David W. Bates, M.D., M.Sc., known internationally as an expert in patient safety, served as adviser for the November 2018 issue of Health Affairs, devoted to the topic of patient safety. The issue includes an essay coauthored by Dr. Bates that explores future directions in patient safety. He is Director of the Center for Patient Safety Research and Practice and Chief of the Division of General Internal Medicine at Brigham and Women’s Hospital in Boston, as well as the Medical Director of Clinical and Quality Analysis at Partners HealthCare. Dr. Bates has served in leadership positions for the World Health Organization’s Global Alliance for Patient Safety, the International Society for Quality in Healthcare, the Board of the American Medical Informatics Association and is a member of the National Academy of Medicine.
The Betsy Lehman Center: In Health Affairs, you and Dr. Hardeep Singh foresee a “Golden Era” in which patient safety is measured and improved “inside and outside the hospital, continuously, routinely.” How likely or imminent is that Golden Era?
Dr. Bates: It is technologically possible now. Several commercially available applications do a good job of measuring most of the main types of adverse events in inpatients — none is comprehensive, but all could be made so fairly easily. But none is required today. We have the strongest requirements today around hospital-acquired infections, which not coincidentally are the ones organizations do the best job with.
For the Golden Era, first we need to develop tools for the outpatient setting analogous to what we have now for hospitals, which wouldn’t be difficult. Second, electronic health records need to be tuned so that safety-oriented decision support is much more effective. And third, organizations need to have safety teams to manage these areas.
Nearly all the focus has been on the inpatient setting; we need some regulation to encourage organizations to balance their focus. Whether and when this happens will depend on implementing the policy steps Dr. Singh and I outlined in our essay. There isn’t active discussion of these yet, but there should be — and it would be a great complement to broader implementation of accountable care, which I see as very likely. I am hopeful we might get there in the next five to 10 years, but that is not a given.
The Betsy Lehman Center: You refer to the need for policies to encourage or require organizations to use proven tools and strategies. Please say more about using public policy to improve patient safety.
Dr. Bates: There are several keys to achieving progress. One is to give the Agency for Healthcare Research and Quality adequate resources to continue to support cutting-edge safety research. The National Institutes of Health could also support some of this work.
Dr. Singh and I also argue that we need reliable metrics to assess safety, which can be extracted routinely electronic health records, and that organizations should be required to publicly report these rates. We suggest avoiding penalties for all but the most severe adverse events — the hospital-acquired condition program has been counter-productive in our view. Incentives are also needed to get organizations to pursue a learning health systems approach to safety, in which measurement creates evidence for improvement. Health systems will also have to expand their patient safety capacity and infrastructure to deal with new issues, such as safety outside the hospital, and safety issues created by new technologies.
New approaches like evaluation of real-time and sometimes “big” data should be used to identify patients who are likely to decompensate or suffer some specific type of adverse event, like kidney failure. Finally, a national safety center would help organizations share key lessons quickly and broadly and disseminate effective interventions.
The Betsy Lehman Center: Would you encourage ambulatory clinics and practices to adopt hospital-based best practices, or do ambulatory practices need to find their own way?
Dr. Bates: Applying hospital-based best practices in the ambulatory setting can be a good idea; for example, when procedures formerly done in the hospital are done in outpatient settings. But many inpatient best practices don’t translate that well and would likely be a waste of time and resources. An example would be to give every outpatient a wrist bracelet with their name on it. We need more evaluation of what works best in the ambulatory setting.
The Betsy Lehman Center: What do you say to people, especially patients and families, who think the need to improve patient safety is urgent and are feeling impatient about the slow pace of progress?
Dr. Bates: It is essential that they continue to make their voices heard. Patient stories about what it is like to be harmed have been valuable for promoting progress, especially on the policy front — it is easy for politicians to relate to patients through their stories. Continuing to push for transparency around rates of harm is also critical. There is a risk that the safety issue could be put on the back burner. That would be tragic in my view; we just haven’t made enough progress yet.
The Betsy Lehman Center: Is there one change or intervention within reach today at either the provider or the policy level that you believe could have a major impact on safety improvement in the short term?
Dr. Bates: Perhaps the biggest would be if the Centers for Medicare and Medicaid Services were to require organizations to publicly report rates of the main types of adverse events in the inpatient setting — hospital-acquired infections, adverse drug events, blood clots or thromboembolic events (deep venous thromboses and pulmonary emboli), falls, pressure ulcers — and to use electronic detection tools to find them.
