Nicolas Argy has 30 years of clinical radiology practice. After graduating from Boston College Law School he was hired as Risk Manager for the Rhode Island JUA, the statewide medical malpractice insurer. Having worked at both academic and community hospitals he has been invaluable in understanding the needs of both private practice and tertiary care centers. He also worked for Brigham and Women’s Hospital, as department chairman for radiology at Cape Cod Hospital.
He had Clinical Process Improvement at Partners Healthcare certification in the methodology and science of process improvement, as well as over a one year period training at Harvard Business School. He also works at the state Board of Registration in Medicine Quality and Patient Safety Committee. Nicolas is IHI certified, and Master Certified in Team STEPPS.
He is a lecturer on a wide range of topics in public health, risk management, population health management, process improvement, patient safety, medical errors, culture of safety, communication/EMR. His blog includes posts on big data analytics, wellness, cost strategies in healthcare, behavioral health, healthcare innovation/finance, pharma/medical device topics and medical legal issues. He serves on the Massachusetts Medical Society Committee for Quality of Medical Practice and on the Committee for Public Health and as an adviser to the Professional Liability Committee.
Nicolas is an Adjunct Professor at Boston College at the Woods College of Advancing Studies.
During the Patient Safety Awareness Week I will publish interviews and articles about patient safety. Today Nicolas talks about evidenced-based medicine, patient centred care, new technologies and the future of patient safety.
Most of the people who work in the fields of patient safety and are interested in adverse event have read “To Err is human”, published by IOM 15 years ago. What has happened after this article?
To Err is human was published 15 years ago. It is a seminal article that we all refer to so frequently. And the sad statement is how little progress we have made in that time.
There are different studies on the number of medical errors, that have been published and it is absolutely staggering how huge the numbers are. The numbers suggest medical errors as the third leading cause of death. 1/3 of interactions with patients lead to adverse events. The Johns Hopkins study, published by BMJ, suggested that medical errors are the third leading cause of death and there is no reason to think that it is any different in any other healthcare system. The numbers ranging roughly from 170 000 to 251 000 deaths caused by medical errors in hospitals in the United States defined by the authors as people dying” from the care they receive rather than from the disease or injury that brings them to care”.
There are people arguing against these numbers, but I will actually suggest that it is underestimated. So, it is a staggering number and there is a huge opportunity to improve and we haven’t made any significant inroads.
There has been plenty of data, that has been published by Agency for Healthcare Research and Quality suggesting that there has been decrease of some of the HAI, but a lot of those trends were actually in place prior to the execution of ACA. So, the exact reason why some of these trends suggest why we are moving in the right direction is unclear. But again especially infections by antibiotic resistant bacteria, another gigantic problem, there is a resent publication 350 million deaths will be caused by the superbugs by the year 2050. The number is just beyond belief. And a lot of this is due to very simple lack of AB stewardship.
What are the reasons for that? Hospitals in the USA have quality and patient safety departments. There are different incentives, initiated by JCI or ACA. There is budget allocated for patient safety. You have also AHRQ, working on those problems.
It is multi-factorial explanation. The major problem was for 15 years there was really no incentive to address medical errors in terms of reimbursement and how the system is set up. We live in a sick care model. Hospitals get paid to take care of sick people, to take care of people who are hospitalized. There is no reimbursement when people are healthy. Traditionally before ACA almost all the hospital acquired conditions were all being reimbursed. If you go into a hospital to treat pneumonia and you fell and you broke your hip the hospital got paid both for the pneumonia and the broken hip. So, it is a sad statement and I am not implying that this is intentionally, but entire industry of 3.2 trillion dollar in the USA is taking care of sick people rather than promoting health. And it is something that I have written about extensively on my blog, that we need to a fundamental paradigm shift. The sad example I give is that hospitals don’t’ get reimbursed for readmissions within 30 days of the discharge. So there have been really big efforts to reduce that. Spending $10,000 to eliminate 30 day readmissions is worthwhile to hospitals but spending an additional dollar to eliminate readmissions from day 31 to 60 actually decreases revenue to the hospital because they would be compensated of that care. What is good for patient well being frequently has negative financial consequences for hospitals and providers . We should be trying to keep the patients out of the hospitals all the time, not only for 30 days. So, again, there just no incentives in place. We need to change that paradigm.
You write and talk about evidence-based medicine a lot. Recently you published an article, saying that the majority of medicine currently practiced has not been scientifically validated and further physicians practice medicine without understanding the biology of the diseases which we are treating. You also share data form Dartmouth Atlas of healthcare and other sources, saying that 50 to 85% of medical practice is not supported by solid scientific evidence. How this is related to patient safety?
They are intimately related. There are many studies that reflect on what percentage of practiced medicine is evidence-based. The numbers are highly variable but I can say that probably half of the medicine that has been practiced is not evidenced based. It is actually fascinating that people argue against science. I never stop to be amazed by people who say that we should reimburse treatment and interventions, and diagnostic procedures which there is no evidence that will help patients. John Ioannides, a highly respected statistician and Professor at Stanford, has reported a decade ago that most peer reviewed published scientific studies cannot be validated or reproduced due to poor statistical analysis or scientific bias. Harm is inherent in a system where care is not based on science.
It is a sad statement that some patients receive treatment for something that there is no scientific evidence that it can help.
So if we eliminate 50% of the treatment, that is not evidence-based, 50% of the errors would go away.
I think we really need to say that we are going to practice medicine based on science, based on objective measures, using the best evidence we have. One of the solutions is not only to require evidence based medicine to be practiced, but to engage patients, to bring patients to the forefront. I have already referred to the expected millions of deaths due to AB resistant bugs and it is simply because we are not practicing evidenced-based medicine.
