance and fall risk reduction in these facilities, so
tailoring those programs to see what the problems are related
to falls, which is a multi-factorial problem. And surveyors
will review resident falls and will continue to enforce
requirements for safety around accidents and supervision.
In terms of nursing home oversight of special focus
facilities, CMS created the special focus facility program in
1998, and it was part of the Nursing Home Oversight and
Improvement Program under the Clinton Administration. The
purpose of the SFF program is to decrease the number of
persistently poor performing nursing homes by directing more
attention to nursing homes with a record of poor survey
performance. Through collaboration with the states, CMS is
working to continually improve the SFF program, and
improvements since 2004 include increasing the number of
facilities that are on the program, providing more data to the
states so they can target the facilities to come into the
program, and posting data on Nursing Home Compare so that
consumers have information about which facilities are special
focus facilities.
In terms of quality assurance and performance improvement,
another initiative under the Affordable Care Act, the
Affordable Care Act directed CMS to mobilize best practices in
nursing home quality and to identify technical assistance to
enhance nursing home quality and performance using a systems
approach. CMS is currently working to roll out a new national
initiative that includes development of QAPI standards and
technical assistance that will enable facilities to implement
those standards. QAPI tools, resources and technical
assistance, including an interactive website, are currently
being tested in a demonstration project and will be available
to all nursing homes later this summer. A new QAPI regulation
will enable the surveyors to then go and see if the nursing
homes are implementing their QAPI plan, whether it's adequate
protection for patient safety.
And finally, in terms of care transitions, currently
transitions in care from one setting to another are very often
fragmented. So someone in the hospital sending a resident to
the nursing home doesn't necessarily transfer the information
that the nursing home needs to take care of that person; and
similarly, somebody going back to the hospital from the nursing
home, the hospital emergency department doesn't always get the
information that they need to really care for that person.
So in terms of this lack of communication, it's certainly
responsible for medication errors and other adverse events, and
as you mentioned, the unnecessary re-hospitalizations that we
see.
So the survey and certification group is currently revising
our guidelines and regulatory requirements for resident
transfers so that we can better focus on what is the
information that we need, and working with the Office of the
National Coordinator so that the elements of data that we
really require are being looked at, and what nursing homes need
is part of that entire discussion. So the Division of Nursing
Homes is also working with its partners to develop new quality
measures that will track 30-day hospital readmissions on newly-
admitted nursing home residents.
So in conclusion, we appreciate the work of the committee
and the support in terms of improving quality and safety for
all of our individuals across the country in every health care
setting, but particularly the work that you're doing around
nursing homes. So, thank you very much.
Senator Blumenthal. Thank you for that statement. While I
was reading the prepared text last night, one of the thoughts
that occurred to me was whether, in the course of those site
visits, is there any kind of notice given before you actually
arrive there? What's the standard procedure?
Ms. Bonner. The standard procedure is that there is not
notice given. These are supposed to be visits where the
facility should be doing the same thing all the time for all
their residents to promote safety. It shouldn't make a
difference when the regulators come in.
However, it's important that these visits be unannounced.
So because they have to occur on a cycle--in other words,
they're annual visits--the facilities have some sense of what
they sometimes refer to as ``the window.'' So within a period
of months, they have a sense that the regulators are likely to
be coming. However, they're not supposed to be announced visits
because, again, we want facilities--and facilities and
providers are teaching, the associations are teaching their own
members that the care should be the same, the quality should be
the same all during the year.
Senator Blumenthal. And how many people go to visit each of
the sites?
Ms. Bonner. So the typical survey team--it's a team, and
there's a team leader, and there are three to four for an
average size facility, a 150-bed facility or so. A very small
facility, there might be two or three surveyors on the team.
But it's important, the way the survey works, some people go
and look at the kitchen, some people look at infection control,
some people look at the medication paths. So it does take a
team of people, and also they're looking to make sure they get
out on all of the different units, and then they come back and
compare notes.
So there's a period of time at the end where there's a
conference and people say, well, did you see a problem with
falls on your unit? And someone else says, yes, I saw that on
my unit. That leads them to sometimes expand the number of
cases they would look at. So it's very important to safety that
that team collaboration happens.
Senator Blumenthal. And the team's report then goes to
someone at CMS, or----
Ms. Bonner. It first goes back to the state survey agency,
and I know Barbara Cass is here today. She is the director of
the agency in Connecticut. So it would go back to the agency,
and some managers would review it, and that's where the
enforcement piece comes in, and I'm glad you mentioned that
because we really try to have enforcement be consistent and
credible across states and across the regions.
So the surveyors bring back what they saw and they discuss
it with their managers. If there's still a question, then
sometimes it gets referred to the regional offices, and then
ultimately to the central office where we are if it's a policy
question or a particularly complex case, which they very often
are.
Senator Blumenthal. Is it always a state team, or does it
have state representation for these 5,000 site visits, which is
a lot of visits?
Ms. Bonner. So we contract with every state, and every
state does have a survey agency. And then the Federal surveyors
are required, under the statute, to go in and do a sample as an
oversight, as a quality assurance, if you will, measure. So the
Federal regions will send in surveyors to do a 5 percent
sample, and they go in a few weeks after the state surveyors
and they repeat the survey to see if the findings are the same,
if they determine any problems, any areas for retraining with
the state.
And there's also an observational survey which is done. So
that's where the Federal surveyors go with the state surveyors
and actually see them interacting. How do they do the
interviews? How do they do the observations? So that serves to
really do just-in-time teaching with those surveyors, whereas
with the comparative, there's a little bit more of how is the
state survey agency doing overall and are there any issues. So
it's our own quality improvement.
I would like to mention that CMS has been working for the
last 7 to 10 years on a computer-assisted, data-driven model
called the Quality Indicator Survey. So in about half of our
states now, the surveyors have laptops that they take with
them. So if they're interviewing a physician or they're
interviewing a resident, they're entering data. The algorithms
in the computer help to drive the surveyors to the areas that
may be the most problematic and target that so the surveys can
be more efficient and effective.
So this new computer system also generates reports. So if
Barbara, who is here in a state where they do the quality
indicator survey, wanted to know information about one of her
survey teams or one of her surveyors--are they citing enough,
are they an outlier--with this new program, we can do it. We
were not able to do it nearly as well with the traditional
survey.
So this program really needs continued development, but
we've had several years now of study, and we're learning more
about it all the time. We think it's extremely valuable in
improving the survey process.
Senator Blumenthal. Who makes the enforcement judgments
based on the data that you collect through the survey? Is that
done in Washington, or is it done at the state level?
Ms. Bonner. It's done at the state level. When there are
the most egregious deficiencies cited, immediate jeopardy and
serious harm, very often those will go to the regional offices
for discussion. And then, again, the regional office, because
they are overseeing several states, four or five states, can
really try to make sure that those decisions are consistent.
There is a grid that is used for things like civil money
penalties and what we call scope and severity, how many people
were affected and how severe was this problem.
So we continue to try to make those systems more reliable
and implemented more reliably throughout all the states and the
regions.
Senator Blumenthal. If there are problems indicated at a
particular nursing home, do you accelerate the re-review or the
re-survey, the visits in that case?
Ms. Bonner. That definitely can happen. Also, if it's
particularly--if it continues to happen in a facility, that
will probably drive the data to have that facility on a list
for potentially getting into the special focus facility program
that I mentioned. So either the surveyors can certainly make
the decision to go back sooner.
We also work very closely with the ombudsman, and the
ombudsman can go into the facility quite often, and that's
another set of eyes and ears. So we have really stepped up our
partnership with the ombudsman program because with safety, the
more sets of eyes that you have on the problem, the better.
So the ombudsman can go in. The state survey agency
absolutely can go back in sooner, and they do that when there's
the most egregious situation. They sometimes will not leave the
facility if they really believe that people are at risk. The
surveyors will call their managers and say that they want to
stay there until the situation is resolved.
Senator Blumenthal. And what is the most serious
enforcement efforts that you can take, and has the level of
enforcement increased in severity and frequency?
Ms. Bonner. The most significant enforcement remedy that we
have is termination from the Medicare and Medicaid program. We
also have civil money penalties. So those are fines, and we can
give those on either a per-day or per-instance basis. So we can
fine up to a certain amount per day for the most serious
infractions. We can also say that there is a denial of payment
for new admissions, and sometimes that's even more effective
with facilities because if you are not going to be able to be
paid by Medicare and Medicaid for any new admissions, it means
you're not going to take any new admissions in most cases.
Senator Blumenthal. And how often have you used each of
those remedies?
Ms. Bonner. We have some data on that, and I don't have
those numbers but I can work with you and your staff to let you
know what those are.
Senator Blumenthal. That would be helpful, if you could.
Ms. Bonner. Absolutely.
Senator Blumenthal. You know, I imagine the argument for
the push-back given to you is if you deprive us of resources,
it's just going to diminish the level of care. As attorney
general, I found that argument given frequently when funding
cutoffs or reductions in funding were suggested. You must find
it as well.
Ms. Bonner. Right, and also we have a very clear role in
survey and certification, which is enforcement. We have
regulations and requirements for participation, and that's what
we do. But that doesn't prevent us from partnering with and
networking with the quality improvement organizations, the
culture change coalitions and other entities, even the
professional associations, because they can do good quality
improvement work that will deter. You know, if they build
better systems, the enforcement, if it's effective, will
promote nursing homes to want to do more quality improvement
work, and those other agencies can do that with them.
Senator Blumenthal. You know, you have talked about in your
testimony various areas, including consumer engagement and four
others that are very, very important, including enforcement. I
wonder if you feel that there ought to be more authority,
legislative authority from the Congress, to strengthen your
ability either in enforcement or consumer engagement or any of
those other areas that you mentioned in your testimony.
