AHRQ Views: Blog posts from AHRQ leaders
We're Keeping Score: Reducing Hospital-Acquired Conditions
As a primary care physician, keeping patients safe has always been important to me. After all, one of the first things we learn in medical school is "do no harm." I've never worked with a single doctor or nurse who didn’t share a commitment to this principle.
Despite the best of intentions, the care we provide sometimes isn’t as safe as it could be. Many safety events aren’t the fault of an individual, but can be traced to systems failures that undermine clinicians' ability to deliver safe, high-quality care. This may occur, for example, when a patient experiences a hospital-acquired condition (HAC), which is a problem that arises as a complication when a patient is in the hospital being treated for something else. HACs can increase the length of a hospital stay, lead to pain and suffering, or even result in death.
HACs are preventable conditions that AHRQ is focusing on with laser-like attention. These include adverse drug events, central line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), pressure ulcers, falls, and more.
I'm pleased to report that our efforts are paying off. The latest AHRQ National Scorecard on Rates of Hospital-Acquired Conditions shows that HACs have fallen by 21 percent since 2010. That's right: from 2010 to 2015, more than 3 million adverse events were averted. Approximately 125,000 fewer patients died in hospitals due to HACs, and more than $28 billion in health care costs were saved due to the decline in HACs.
In 2015 alone, an estimated 37,000 deaths due to HACs were avoided. By comparison, that’s more than the 35,000 Americans who lost their lives that year in motor vehicle accidents.
These are astounding numbers. They also affirm the decision by Congress more than a decade ago to assign AHRQ the task of building a foundation of patient safety research and developing, demonstrating, and evaluating strategies for reducing patient harm and making care safer. We’ve done just that, and now AHRQ's comprehensive set of tools to help prevent HACs, along with concerted national attention, are leading to significant change.
Many organizations supported this progress toward a safer health care system, including the Partnership for Patients initiative, a public/private partnership working to improve the quality, safety, and affordability of health care. Examples of efforts that helped to make it happen include:
- Hospital leaders prioritizing HAC reduction;
- Frontline clinicians learning how to apply patient safety knowledge through tools developed by AHRQ and others;
- Payment policies by the Centers for Medicare & Medicaid Services (CMS) and other payers, creating financial incentives for improvement;
- Public reporting, making hospital performance transparent;
- Technical assistance by CMS’ Quality Improvement Organization program and the Department of Health and Human Services' Partnership for Patients; and
- Electronic health record systems, enabling easier access to data.
I'm particularly proud of AHRQ's role in developing and testing much of the evidence on how to prevent HACs. For instance, hospitals frequently use AHRQ's Comprehensive Unit-based Safety Program, a proven method that combines improvement in safety culture, teamwork, and communications with evidence-based practices to prevent harm and make the care patients receive safer.
CUSP is a perfect example of how collective effort can effect change. Let me explain. First, AHRQ funded research to develop the CUSP methods, initial testing, and broad implementation to reduce CLABSI. CMS then publicly reported hospital performance on CLABSI and created financial incentives for improvement. HHS prioritized prevention of CLABSI, CAUTI and other HACs as focus areas for which its Partnership for Patients could provide technical assistance to hospitals. And hospitals nationwide made reduction of CLABSI and other HACs a priority.
In other words, a lot of entities played a role and worked together, and patients benefited as a result. That impressive teamwork drew from and built upon the investments Congress has provided to AHRQ since establishment of its Patient Safety Program. It gets me thinking about how much more could be done with additional sustained investment to address the harm that still occurs.