People are using antibiotics haphazardly and we get horrible superinfections and literally millions of people die. It is really tragic.
You mentioned that we need to bring patients to the forefront. Tell us more about the value of patient-centered care and informed consent and their connection with patient safety.
It is an excellent question, because patient-centered care is the golden rule in healthcare. Treat patients as you or your loved one would want to be treated. And that does not happen often. Very frequently people get care that is either promoted by the medical industrial complex, medical pharma, medical device manufacturers, medical literature in terms of academic, but again without solid scientific evidence. The key for informed consent is the basic principle of letting patients know risk, benefits and alternatives. And I use the example to informed consent as a method of living of your life. You shouldn’t be making your decisions about buying a car, going to a vacation or buying a new home without not knowing what the alternatives are, what the benefits of a one place are over another. Would you go on a vacation where it is a politically unstable government? I would say that people spend more time choosing their auto mechanic that choosing their physician. Informed consent is the continuation of patient engagement.
We have this amazing thing called internet where people can get information. I always suggest that people should get a second opinion. Second opinions can be invaluable. And the first thing I hear is that “my doctor will be insulted”. As a radiologists with more that 30 years practice, when my patients ask me for a second opinion I would strongly encourage them to get that. And I would tell them that “if you hear something different then I told you, I want to be the first person to know.” And if your doctor does not allow you to get a second opinion, I would say: it is time to get a new doctor.
Let’s “move” to my country. We are as a toddler in terms of patient safety. What are your recommendations for a country like Bulgaria?
The recommendations one makes depend on whether it is a resource rich country or resource poor country. Patient engagement is extremely valuable and should be encourage. The practice of evidence-based medicine. And those things are low hanging fruits. Patient engagement and involving the patient in healthcare decisions significantly reduce the medical errors. The reality is that every delivery, even in poor healthcare settings, needs to be done using techniques that are evidence-based and involving the patients in the decision-making. And again the more complex the system gets, the more prone it is to error.
Those keys are easily open to every country and provide opportunity.
The other key is the culture of safety and the concept that you can improve. This is crucial for minimizing medical errors and enhancing patient safety. Commitment to safety and excellence. A commitment to caring about the patient and the system is a pathway to safer, better, higher quality care. Donabedian, said love is ultimately the solution to taking care of and enhancing safety and quality. Deming’s work in terms of system improvement. Eleven of all the measures that Deming describes are related to human factors. And those human factors need to be taken account of when making decisions to enhance patient safety. The reality that there are enormous tools available. Whether you use Lean or Six Sigma or any other systems or analytic tools. The key is to recognize them, to use them.
The key is that after good system analysis whether that be an RCA or PDSA cycle operationalize your solution and implement them in a fashion that is effective. If the solution is to write a new policy and educate you will fail in changing your system. Education alone does not change behavior. When you correct errors in the system you need to do in a neuro cognitive aware fashion, which means a fashion that will create a sustained change in human behavior.
What is your opinion on new technologies. Could they improve patient safety? For example patient electronic records?
Another excellent question. Technology is viewed as a “quick fix”, unfortunately there is no quick fix. And the technology can actually exacerbate the problem of patient safety. The best example I can give is the one you gave: electronic patient records. Literally thousands of patients have died due to poor handwriting, meaning they received the wrong medication because the pharmacists couldn’t read the handwriting. So, the gut feeling is that when you change writing with electronic patient record you will never have another patient dead due to poor handwriting. The problems is that what we traded for bad handwriting is “fat fingers”. So “fat fingers” that hit the wrong key or double quick the mouse prematurely cause the same error. You just hit the key for 40 milligrams of codeine instead of 30 milligrams of codeine. Technology often is seen as a solution and it is a superb solution: the pharmacy delivery system for example.
Every technology should be measured and viewed within the context of human factors and the context of the system. One great example is the “alarm fatigue”. We think that alarms could safe lives. But healthcare proffessionals often ignore the alarms, because we have so many false positive alarms.
Technology has the potential to solve certain very discrete problems, but it can actually exacerbate other problems or create new problems. And whatever technology is adopted, should be done in a way it is understood how it will interface in the workflow and delivery of healthcare.
What is the future of patient safety?
Well, for example, the ABR bacteria really indicate how vulnerable both resource rich and resource poor geographies in the world are. And people will die of super infections whether they are in Africa, India or New York. I thing honestly the solution to patient safety requires a bigger commitment. To move from a sick care model to wellness model.
I will tell you an anecdote about a hospital who purchased a practice that was highly successful, very profitable. They did excellent population health management, they had same-day appointments for their patients, and they were efficient and the patients were very healthy. So, when the hospital purchased the practice, they wanted to convert their existing employed physicians to that model. And then the financial office looked at this and said: “based on the fact this practice give same-day appointments our ER visits will go down with 29%. They do good population health management and they have lower incidence of diabetes, heart failure, and lower rate of hospitalizations due to chronic conditions and switching over a healthier model the hospital will going to lose between 85-100 mln. dollars per year.” And they did not make this conversion. This is an example of how the incentives are.
And I say that anecdote in the context of patient safety, because we need to change the model. And again self-ensured employers have no vested interest in medical industry complex, they have interest in keeping their employees healthy, productive, low absenteeism. All those incentives are incentives of wellness and health and being better. Self insured employer would always make the right decision in the situation of the anecdote I mentioned. Again, the government should adopt the same principles, but the government doesn’t have this incentive because of the huge lobbies.
Moving from sick care to wellness care means that if we are not taking care of sick people, they cannot get injured by medical errors.
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