Ms. Bonner. I think that in the nursing home reform law,
there is quite a bit of authority. I think it is a combination
of using that authority effectively, and one of the most
important things that we can do to be able to do that is to
have Congress support the President's budget for survey and
certification. That appropriation allows us to do the training
and implementation and use experts such as you have assembled
here today, and so forth.
But it's really extremely important that Congress supports
the President's budget in 2013 for survey and certification.
Senator Blumenthal. Well, I'm glad that you made that
point. I should also say, because I've neglected it, that the
record of this hearing is going to be made available to all of
my colleagues on the Special Committee on Aging, and I hope
that they will be advocates for the resources that the
President is planning to request, because my guess is--more
than a guess--my feeling is that those resources may not be
completely adequate even themselves, knowing how the process
works, and I'm not going to ask you to comment on that point.
But I know that a lot of my colleagues share that feeling.
I want to focus on one area in particular, and I will take
up your invitation to follow up afterwards on some of these
other points. Anti-psychotic drugs, how are we doing in that
area? Obviously, they've been a problem. They still are a very
severe problem in many nursing homes, over-use of that kind of
medication. How are Connecticut and the rest of the country
doing in trying to combat misuse of anti-psychotic drugs?
Ms. Bonner. Well, we're fortunate right now that we have a
new initiative, the CMS National Partnership, to reduce anti-
psychotic use and improve dementia care. And through this
initiative, we've been able to work with people in all the
states, and one of the things that CMS has been doing is
contacting state by state anyone who is interested in this area
and anyone who is working on it.
So in Connecticut, you're very fortunate. You have some
people at Yale University--Dr. Mary Tinetti, Dr. Elsa Weickers
and others, as well as Qualidyne, the quality improvement
organization here. All of these are organizations and
individuals who have done specific work in this area.
So we've been reaching out to all of the states to find out
who is already doing work in this area so we can learn from the
best practices. We have identified at least 150 nursing homes
in this country that have reduced anti-psychotic use or
completely eliminated it, again over a period of years. It's
really changing culture, and I know you're going to hear more
about safety culture from the other panelists. But changing the
culture in a nursing home from one where people reach for a
medication when someone has a behavior like yelling or
wandering or kicking or anything like that, as opposed to a
person-centered approach, really changing that culture takes
some time.
But we are now aligned with all of these different agencies
throughout HHS. We're working with AHRQ that has a number of
programs I know people are aware of for prescriber education,
and we have SAMHSA and HRSA and other agencies that are also
working in this area.
So again, on these state calls, we've been impressed that
there is some work. There is a tremendous amount of work left
to do. The public reporting we believe is going to be very
helpful. We've been hearing from people around the country that
they want the data. So Connecticut wants to know what their
rate of use is so they know what kind of improvements they need
to make.
But the 15 percent reduction is a national number. So some
states may have a lot farther that they can go to be able to
reduce anti-psychotics, and other states are already doing a
better job. So we're sharing that information back to the
states, working with the state agencies, regional offices,
QIOs, individual researchers, and this really resonates with
people, there's no question. We've had folks who are nursing
home residents speak with us. We've had family members come and
be part of the precedents with CMS in Baltimore. So people are
really coming together around this initiative, and we have a
lot left to do.
Senator Blumenthal. I know that you're working on it, and
yet I was struck by some of the statistics in your testimony,
an increase of 12.6 percent to 14 percent of the facilities
with these kinds of problems. And 19.2 percent, I think, in
2011 and 2012 two out of five cognitive impairment and
behavioral, or I should say individuals who experienced
cognitive impairment and behavioral problems received anti-
psychotic drugs without any diagnosis of psychotic conditions,
and those are very recent numbers, I gather, from your
testimony. So there is really a need to address this issue, in
my view, much more aggressively, and I take it from your
testimony you agree.
Ms. Bonner. Absolutely, and I didn't mention what we're
doing on the surveyor side. So the survey guidance was updated
in 2006-2007, but as you know, clinical practice changes very
quickly, so we are looking at that again. We have some experts
who are pharmacists from across the country. By focusing the
surveyors on this on every survey, we've said to the surveyors
we expect that on every single survey, whether you think this
is a problem in a particular nursing home or not, that you will
be asking the nursing home administrator and the director of
nurses what are you doing to reduce anti-psychotic use in this
nursing home, how do you approach it.
By doing that, the surveyors will get a sense very quickly
of whether or not they are approaching dementia care with non-
pharmacologic approaches, individualized care. Does staff take
the time to get to know a resident? Do they figure out what
works for an individual and pass it along to others on other
shifts, and are the direct care workers really involved?
Because historically, again, the issue is we haven't considered
safety culture, and so we haven't made sure that nursing
assistants who know the residents best are at the care planning
meetings, and that families are involved in care planning
meetings. They get invited, but is there a real effort being
made to involve them, particularly when someone has dementia
and has these behaviors? Does someone say, you know, tell me
about your father?
If you were the patient, I would say to your family, tell
me about what was Senator Blumenthal most proud of? What did he
write about in the Yale Law Journal? And maybe they would bring
in some articles that you worked on or some cases. So I would
learn enough about you that you would start to trust me as a
caregiver and we would have a relationship. So on the days that
you were feeling anxious or upset about something, I would know
something to talk about with you that even if you didn't
remember what you had for lunch that day, you would probably
remember some of those things that are really hard wired.
Dementia care is like cracking a code sometimes. It's like
really getting to that one thing that will still work with
someone even when their brain is very diseased, and that's what
the facilities that have been successful have been able to do,
and they've really involved the direct care workers and the
rest of the team.
Senator Blumenthal. Well, I would be interested in that
list of 150, and especially if any of them are in Connecticut.
Maybe we can use them as models for what should be done
elsewhere. I agree that part of it is culture, but enforcement
against abuse or misuse also sends a signal about the
importance of changing culture and changing standards.
Preventable falls, maybe you could comment a little bit
about the work that's being done there, which I gather is not
unrelated to the overuse or misuse of anti-psychotic drugs.
Ms. Bonner. Right. When people are on high doses of anti-
psychotic drugs, obviously that's one of the many factors in
falls. So falls is a really complicated problem because it's
multi-factorial. There can be issues in the environment that
lead to falls. There can be medications, disease processes,
things like Parkinson's and diseases that affect balance,
vision, activities, all manner of things. So there are many,
many fall risk factors, and falls are one of the top
deficiencies that are cited by surveyors.
One of the things that we're doing that we think will be
important is through our public reporting and increased
transparency on Nursing Home Compare, we're going to be posting
this summer a new quality indicator, a quality measure. That
will be the percentage of residents who have sustained a fall
with a serious injury. We're not necessarily trying to prevent
everyone from every single fall. Some falls are not injurious,
and we don't want to tie people down, as we did in the past.
So this new measure of serious or injurious falls will
again allow a facility to look at their own data and use a
data-driven system to improve quality, and this is also what
we're teaching in the Quality Assurance and Performance
Improvement initiative. So through quality assurance
performance improvement we're developing a set of tools in
technical assistance that the QIOs can use, the professional
associations can use, and they will be available on a CMS
website in the next several months. So facilities will be able
to see, oh, here are some tools that we can use to reduce the
risk of falls in our facility, and then along with the public
reporting, it helps us because consumers go on Nursing Home
Compare and they see what's on the website. So if they're
considering a nursing home, now they have information.
So they can go to the nursing home administrator and say,
you know, I went on Nursing Home Compare and I saw that your
nursing home had a high rate of falls. Can you tell me about
that? And there might be an explanation in terms of the types
of residents that that nursing home takes, but it's a very good
question to ask a nursing home administrator. So it gets that
dialogue going.
So we're really trying to get consumers more involved,
nursing home residents more involved. I know Brian Capshaw is
here today. He's a nursing home resident in Connecticut. He's
done some work with us, and he's a good student of the
regulations and helps remind us about things very often. But in
terms of falls prevention, consumers being really well educated
and asking good questions is something that CMS very much is in
favor of.
Senator Blumenthal. And I gather the Quality Assurance and
Performance Improvement program is aimed at all of these
problems. It is also aimed at something that I think is also
very important: establishing a partnership with hospitals so as
to reduce premature discharges or readmissions that are so
expensive to CMS and to states.
Ms. Bonner. Right. Almost any clinical issue involves some
sort of care across that transition, whether it's a pressure
ulcer and someone is left on a stretcher for too long and it
gets worse, or an anti-psychotic that was prescribed in the
hospital and then is no longer needed but the information
doesn't get transferred, so the person is just continued on the
anti-psychotic in the nursing home, and all of these transfers
back and forth.
So absolutely, the QAPI program requires a plan on the part
of the skilled nursing facility, and it's got to be systemic.
It's got to address problems across every component of the
skilled nursing facility. It's not just about nursing. It's the
maintenance department and the housekeeping department and the
business office, across all of those areas, and it's also got
to make sure that the nursing home knows how to use data and is
managing with data, that leadership is involved, and that
projects--you know, small tests of change. So testing out a
project to see what--let's take fall prevention.
They might say, well, we've got a problem with falls. We've
looked at our data. Let's try one thing with just a few of our
staff on one of our units and see if we can reduce the falls on
that unit through some interventions. Maybe regular pharmacy
rounds of the medications would be an example that a number of
facilities have tried. And then they would look back and see if
there was improvement, and if there was, then they might expand
it to the rest of the facility.
But those systemic kinds of approaches in their plan is
what the QAPI program is about.
Senator Blumenthal. Among the nursing homes that have been
particularly active on anti-psychotic drugs or on preventable
falls, can you give us an idea whether any are in Connecticut?
That is, the good guys, so to speak, who have done really
pioneering work on these issues.
Ms. Bonner. There are definitely a number of homes in
Connecticut that have done pioneering work in a number of
areas, not only anti-psychotics and fall reduction. Again, with
Dr. Tinetti at Yale, and Dr. Baker also, and those programs
around Warfarin use. Warfarin is an anti-coagulant that leads
to bleeding and is a very high-risk drug. It's very often
associated with morbidity and mortality, and there are some
programs, some pilot programs in Connecticut that have looked
at how nurses in nursing homes monitor a high-risk drug like
Warfarin, and the principles were the same as monitoring
similar, an anti-psychotic high-risk drug as well. So there has
definitely been some very good work in Connecticut.
Senator Blumenthal. Well, I'd like you to give me a list of
them because I'm going to go visit them.
Ms. Bonner. I'm glad you want to go visit the good ones.
Senator Blumenthal. Well, I'm going to go visit some of the
bad ones as well.
But I really want to thank you for your being here today.
It really means a lot, and we have a lot of areas that I would
like to pursue with you. I think you may know my staff, Rachel
Pryor, who deserves credit for helping to put this hearing
together, and when we're all back in Washington I'd like to
make a point of getting together again and getting some of that
additional information.
We could spend a lot more time here but we have another
panel afterward, and they are busy. I'm sure you have places to
go as well, and I just can't thank you enough for the good work
that you're doing, and your colleagues at CMS as well, in this
very difficult and challenging area. It is so critically
important not only for saving dollars, which will be a priority
going forward as the Affordable Care Act is implemented, but
also for stopping the kinds of patient safety violations that
are so negatively impactful on people's lives.
So thank you for your great work, and thank you for being
here.
Ms. Bonner. Thank you. We look forward to those further
meetings.
Senator Blumenthal. Sure. Thank you, Director Bonner.
[Applause.]
Senator Blumenthal. I'm going to ask our next panel to come
forward.
While they're doing that, I would like to thank other
public officials who are here today. I said hello earlier to
our Commissioner of Public Health who is here.
Jewel, if you could please stand up? Thank you so much for
being here.
[Applause.]
Dr. Mullen. If I could just note that Margaret Hath, the
Director----
Senator Blumenthal. Any of your staff you'd like to
introduce, please stand up.
Dr. Mullen. They are also going to go out and survey, if
you would like to join them.
Senator Blumenthal. Okay. Vicki Veltri, who is the health
care advocate, I saw her earlier. Thank you for being here.
[Applause.]
And I think I saw Nancy Shaffer, who is the state
ombudsman. Thank you for being here.
[Applause.]
Thank you. And I also saw Jeannette DeJesus, who is special
advisor to the governor, Governor Malloy. I know he's very
interested in this issue.
Are you still with us, Jeannette?
[No response.]
Maybe not.
But thank you all for being here, and I introduced before
Edith Prague, who is still with us.
For the next round, and if you could please come forward,
we may need to get some chairs for the members of the panel.
We are, by the way, distributing cards to the audience so
that you can ask questions of this panel. And what we may have
to do--I'm not sure how the microphone will work, but we're
going to begin with Jean Rexford, and then as we go from one
panel member to another, we can have you take a seat in front
of the microphone.
We're going to begin with Jean Rexford, who is a long-time
friend and partner in these efforts of mine, and I want to
thank her for the great work that she's done in this area. She
founded the Connecticut Center for Patient Safety in 2004 and
currently serves as its executive director. Her organization
works to promote consumer involvement in patient safety
efforts. She was previously chair of the Connecticut Health
Foundation, and she has represented consumers on the National
Committee for Quality Assurance and the National Quality Forum.
Jean, do you want to begin?
STATEMENT OF JEAN REXFORD, EXECUTIVE DIRECTOR, CONNECTICUT
CENTER FOR PATIENT SAFETY, REDDING, CT
Ms. Rexford. Good afternoon, Senator Blumenthal, and thank
you for the opportunity to provide testimony today about
patient safety and for bringing attention to this serious
public health issue.
According to the Inspector General's November 2010 study,
it can be estimated that there were 950 Medicare beneficiaries
in our own state that died in our hospitals, and you can
probably add another 22,000 people who got an infection from a
facility that same year.
Behind each statistic there is a name, a family, a story of
sorrow. For some, it's medical bankruptcy. For others, it is
unemployment. But for all patients harmed by the health care
system, there is a physical and emotional pain, a profound
broken trust and disbelief that while being treated, they had
been harmed by preventable medical errors.
The Connecticut Center for Patient Safety was formed in
2004 to be the voice of the consumer patient. We are determined
not to be forgotten collateral damage in a terribly broken
health care system. Today we are joined by other advocacy
groups in the national patient safety movement. Loosely
organized through Consumer's Union Safe Patient Project, we
work together to promote patient safety, improve quality, and
protect patients' rights.
In Connecticut, we are working with another patient-focused
advocacy group called Jump Start. We are trying to shine a
spotlight on the need to put the patient first and foremost in
this vast medical-industrial complex and the regulatory
agencies that have in the past not always put the patient
first.
We began our work with hospital infections. When I learned
in 2005 that there were just two infections reported across 31
hospitals in Connecticut, I knew that it was a good issue to
tackle. We were told by hospital executives with whom we spoke
that most infections were expected, which revealed to me a
fundamental gap between consumer and medical facility
perspectives. I can assure you that no health care consumer
expects to visit a licensed medical facility and acquire a
deadly infection as a result of receiving care. It was not
difficult to amass stories of patients and families and what
had happened to them when they had acquired an infection. Keith
lost his job. Mary will never walk again after a hip
replacement.
We brought these stories to our legislature, and
legislators added their own. Twenty-six states now have
legislation requiring public reporting of hospital-acquired
infections, and the Federal Government has paid attention.
There is an impressive nationwide effort to begin to address
infections and needless suffering and costs. But think of the
individuals who have died and their family's loss because
medical facilities were slow to react without legislative
intervention.
We have learned over the years that legislation has
limitations. The health care consumer will never get all that
we want or deserve. There is absolutely no road map for the
consumer patient safety movement, and only meager funding for
our advocates. When funding is awarded for patient safety
improvements in the clinical setting, there is never a
requirement for consumer representation on medical facility
commissions, panels, and workgroups studying patient safety,
innovation and quality improvement. Most funded endeavors
exclude patient voices altogether.
While we have worked hard to collaborate with hospitals to
get a seat at the table to solve the patient safety epidemic,
we concurrently faced obstruction by the industry's powerful
and well-funded lobbyists serving profit motives first. We
realize we had to think more creatively and decided that nurses
can make an enormous difference in the quality of care in
keeping patients safe. So we started an outreach program to
nursing schools. Collaborating directly with providers instead
of institutions seemed a far more positive way to work.
Our nursing education program has been successful and
continues to grow. Some doors have now opened, and we regularly
participate in state and national efforts. However, there is
much work to be done to bring awareness to an issue that for
too long has been accepted by the medical community, overlooked
by regulators, unknown to the vast majority of the general
public and unsuspecting patients, and out of the realm of
consumer protection.
Without transparency and accountability, patients will
continue to be harmed by medical facilities that tolerate
errors at a rate unheard of in any other safety-sensitive
industry. We are eager to work with medical facilities and the
health care system and have just recently begun collaborating
with innovators that welcome our participation. Testimony
provided later today will provide an example of islands of
excellence that have begun to take shape and make progress. But
why aren't these islands the norm instead of the exception?
Nineteen months ago the Federal Government launched the
Partnership for Patients. It was an important initiative for
health care providers, but it wasn't with patients. It was for
patients. After nearly two years, we were finally contacted,
advocates across the country, and invited to Washington. The
next week after we were excited about showing up, we were told
not to come. There was no money. There was no money for the
patients, for the advocates. We were, sadly, an afterthought.
Patients and patient safety must be a reflex. Only when we
become an equal partner will we begin to see safe, patient-
centered care.
Thank you, Senator Blumenthal, for your never-ending
commitment to ensure that patients and consumer voices are
heard.
Senator Blumenthal. Thank you.
[Applause.]
I am going to ask each of the witnesses in order just a
couple of questions, and then we'll take questions from the
audience.
Jean, thank you very, very much. You know, I remember last
night reading your reference to a patient safety epidemic. Do
you think that's an accurate description of the extent and
severity of the problem?
Ms. Rexford. Absolutely. In fact, this morning on the news
there was a helicopter where four people died. Dr. Lucien Leaf
talks about the jumbo jet of Americans that die on a daily
basis from failures within our health care delivery system.
These are huge numbers. And so it's not only the toll of the
suffering, but it is the cost to the industry.
I have been frustrated in that we're always talking about
access, we've got to have access, and I believe that. But we
need to talk about what we are accessing. We want to provide
safe, reliable care. It's the only--you know, every once in a
while they'll say we provide experience-based medicine, and I'm
thinking, we weren't doing that before? It is of concern that
the patient isn't always put first.
Senator Blumenthal. And what has been the response since
you were invited to Washington? Have you found greater
receptivity since then?
Ms. Rexford. Well, I think people are really trying. The
FDA recently asked consumers to come and spend a day at the FDA
to begin communication. There were 200 people in the room. I
would guess I was one of three consumers that was non-
conflicted, and that has been the challenge, to find people
that don't have financial ties to the industries that make up
health care. Many of the other consumers were representing
disease groups, whether it was Parkinson's or AIDS, all of
which have heavy funding from the pharmaceutical industry.
So the non-conflicted voice is of critical importance. When
I do serve on national panels, I am always thanked because I am
able to say what providers really want to say, but they can't.
Senator Blumenthal. Thank you very much, and we'll be
coming back to you.
I'm going to invite the next panelist, Dr. David
Blumenthal, who is Samuel O. Thier Professor of Medicine and
Professor of Health Policy at Massachusetts General Hospital
and Partners Health System and the Harvard Medical School. He
serves as Chief Health Information and Innovation Officer for
Partners Health System in Boston. From 2009 to 2011, he served
as National Coordinator for Health Information Technology under
the President of the United States, Barack Obama, and in that
role he was charged with building an interoperable private and
secure nationwide health system supporting widespread use of
health information technology to improve patient outcomes.
There's more that I could say, but I am a somewhat
conflicted observer.
[Laughter.]
To use the word that Jean Rexford did.
Thank you for being here, Dr. Blumenthal.
STATEMENT OF DAVID BLUMENTHAL, CHIEF HEALTH INFORMATION AND
INNOVATION OFFICER, PARTNERS HEALTHCARE SYSTEM, BOSTON, MA
Dr. Blumenthal. Well, Senator Blumenthal----
[Laughter.]
It's a pleasure for me to be here. This is a unique
opportunity for me to testify before you in your home state and
bring you greetings from the neighboring State of
Massachusetts.
I'm going to talk about patient safety from a particular
point of view, and that is from the point of view of one of the
important pillars of patient safety, the availability of
accurate and timely health information. We need to supply our
key decision-makers in health care with the best possible
information they can have at the time they need it, accurate
information. Inaccurate information is an important cause of
safety problems. Up-to-date scientific information, when it is
lacking, is another important cause of safety problems.
This vital lifeblood of patient care and of safety, good
information is one of the most critical resources that
clinicians have in their care of patients on a day-to-day
basis. The best circulatory system for that lifeblood in the
21st century is electronic information systems. Virtually every
blue-ribbon panel and every expert that has looked at patient
safety has enumerated a long list of things that we need to do,
and invariably one of them is to improve information through
better information systems using modern technologies, which are
almost inevitably electronic.
So, this apparently very complicated topic of information
technology is actually very simple. It's about empowering
people to do the right thing by enabling them to know what the
right thing to do is.
So, we've made a lot of progress on that topic since the
Obama Administration came into office and since the Congress
passed the Health Information Technology for Economic and
Clinical Health Act (HITECH), which you mentioned in your
opening remarks. This 2009 piece of legislation, which was part
of the stimulus bill passed at that time, put aside many
billions of dollars to reward physicians, hospitals, and other
caretakers for becoming meaningful users of electronic health
records, which also have to be certified by the Federal
Government.
Since that law was passed, very dramatic changes have
occurred. The proportion of American physicians and hospitals
with electronic health records has doubled. The numbers of
meaningful users of electronic health records, both doctors and
hospitals, is now approaching 100,000. The Federal Government
has spent over $5 billion in incentive payments through the
Medicare and Medicaid programs to reward them as stipulated by
law.
So, we are definitely on a new trajectory, but more could
be done. Specifically on the topic of this hearing and the
topic of your committee, the Special Committee on Aging, there
is one particular oversight that needs to be corrected under
the HITECH Act, and that is that the HITECH Act does not
support long-term care providers, home health providers, or
rehabilitation facilities for the adoption and meaningful use
of electronic health records.
This is not a wise choice. We need to do better. Of course,
covering the full continuum of care is essential, and the
information that's necessary to care for patients in long-term
care, home care, rehabilitation, and other areas outside the
acute care setting is every bit as important as in the acute
care setting.
This is especially true for the 5 percent of Americans who
account for 50 percent of our spending, patients with multiple
chronic conditions, with chronic illnesses, the kinds of
patients who one finds among the elderly and in long-term care
facilities. For these patients, coordination of care is
especially important to avoid safety problems; knowing what
patients have received in the way of care in the past, knowing
what drugs they're on, knowing what their allergies are. All of
this information needs to be part of the care that's provided
in long-term care settings, as well as in acute care settings.
The HITECH Act didn't cover those other facilities I think
in part because it needed to start somewhere. It needed to set
bounds around the level of expenditure. But as we plan for the
future, it's clearly the case that the umbrella of the law has
to extend to include those kinds of caretakers and those kinds
of facilities as well.
As the law is implemented, there's another area where I
think that Congress needs to be attentive and careful, and that
has to do with the level of performance that we demand of users
of these modern information systems. There are two basic,
important things that information systems do. The electronic
health record itself is not a powerful tool. It's just a
repository for information. The power of these tools derives
from two uses of the information. One is to exchange it, to
enable the information to follow patients, to move wherever the
patient moves; and the other is to use it to make clinicians
smarter and caretakers smarter.
The latter is done through embedded algorithms, reasoning
logic that takes the best information that is available to
medical science, as well as information about patients, and
wraps it up in a way that presents it to clinicians in a way
that they can use most effectively.
Health information exchange and clinical decision support
are the waves of the future, and they are both incorporated
into the meaningful use framework. The meaningful use framework
encourages the use of these techniques but they are demanding,
more expensive, and they require things of the profession and
the health care institutions that are not straightforward. As
they come into effect, especially as the Center for Medicare
and Medicaid Services and the Office of the National
Coordinator promulgate increasingly demanding regulations for
compliance with meaningful use, I fully expect that there will
be efforts by my colleagues in the health care industry to
postpone, mitigate, and reduce the demands associated with the
meaningful use framework. I hope the Congress will stand firm
in supporting the Administration as it tries to push the
frontier on making good use of information for improving
patient care, for improving quality of care, for improving
safety and reducing the cost of care.
The last point I would make, following a consumer
representative I feel I have to make, is that one of the things
that health care consumers do care a lot about is the privacy
and security of information that's in medical records. They
care about it in the non-health care world, in their finances
and in the personal choices that they make on websites and over
the Internet. But there's something special about health care.
So, I think that the Congress needs to reexamine, and the
Administration needs to reexamine the current privacy and
security framework, because it is not currently adequate to
provide the security and enable the trust that we need to make
sure that patients and their families are trusting of and fully
cooperating with the collection and distribution of information
using electronic technologies.
So with those comments, Senator Blumenthal, I will conclude
my remarks. I'd be happy to take a few questions.
Senator Blumenthal. I promise only a very few.
Dr. Blumenthal. None of them personal.
Senator Blumenthal. In your written testimony--by the way,
I'm going to ask that all of the written testimony be made a
part of the record. I know that the witnesses understandably
shortened what they had to say, and without objection I'm going
to ask that it all be made a part of the record, and we'll
distribute it to my colleagues.
You mentioned in your written testimony the radiology order
entry as an example of how IT can save the system from errors
or make for better and more effective treatment. That's just
one example. Maybe you could just describe that.
Dr. Blumenthal. Sure, sure. So this is a story that comes
from my personal experience, 35 years as a primary care
physician, and that I told frequently when I was working in the
Federal Government. At my home institution at Massachusetts
General Hospital, where I practiced for many years, we had a
fairly advanced information system, and one of the things that
we had was a form of clinical decision support. I mentioned it
in my remarks, a way of making clinicians smarter.
What this system did was, it was called radiology order
entry, required that you enter some information about the
patient in support of ordering a high-cost imaging study, a
magnetic resonance image study or a computerized CAT scan study
of the head or the chest or the abdomen, whatever the body part
might be. And after you'd entered this information
electronically, it would then do two things.
First, it would compare your test ordering and the
patient's information to the guidelines of the American College
of Radiology. This it did in real time. So you would get
feedback in milliseconds on whether your decision conformed to
the recommendation of the nation's best thinkers about ordering
tests.
The other thing it did--both these systems, by the way,
were home grown--is it looked back through the patient record,
and if the same test or a similar test had been ordered within
three months, it would essentially say are you sure you want to
do this, because either you or somebody else had just ordered
this test, and you might be able to get the information you
need without doing this high-cost test.
And we found, I found personally and I know that many of my
colleagues found, that either they weren't aware that something
had been ordered or their logic may not have been in accord
with expert opinion, and often this meant changing a test to
order a different one, either adding something to it or taking
something away. Sometimes it meant canceling the test
altogether because a similar test had been done and the
information was available.
So what this did is it actually reduced the collective
costs across the health system, the collective amount of high-
cost images that were ordered over time. There was a very
dramatic reduction in the rate of increase in those tests, and
I often think of this as kind of health policy nirvana. What it
did was it got physicians to change their behavior in a way
that made the care higher in quality, reduced the cost of care,
prevented unnecessary radiation exposure for patients, and
prevented them from being inconvenienced by the need to come
back to get a test. Often we would end up sending patients to
outlying facilities because at Mass General our facilities were
so busy. So, it saved all that inconvenience, and it did it
with no coercion, no financial incentives. It just made doctors
better at what they wanted to do, better professionals.
So that's sort of the power, I think, of information at the
right time and the right place. If you'd given that information
a half-hour later, it wouldn't have been worth anything. But
because it was present at the time the test was ordered, it
made a huge difference. We have almost unlimited opportunities
to do that using information technology.
Senator Blumenthal. And it saved money.
Dr. Blumenthal. It saved test ordering, which saved money.
Senator Blumenthal. You mentioned that 5 percent of the
individuals who receive health care are responsible for 50
percent of the spending. Is that an inevitable proportion, or
are there steps that we can take either through long-term care
efficiencies, nursing homes, rehabilitation, to drive down
those costs?
Dr. Blumenthal. Well, we can drive down, certainly reduce
the rate of increase in the cost of that 5 percent. I think
it's unclear whether you can ever or would want ever to spread
those costs across a larger proportion of the population. The
fact is that as we age as a population, we tend to get more
people with chronic illness, and they tend generally to be a
minority of the population.
So I don't expect that proportion, that concentration of
cost to change, but I think we could care for that group more
efficiently.
Senator Blumenthal. The concern that you raised about
privacy and security is very much on people's minds, whether it
relates to IT or simple paper records, and I've actually
sponsored a measure and have a number of co-sponsors--it's been
reported out of the Judiciary Committee--that would impose
requirements for actual systems. Many corporations, including
health care institutions, have no systems, and it provides
penalties in the event that they don't, and provide a private
right of action in the event that there are breaches, and other
remedies in the event that there are breaches.
But I think you've rightly identified the medical care area
as one where people are understandably and rightly sensitive,
and I take it that you feel that there is the need for
additional protection.
Dr. Blumenthal. Yes. There is the need in part because
though we complain in the medical profession and in the health
care industry a lot about HIPAA, which has become kind of an
epithet as an obstacle from different points of view, an
obstacle to whatever people are setting out to get, the fact is
that it was created in the pre-Internet age. It was created
before the current use of information was ever imagined, before
the Internet, with all its benefits and all its risks, was
considered.
So there are whole groups of institutions which now are
custodians of health care data--take Microsoft and Google as
two--that are not at all regulated under the HIPAA provisions.
There are also big gaps in HIPAA itself. It's actually quite
porous and fairly easy for practitioners to exchange
information, to move information around legally, and often
necessarily, without getting patient consent.
So that's not to say it's the wrong thing to do, but I do
think it needs, in the Internet age, to be reexamined. This
will require a series of things. It requires some of these
necessary changes and considerations to be done through
regulation. You don't need congressional action. Some will
need, though, congressional action because they are part and
parcel of the regulation of information in commerce using the
Internet, and that is a topic that is under active discussion
right now. It's not an area of my expertise, but I do
understand that you can't address the health care area in
complete isolation from all the other uses of the Internet.
Senator Blumenthal. Susan Davis, who will follow you, talks
about patient misidentification and the potential with the same
name, the same birth date, to be misidentified and confused. Is
that a problem that you saw during the time that you served as
national coordinator in this area?
Dr. Blumenthal. It was a great concern. Of course, the less
privacy you have, the easier it is to identify people. The
ultimate form of identification would be some kind of national
patient identifier, and I was often asked about that. If we all
had to have a unique number that was incorporated into our
medical records, it would be from an information standpoint
very easy to avoid making errors in identifying patients. But
that would run afoul of many deeply held views about what the
role of government is, what it should know about people, and I
don't see that as likely.
Lacking a unique number associated with everybody, we will
never find a way to identify people that is absolutely perfect
and secure with 100 percent accuracy. So the challenge is to
identify the best technical systems that we have to identify
people with an error rate that's tolerable, and educating the
public about that as a risk of information systems inherently
is a big challenge.
It's not reasonable absent a national identifier, and even
to some degree with a national identifier, it's not reasonable
to expect that we'll ever have 100 percent certainty in
identifying individuals, especially with common names and
without very distinguishing physical or medical problems.
Senator Blumenthal. Thank you, and thank you for your
testimony today.
Dr. Blumenthal. My pleasure.
Senator Blumenthal. I'm going to ask Susan Davis to take
the microphone next. She is the CEO of St. Vincent's Medical
Center and Market Leader of the Ascension Systems of Hospitals
across New York, Connecticut, Florida, and Alabama. She has
been at St. Vincent's since 2004, overseeing the most ambitious
technology upgrade to support patient safety in the medical
center's history and indeed probably in the history of our
state. She has aggressively implemented systems of patient
safety reforms that have resulted in one of the lowest rates of
infection in the nation, and she's been appointed by the
Connecticut Hospital Association to lead all Connecticut
hospitals through St. Vincent's model and example. She has
received local and national recognition for her commitment to
patient-centered care, and I can say about her as well as
others of the witnesses today that I've been very proud to work
with you, Susan. Thank you for being here today.
And I might just mention that I know that many of you have
other schedules. If you find after your testimony that you need
to leave, we won't hold it against you. We're going to be
keeping in contact with you, and obviously all of your
testimony will be made part of the record.
Thank you for being here.
STATEMENT OF SUSAN DAVIS, CHIEF EXECUTIVE OFFICER, ST.
VINCENT'S MEDICAL CENTER, BRIDGEPORT, CT
Ms. Davis. Thank you very much, Senator, and thank you for
that very gracious introduction. My father would be proud.
The point that you made about my role with the Connecticut
Hospital Association is perhaps one of the responsibilities
that I am very proud of. We heard our consumer advocate speak
about the need for hospitals taking patient safety seriously,
and I'm proud to say that the Connecticut Hospital Association
agrees and is working together with every hospital in the State
of Connecticut to put aside our competitive issues that we have
in our communities and work together to create a culture of
safety by building in reliable behaviors amongst the health
care workers.
Our objective is to eliminate serious safety events and
make our hospitals collectively in the state, and I believe
it's the only state in the country that has made this
commitment to provide our patients and our communities a safer
environment. And I'm pleased to say, Jean, that this initiative
was developed with a consumer as part of our planning group, so
you're teaching us well. Thank you very much.
But patient safety is my passion, and what I am going to
speak to today is not the issue of safety from the standpoint
of serious safety events or building a culture of safety and
reliability, but from the IT side.
I feel a little--is Dr. Blumenthal still here? Good.
[Laughter.]
I feel a little bit overwhelmed by his presence, but I'm
going to try to give you a perspective from the health care
side.
Senator Blumenthal. He's much more imposing than I am.
[Laughter.]
Ms. Davis. Not so.
[Laughter.]
But as you know, St. Vincent's is part of Ascension Health,
which is the largest Catholic health system in the country and
has undergone a number of initiatives around the country to
create an IT platform that will enable us to use information
technology to improve the delivery of care across the
continuum, because it's not just about hospitals. As we move
forward with the Affordable Care Act, the exciting part of it
is we're going to be looking at payment for value and also
payment across the continuum. In order for us to be able to do
that, we need to be able to transport information and data
about the patient across that continuum.
Unfortunately, that's not the case today. The Bipartisan
Policy Center in Washington, which I'm sure you're familiar
with, issued a report that highlighted a number of issues that
need to be addressed if we're to be successful in building an
electronic infrastructure to support quality, value, and the
care across the continuum.
Our delivery systems and payment reforms must promote
quality and value, but they require providers to deliver care
and bring important health care information about the patient
to the point of care. And while the High-Tech Act has been very
significant in exacerbating the adoption of electronic health
records, we have two major issues that I'd like to speak to.
One is the interoperability of our information systems, and the
second is the unique patient identifier.
On the interoperability of our health care systems, I'd
suggest that there needs to be standards and certification
requirements associated with CMS' Medicare and Medicaid EHR
programs, and they should be expanded at Stage 2 because we
need to be required to transmit additional data across
providers and in different settings, and that's not the case
today. Clinical IT vendors have proprietary standards which
prevent easy data exchange between systems, and frankly, those
proprietary practices are barriers.
Think about the fact that the U.S. banks have figured this
out long ago. Without standards, investments in HIT are
minimally optimized and increases the overall cost to the
health care delivery system.
The second point I'd like to raise is one that you
discussed with Dr. Blumenthal, and that is the unique patient
identifier. Again, the Bipartisan Policy Center issued a report
titled ``Challenges and Strategies for Accurately Matching
Patients to Their Health Data.'' In Harris County, Texas, there
are 2,400 people named Maria Garcia; 231 of them have the same
birth date. In that county alone, there are almost 70,000 pairs
of patients who share both names and birth dates. That's not
unique to Harris County, Texas or the State of Texas. That
happens across this country, and patient misidentifications
vary from 8 to up to 20 percent and have significant impact on
medical errors.
While we need to be conscious and concerned about patient
privacy, we also have to find a way to move closer. I
understand that Dr. Blumenthal said that we will never have a
unique patient identifier, but we have to move closer on that
continuum to eliminate this problem of duplication of names and
birth dates to improve the safety of the health care we provide
to patients.
Hospitals have developed workarounds, but those workarounds
are dependent on people. Human error occurs, and people need to
be added to health care systems to do this manual work, and
that only adds cost to the health care system.
There is one additional point I'd like to make in closing,
and that has to do with the alignment of Federal quality
measures. CMS has offered three ways for providers to begin
moving to provide accountable care under its newly-created
Accountable Care Organization program, Medicare Shared Savings,
Pioneer ACO, and Advanced Payment Initiative. These are very,
very exciting opportunities for hospitals.
One of the best parts of those three initiatives is the
fact that the measures across the various payers, either
Federal, state or local, are required to be consistent
measures. It enables those participants in those three programs
to pull data that is the same for each of those initiatives. We
are really appreciative of CMS' efforts to standardize data and
data measurements. However, it has to go broader than to those
providers that are participating in these accountable care
organizations.
The broader U.S. health care system needs to align both its
payment and technology processes to assure high quality and
high value. Health IT and provider adoption of EHR technologies
must become an integrated component of the health care system
transformation that is grounded in policy which facilitates
provider access to secure patient health information.
I welcome the opportunity to serve as a continuing resource
to you in your important work, and thank you for inviting me to
be part of this testimony.
Senator Blumenthal. Thank you, and we certainly will take
advantage of your offer to be a continuing resource.
You mentioned that the effort has to be broader than the
ACO, the accountable care organizations. Can you expand on that
a little bit?
Ms. Davis. Yes. I'll take it from a local perspective. We
provide measures on almost 75 indicators. Now, I'll make two
points on that. First, we have got to move from process measure
to outcome measures because that's the value that we provide,
the outcome to the patient. Patients can still get bedsores
even if we're being measured and the fact that we document
turning patients every two hours. The definition of those
outcomes are different when we're reporting them to insurers,
managed care companies, CMS, Joint Commission, or statewide
agencies.
So what we need as providers is a consistent definition of
those outcomes so that we're able to report it to everyone. We
believe in transparency, but when you take those 75 measures
and put three or four different definitions in there, it's just
additional work and opportunities for error, and it takes us
away from ensuring the outcomes that we want to deliver.
Senator Blumenthal. Good point. You also mentioned--that
one of your recommendations is to expand consumer engagement in
electronic tools. How exactly do you think we ought to do it?
Ms. Davis. Well, you know, I think we're fortunate to have
organizations like Jean's who really advocate for the consumer;
not to say that we as providers don't also advocate for the
consumer. But it's amazing to me the amount of information
that's out there that consumers do not gain access to, and I
think we need to start with educating consumers about the
information that is available to them now to help improve their
health outcomes.
But in addition to that, I think that patient portals that
can be developed by hospitals, by a health system, and giving
patients access to them in an easy, accessible way is one of
the best ways for patients to get access to their information.
But in order to do that, we need interoperability, and we need
unique patient identifiers to protect the privacy of those
patients that have duplicate personal patient information.
Senator Blumenthal. And these ideas, I think, really go
very well with the suggestion that Jean Rexford made, that we
need partnerships for patients, but even more partnerships with
patients so that they are involved and engaged as participants,
not just the objects of what happens.
Ms. Davis. Absolutely. As health care providers, we
sometimes think that we know what patients want. We don't. And
unless the patient has a seat at the table, we're not going to
move this health system along as we need to, to better meet
their needs.
Senator Blumenthal. Thank you.
I'm going to ask--I wish we had more time for each of our
witnesses, but I know that we are limited in terms of time. I'm
going to ask Ms. Henderson, CEO of Hill Health Center,
Connecticut's oldest community health center, to be our next
witness. Since her arrival, she has directed the rebuilding
efforts of a legacy institution with a 40-year track record of
innovative patient care.
I've been tremendously impressed by the great work that
you've done there, and thank you so much for being here with us
today.
STATEMENT OF JAMESINA HENDERSON, CHIEF EXECUTIVE OFFICER,
CORNELL-SCOTT HILL HEALTH CENTER, HARTFORD, CT
Ms. Henderson. Thank you. Thank you so very much, and good
afternoon, Senator Blumenthal. Thank you for the opportunity to
contribute to your research on this most important subject.
I am Jamesina Henderson, CEO of the Cornell-Scott Hill
Health Corporation, Connecticut's first federally qualified
health center and one of its largest. And may I add that each
federally qualified health center is required to have 51
percent patient participation on its board of directors, so
there is patient voice.
We were established in 1968 as a primary care institution,
and through our 44 years of growth, expansion, and development
of services in medical, dental, and behavioral health care, we
have become the nation's best example of integrated care. We're
not alone in arriving at this conclusion. Linda Rosenberg, the
CEO of the National Council of Behavioral Health Care, who
visited with us recently and is responsible for leading an
association comprised of over 1,900 behavioral health care
organizations nationwide, stated that in all of her experience,
we are the best example of integrated care that she has ever
seen.
I believe our perspective on care integration is critical
to your efforts on patient safety, and I'd like to explain why.
Throughout our history of providing care to the 33,000
people who consider us their medical home each year, we have
focused on delivering a quality experience, from scheduling to
the reception desk to the treatment room. One of the challenges
we have faced is ensuring the appropriate sharing of
information between our medical, dental, and behavioral health
providers. Many of our patient population receive services from
all three disciplines, and as many of you know, there are many
connections between mental health and physical health.
In one of our most recent efforts to tackle this problem
head-on, which is what we like to do at the Cornell-Scott Hill
Health Corporation, we challenged the marketplace to provide
what we know is the right contributory solution to improve
patient care and patient safety, a completely integrated
electronic health record structurally built on a foundation of
information sharing across all three care disciplines. We
demanded a solution that mirrored our practice of integrated
care, and only one solution provider heard our call.
I'm proud to say to this committee that the Cornell-Scott
Hill Health Corporation, in partnership with General Electric,
is leading the transformation of electronic health records. Our
system, which is now in place at several of our 16 care sites,
is likely the first in the nation to provide full integration
and sharing of information across all care disciplines.
We know from experience that communication and sharing of
information is critical to patient safety, continuity of care,
and to an enhanced patient experience. Technology aside, there
are other ways we know this to be true. And like the technology
solution we are implementing, there are other collaborative and
partnership solutions underway in our health care environment
equally deserving of mention.
Today we have no less than three programs in place, funded
through foundations and others, to provide patient navigation
services to patients with specific conditions. Just last month
we were awarded a grant from the Komen Foundation to provide
patient navigation services to women with breast cancer. What
these foundations know and are willing to put their funding
behind is the true value of communication, information sharing
and care management. They know that if patients diagnosed with
specific conditions are assisted along the path of the health
care continuum, they stand a better chance of improved health
outcomes.
Technology cannot do this alone. It is an important, even
critical component, but the human component is needed. Patients
need to know they have an advocate fighting for them, working
with them to ensure their needs are going to be met. This gains
increasing importance as the population in general, and our
patient population specifically, ages. More complex medical
conditions and treatment regimes, including medication
adherence, demand greater attention.
Patient navigation is a clear success story. With it, we
stand a better chance of our patients receiving the right care
at the right time in the right place. Patient navigation can
help us reduce non-emergency visits to emergency departments,
which of course everyone knows will reduce costs throughout the
health care system. What makes this a difficult solution to
implement is the simple fact that patient navigation services
are not a reimbursable expense from our current payer mix.
Another challenging aspect of providing this service is the
lack of training and workforce development opportunities to
help us transform the existing workforce into 21st century
caregivers capable of coordinating care across multiple
specialties and institutions while simultaneously delivering on
our promise of an exceptional experience.
I'd like to make one additional point before concluding
with the recommendations. All of us in the health care field
understand the growing complexities in delivering quality care.
With the confirmation of the Affordable Care Act, we know the
future of health care is going to be different tomorrow than it
is today. One area we know will not be different is the
expectation of our patient, high quality and safe care from
their provider. We believe the vast majority of our patients
have elected to make us their medical home precisely for that
reason.
A medical home is more than a label. It is an affirmation
of expectation and of value. And underpinning that expectation
and acceptance of a medical home is trust. The simple and
powerful truth is that our patients place their trust in us,
all of us in the health care field, to do what is best for
them. A successful handoff or transfer of a patient and their
clinical information builds trust, and when coupled with the
overt acceptance of responsibility for an individual's care,
then and only then have we all succeeded in transforming health
care.
My recommendation to you, Senator Blumenthal, and to your
colleagues on this committee and in the Senate, is to draft
legislation that supports our efforts to provide seamless,
accountable, and beneficial patient navigation across the
health care spectrum. With it, we can improve patient safety,
achieve better outcomes, and reduce costly interventions.
Once again, thank you for the opportunity to share my
thoughts on this most important issue.
Senator Blumenthal. Thank you. And by that recommendation,
I assume you would also recommend that patient navigation be a
reimbursable expense.
Ms. Henderson. I certainly do.
Senator Blumenthal. And how would you, if you were to make
that argument, or elaborate on it I should say, talk about how
cost effective it will be, that the investment is worth the
savings, the improved effectiveness of health care.
Ms. Henderson. Well, I think it's well known the cost of
the improper use of emergency departments, and the reason
people do that is because they are directed by the system to go
to the emergency room. That structural guidance needs to
change, and we need more people. As much as we applaud the
electronic health record, there is nothing like an actual
person helping to assist patients go to the right place and
encouraging them to transfer information essential to their
better health.
Senator Blumenthal. And that's what's necessary to permit
and foster and promote patient navigation, which is really
navigating for patients in what is now all too often a maze to
them.
Ms. Henderson. Yes.
Senator Blumenthal. Seemingly a maze of fragmented,
different stops along the way to health care.
Ms. Henderson. Absolutely, and to encourage their active
participation in whatever that acute situation is, and their
prevention and wellness. We expect to differentiate in the
future at the Hill Health Center by focusing on prevention and
wellness and active, proactive engagement of patients.
Senator Blumenthal. Well, I want to thank you. First,
congratulations on having a fully integrated health IT system.
Ms. Henderson. Thank you.
Senator Blumenthal. And for your use of patient navigation,
and thank you for being here today.
Ms. Henderson. Thank you very much.
[Applause.]
Senator Blumenthal. We're going to go to Scott Ellner. Dr.
Ellner is the Director of Surgical Quality and Trauma Surgery
at St. Francis Medical Center. He completed a Patient Safety
Leadership Fellowship with the American Hospital Association
and the National Patient Safety Foundation. He is co-founder
and chairman of the Connecticut Surgical Quality Collaborative,
which is a statewide data-sharing framework for all Connecticut
hospitals to learn from each other.
Thank you for your great work in this area, Dr. Ellner.
STATEMENT OF SCOTT ELLNER, DIRECTOR OF SURGICAL QUALITY, SAINT
FRANCIS HOSPITAL AND MEDICAL CENTER, HARTFORD, CT
Dr. Ellner. Thank you, Senator Blumenthal. It's a pleasure
to be here today amongst all the esteemed luminaries on this
panel, and I'm excited to testify on behalf of a surgeon's
perspective on value-based health care delivery.
As a general and trauma surgeon employed at Saint Francis
Hospital and Medical Center, I am honored to share with the
committee our efforts to improve the value of health care
delivered to our patients. Value can be equated to health
outcomes for every dollar spent on health care services. This
value proposition redefines the next steps which should be
taken toward health care reform and which can be achieved
through the full continuum of care; simultaneously improving
the experience for patients and their families, improving the
overall health of populations, and reducing the per-capita
costs of health care provided.
Now, Susan Davis had discussed outcomes, and my vision as a
health care provider is about improving patient outcomes and
moving away from studying process measures, but, looking at
outcome measures, and this can be done through the careful
measurement of these outcomes.
It's a well-known management axiom that if it's not
measured, then it cannot be improved. Over the last five years
at Saint Francis Hospital, my team has collected and reported
on 30-day post-surgical complications through a risk-adjusted
and transparent database. Knowing our outcomes has allowed us
to realize not only how good we are, but how much better we can
be. Over this time period using our data, we have implemented
specific patient safety initiatives to improve our patient
safety outcomes.
For example, nurse-driven protocols for early removal of
in-dwelling urinary catheters resulted in a 62 percent
reduction in urinary tract infection rates. Improved care
bundles in the intensive care unit to prevent hospital-acquired
pneumonias reduced our pneumonia rates by 33 percent. We
developed an operating room team training program to
effectively implement a surgical checklist to prevent safety-
compromising events in the surgical setting. This resulted in a
70 percent reduction in post-operative complication rates, and
I'm proud to say we were recognized by the Joint Commission for
demonstrating best practice during our time out for universal
protocol in the operating room.
This has a big impact on costs. Knowing our outcomes has
allowed us to develop these performance improvement initiatives
to prevent costly readmissions in health-care-acquired
infections. In fact, two years ago in one study, we found on
average that patients who developed the dangerous C-DIFF
infection, which is hospital-acquired or health-care-acquired,
added up to an excess cost of $54,000 to those patients' care.
By obtaining better outcomes, we can identify opportunities to
eliminate waste and reduce those costs.
Through our electronic health record system, our
information is now streamlined so we can automate our data
collection for real-time monitoring and make adjustments as
needed.
I'll tell you, this morning I saw 22 patients in my office
on my electronic health record. All the data was input. I wrote
a letter to each of their primary care physicians and the
patients received a summary of care to go home with for them to
use for transfer to other physicians if they didn't have the
patient portal system. So we are implementing the electronic
health record to its fullest potential not only to help the
patient navigate the system but also for measuring our
outcomes.
But, we have to be prepared to change the culture in order
to make these adjustments, and this starts with medical school
training. The behaviors and actions of the doctors today come
from the core curriculum in the medical schools and the
residency training programs. We are, in fact, still taught 19th
and 20th century management principles for human interaction.
Consequently, there is a hierarchy or an authority gradient in
medicine which exists today, and at times this can be
intimidating to patients. It can impede communication and
collegiality among providers: be they doctors, nurses,
pharmacists, or physician assistants. It's time to level this
authority gradient, to remove these behaviors, to better the
communication so that we can work together as a cohesive unit
for the betterment of our patients.
I'm proud to say that next week at the University of
Connecticut, School of Medicine, we will be teaching our first
course in patient safety as part of their curriculum. We are
going to be teaching the future providers in health care how to
be the best advocates for their patients and how to work
together as a cohesive, integrated unit.
Jean has been an important advocate for her patients, and
we have reached out to her, and recently, last March at Saint
Francis Hospital, we had a very successful patient safety
awareness day with a goal of collaborating with our patients.
We brought them in from the community and we discussed efforts
on how they can safely navigate the system. It was a successful
day where patients felt like they were listened to, and on the
other hand we were able to hear what they had to say to help
them come to the hospital and leave safely.
One other thing I just want to mention is that Hospital
Compare is now looking for hospitals to present their outcomes
data, and what we have done is we have participated in a new
pilot, the only hospital in Connecticut to report our elderly
serious outcomes after surgery.
So with that, I want to thank you for allowing me to
testify today. It's been an honor.
Senator Blumenthal. Thank you for being here. I feel
badly----
[Applause.]
I feel badly for taking you away from those 22 patients and
others that you would be seeing right now, but your
contribution has been immeasurable. Quite honestly, those
numbers of reductions in urinary tract infections and pneumonia
and other accomplishments, measureable outcomes, are really
extraordinarily impressive.
I guess my first question is: was it difficult to get
support or buy-in from the nurses and the doctors and others
who are in the trenches for the steps that were necessary to
achieve those outcomes?
Dr. Ellner. Well, I think that one of the challenges that
you have to face anytime that you're going up against an
embedded culture is to change the mindset from the way we've
always done things to the way we should be doing things on
behalf of patient safety.
Because I am a frontline worker, I'm there in the
trenches--I was there last night operating on a patient with a
small bowel obstruction--they know me. They are able to relate
to me and understand that if I'm truly passionate about this
then this must be important. And so I was able to develop a
team of stakeholders who understand it. Some of them are here
today. Then I was able to go to senior leadership, particularly
our CEO, Chris Dadlez, who has been behind us 100 percent and
he understands the importance of this.
I can tell you that if the leadership in your organization
understands how important patient safety is, then you're going
to be successful. It aligns the organization.
Senator Blumenthal. Well, I know your CEO, and I'm very
glad that you brought some of your stakeholders and your team
here today because they really show how leadership can get
results. This is not pie in the sky stuff. This is real-life
steps that can be taken, can achieve results, and I think it's
a very powerful story.
I guess the other question I have for you is: do you think
that the teaching, the curriculum that you developed for the
University of Connecticut, can be replicated and done
elsewhere?
Dr. Ellner. I believe it can. We look at the World Health
Organization as a model and use some of their baseline
teachings to develop the core curriculum, and the goal is to
not only roll this out here at the University of Connecticut
but to implement it in the nursing programs and the pharmacy
schools so that it's an interactive process with all health
care providers, not just the physicians.
So ultimately that is our goal. And then on a side note,
what we'd like to do is make this into a 4-hour certification
program for all providers, for all personnel within our
hospital, so that like you have to become basic life support
certified, know how to do CPR, you have to be patient-
certified, patient-safety-certified.
Senator Blumenthal. Patient safety certified. That would be
a great qualification to spread more generally among health
care providers and institutions.
Well, thank you very much.
I'm going to ask questions that have been submitted by the
audience, and I guess some of them are general questions, and
I'm going to ask them in exactly the way they have been written
and open it to whomever would like to respond if they're not
addressed to one person, and identify who has submitted them.
The first is from Ann Yedlin of New Haven, and the question
is: ``What role does staffing play in patient safety, and how
is this being addressed? Numbers, training, empowerment.'' For
any of you who would like to respond.
Ms. Davis. I'll try taking a shot at it. I think there are
a lot of studies that are out there that talk about the
relationship of the number of registered nurses to patient
outcomes, patient satisfaction. So I think that's got to be an
issue amongst all of our hospitals, within all of our
hospitals, because there are data there that supports it.
But it's just not having a person. It's just not about
numbers. It really is about the culture in our organizations
and the behaviors that we all exhibit. We talk about in higher
liability of 200 percent accountability. I'm accountable for
the work that I do, but I'm also accountable for the work that
Jean does in making sure that if I see her forgetting to wash
her hands or not putting isolation balm on, I stop her;
speaking up, creating a culture where employees, it doesn't
matter what you do in the organization, whether you're the CEO
or a registered nurse or a housekeeper or dietary worker. If
you see a health care provider doing something that you know is
wrong, like not washing their hands, or putting a mask on when
you're going to put a central line in, you have to empower
those individuals to speak up, to stop the line, so to speak,
and that's not about numbers. That's about culture. That's
about setting the expectations within the organization.
Senator Blumenthal. Thank you.
[Applause.]
Our next question--I'm asking these in the order that they
were submitted--is from Maggie Ewald, who is the Long-Term Care
Ombudsman. She's from Columbia, Connecticut. ``How does a
patient correct or change a previous erroneous diagnosis in his
or her, medical record?''
[No response.]
Participant. Well, I guess they don't.
Ms. Davis. No, they do. They absolutely do. Most
organizations have a process for that in their policy that
enables that to happen. It's not easy. I will tell you that,
because a physician has written a diagnosis in a medical
record, they've made that diagnosis based on scientific and
qualitative data.
But there is a way in which you can contact the hospital
where you believe the erroneous medical record entry is and
work with the hospital and the physician to have your complaint
reviewed and potential for changing the medical record.
I've seen it done, it does work, and I've seen those from
the DPH standpoint understand the process. But that is
generally the path that you should follow to get it done.
Senator Blumenthal. Next question from Sean Jeffrey of
Branford, Connecticut. ``Medication reconciliation between care
settings is an important source of errors and potential danger
for seniors. Pharmacists are best situated to make positive
changes. However, pharmacists need to be recognized by CMS as
health care providers to ensure they have the ability to work
across care settings to incorporate medication data across
electronic records to ensure proper communication and make sure
the right drug reaches the right patient at the right time. The
American Society of Consultant Pharmacists looks to partner
with your office and the Senate Aging Committee.''
I guess that's a comment more than a question. If you wish
to comment, we would welcome it.
Ms. Bonner. Thank you for that comment, and I just want to
add that we are working with ASCP, the American Society of
Consultant Pharmacists. Our regulations right now for the most
part, as you pointed out, are really in silos. We have nursing
home regulations, we have hospital regulations, we have home
health regulations. One of the things that we're doing now, CMS
is looking to see how do the regulations need to change now
that we're looking at accountable care organizations and
looking at care transitions.
The pharmacists have played a tremendous role in the anti-
psychotic work that we talked about earlier, and we're very
pleased that ASCP is a partner with us. So we'd be happy to
work with them, and Mr. Jeffrey here in Connecticut as well.
Senator Blumenthal. We have a question from Martin Spriglio
of Stratford. ``Will there be funding for nursing homes to put
electronic health records? All others receive funding--
hospitals, doctors, et cetera.''
I guess I will answer that question, but I will open it to
others. I certainly hope there will be funding for it, and I
will support it if the President is willing to support it as
well. Anyone else who wants to comment can, but I think that
kind of funding for nursing homes is vitally important.
Kathy Tynan McKiernan. ``What plans are underway to improve
quality of care and disincentivizing quick decisions to
hospitalize or re-hospitalize patients in nursing homes?''
Ms. Bonner. There are a number of initiatives that are
going on, but most recently----
Senator Blumenthal. Sorry about the logistics here.
Ms. Bonner. I'm sorry I have my back to you so that you can
hear me. There is a recent initiative from the Federal
Coordinated Care Office of Health, which is the office of the
dual eligibles, people who have Medicare and Medicaid, and it
is specifically a proposal. They're reviewing the people who
submitted them now to look at re-hospitalization, avoidable re-
hospitalization of nursing home residents. That is one of the
primary outcomes, as well as, again, the use of anti-psychotic
medications, and others. But that is one specific initiative
where nursing homes are partnering with physicians and other
groups to come in and provide primary care and work together
collaboratively on primary care nursing home issues to prevent
re-hospitalizations.
CMS is working with a number of partners as well. In
Connecticut, there is a particular group in New Haven that was
funded under the Section 3026 of the Affordable Care Act on
care transitions, and that's again a group that includes
skilled nursing facilities, hospitals, community-based
organizations to look at unnecessary re-hospitalizations,
including those of nursing home residents. So a number of the
programs under the Community-Based Care Transitions section of
the Affordable Care Act are looking at that as well.
Senator Blumenthal. Thank you.
This is a question for Jean Rexford from Brian Capshaw,
resident counsel, President of Aurora Senior Living of East
Hartford. He's an executive board member of the Statewide
Coalition of Presidents of Resident Counsels of Connecticut.
Is Brian still here?
Mr. Capshaw. Yes.
Senator Blumenthal. Great. ``Connecticut law requires that
nursing home staffing levels result in 1.90 (second lowest in
the country) total nurse and nurse's aide hours per resident
per day. With this low number, nursing home resident safety is
an issue, such as falls, because not enough staff is available
and residents try to do things for themselves. The Federal
Government leaves this up to each state. Would you support our
attempt to change the Connecticut law from 1.9 to 2.3 in 2013,
and 2.3 to 2.7 in 2014 in the next legislative session? The
Office of Fiscal Analysis shows little cost to the state.''
Ms. Rexford. That's known as being put on the spot. It
would be certainly something I would be very interested in, and
our group would be very interested. We have just begun working
on nursing home issues. As you know, we have focused on
hospitals. But over the last few years, we've had more and more
calls about problems within the nursing homes.
Clearly, in some nursing homes it is the same complaint,
whether it is medication or falls, that are repeated, and
there's been a movement in California particularly that looked
at staffing levels that was driven by consumers. So it would be
definitely something we would consider.
Senator Blumenthal. I'm going to ask Brian's next question
because I think it deserves to be asked, and you can answer it
or maybe talk to Brian individually since he's here. But I'd
like the whole panel to hear it.
``The last three Connecticut nursing homes that were found
to be negligent in causing a resident's death were fined an
average of $560. Connecticut law says DPH can fine nursing
homes up to $3,000. With these small fines, there is no
incentive for owners to provide safe care. I've looked at
recent cases from 10 other states and found the average fine to
be $18,000. The Federal Government allows states to set their
own monetary penalties. In the 2013 legislative session, we
will be asking the Connecticut legislature to raise the maximum
fine to $10,000 and the minimum fine for causing a resident's
death to $2,000. Would you support our effort?''
Ms. Rexford. We are absolutely looking into this. In fact,
this past year the Connecticut legislature passed animal
cruelty fines. The first time is $1,000, and it can go up to
$5,000, and criminal charges can be filed. One of our members
has just done a spreadsheet on what our fines are and what they
are in other states, and we would be very happy to share that
with your office, and I have a feeling we'll be sharing that
with the legislature next year.
Senator Blumenthal. And may I just say, Brian, you've asked
about state law, but perhaps we can talk about changes in
Federal law and obviously work with Jean and other members of
the panel that may be appropriate in this area. So thank you
for the question.
The next questions are first from Patricia Kellmer of
Farmington, and this one is for Susan Davis. ``Can you
elaborate on the Connecticut Hospital Association's plans to
bring culture change to Connecticut hospitals? What are your
goals, and how do you intend to achieve them, especially for
those hospitals not already willing to change?''
Ms. Davis. Sure. The Connecticut Hospital Association,
through its Committee on Patient Care, Quality and Safety, has
been working over the past three years to put a plan in place
that will involve all the Connecticut hospitals in, first of
all, making a commitment, doing education of the leadership,
and bringing in a consultant from the nuclear power industry
that really does work on safety to teach us about all the
principles of changing behavior, because in order to change a
culture, you have to start with changing behavior.
The Connecticut Hospital Association has held two boot
camps in the month of June where we had CEOs, physicians,
frontline staff, and medical leaders come for a two-day event.
Each boot camp was two days where they learned about some of
the tools that can be used and the process for helping to
change the culture and create a culture of safety and high
reliability, looking at serious safety events, using tools to
monitor the serious safety events and improve the outcomes.
I can speak to what we've done at St. Vincent's. We have
gone through this process and we, in fact, have educated all of
our hospital employees in a three-and-a-half-hour course that I
taught, as well as all of our senior leaders taught to every
one of our 3,500 associates about safety and reliability, and
we also did the same thing for our physicians. That was taught
by medical staff.
So it's a real commitment. But when you try and answer the
question that you asked earlier of Scott about how you change
this culture, it's easy, because you change it by touching the
heart of the caregiver. Caregivers come into health care
because they want to make a difference in people's lives, and
when you can tell stories of people that we have harmed,
unintentionally harmed, it helps the caregiver understand their
role better and what they could have done differently in order
to avoid that medical error.
Senator Blumenthal. Our last question is from David
Shapiro, and I think it's broad enough to be addressed to any
of our witnesses. David Shapiro, M.D., West Hartford, ``How can
we truly achieve `collaborative patient safety' if hospitals
are constantly demonstrative of their competitive stance?
Billboards, ads, et cetera, say `we're the best,' but it's less
than accurate.''
So that one I will open to any of you. Again, I'm reading
the questions, I'm not asking them, but I think all of these
questions really deserve to be asked, and others, because it is
the consumers, the folks who are here today, who ought to have
an opportunity to be engaged and involved. So, any of you may
choose to answer.
Ms. Davis. I'll take a shot at it first since I've had the
opportunity to work through this with the Connecticut Hospital
Association. What I would say to you is it's a journey, it's
not an event. But to get all the hospitals in the State of
Connecticut together to say we're going to put aside our
differences and our competitive nature on issues and work
together to share information, share data, is a huge
undertaking, and it's a leap of faith, because we did have
discussions where some hospitals said, well, if I'm sharing my
data on my serious safety events, I don't want to see Hospital
Y putting a billboard up and saying come to us because Hospital
X has this many serious safety events.
We as providers have to be bigger than that. That's what I
would suggest to you. We have to understand that we're not
doing this for a competitive reason. We're doing it for our
patients, and that's what gets us up every day to come to work.
Senator Blumenthal. Dr. Ellner.
Dr. Ellner. I think part of the culture in health care is
that there's a zero sum competition right now. There's no
incentive for us to display our outcomes. We get paid for
quality, whether it's good or bad. So what we have to do is we
have to work together with CMS or the payers to put our
outcomes out there and be transparent, because that's what
we're going to move toward, a more transparent outcomes
reporting type of system. Unfortunately, this type of
competitive or zero sum competition, as Michael Porter calls it
at Harvard Business School, is not going to work five years
from now. It has to be based on value, your outcomes and the
amount that it costs to get those outcomes.
So part of the collaborative that we have in the state, the
Surgical Quality Collaborative, we have 17 hospitals that have
come together, 17 out of the 30, that are willing to share
their data in a collegial framework understanding that this is
about our patients. It's not about billboards. It's about
improving our patient's outcomes.
Senator Blumenthal. Thank you. I think that is a highly
appropriate comment on which to end this hearing. If any of our
witnesses have anything else they would like to add or any
closing comments, I'd be happy to entertain them.
[No response.]
If not, let me just say how truly thankful I am to each of
you for being here today. You have added enormously to the
information available to us. I can tell you I've been in the
United States Senate for about a year and a half. I haven't
heard a more thoughtful or insightful panel, and I'm very, very
proud that it happened here in Connecticut.
I'm very proud also that Connecticut is really at the
forefront. We have some leaders here, and I think that the more
we can add to this movement, the better. As Susan Davis said so
well, it isn't an event. This hearing is not the end. It really
is a journey, and I really want to thank all of you on the
panel and others who are in leadership who have attended today
for your really extraordinary work on this very, very important
issue. Thank you very much.
We will keep the record open for a week so that anyone who
wants to submit anything more can do so, and it will be
included in the record, including, by the way, comments from
others who may wish to submit them for the record.
For now, the hearing is adjourned. Thank you.
[Applause.]
[Whereupon, at 3:21 p.m., the hearing was adjourned.]
APPENDIX
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