Healthcare Quality & Provider

Advisory Committee

SustiNet Healthcare Quality and Provider Advisory Committee Regular Meeting

April 15, 2010

Meeting Minutes

Committee Attendees:  Margaret Flinter, Co-chair; Todd Staub, Co-chair; Steve Karp; Paul Grady; Tina Brown-Stevenson; Robert McLean; Nelson Shub; Leslie Connery; Rodney Hornbake; Alison Hong; Mike Hudson; John Lynch; Jean Rexford; Claudia Gruss; Gary Harding; Linda Spivak; Jeff Walter; Clarice Begemann; Jody Rowell; Jerry Hardison; Lynne Garner; Sarah Long; Bob Scalletar; Teresa Dotson

Office of the Healthcare Advocate:  Vicki Veltri

Margaret Flinter and Todd Staub, co-chairs of the Committee, welcomed all members and attendees. 

Todd reported on the SustiNet Board of Directors retreat that was held on 4/14/10.  A timeframe was developed to assist the five Committees and three Task Forces with completing their reports in a timely manner.  A template will be designed so that each Task Force and Committee can submit recommendations in a similar format.

The timeline is:

Consultants will be hired to help with writing and pulling reports together.  Task Force reports will go directly to the Legislature, whereas the Board will take the final Committee reports and create a final product to present to the Legislature.  Also discussed during the retreat was the need for communication among groups in order to collaborate, helping to achieve goals in a timely manner.  The other charge to the Board is that within 60 days of the signing of federal healthcare reform the Board must present an interim report to the Legislature on the impact this has on SustiNet.  Todd said that federal legislation gives SustiNet a very good chance of being real.  Essentially SustiNet will become a public option for CT, providing an opportunity to reform a large segment of healthcare delivery.  Margaret said that the price tag originally associated with SustiNet will go down based on federal reform because of additional subsidies.  She also said that Stan Dorn, who is acting as a consultant for SustiNet, gave a valuable power point presentation that is now posted on the Sustinet website.  She said that a new development is that SAGA clients may be enrolled into Medicaid, which would be an important step in providing coverage for a vulnerable population.

Jean Rexford facilitated a discussion on patient safety, beginning with general principles of patient safety.  She said that hopefully all the changes that happen with SustiNet will contribute to a culture of patient safety.  Linda Spivak said there needs to be a principle about the responsibility for (inaudible) a continuum of patient safety.  Margaret said that it is essential to measure and report (inaudible).  Rod Hornbake said that National Quality Forum has a document posted for public comment that summarizes public reporting and patient safety event information that he thought would be helpful to this Committee.  Tina Brown-Stevenson wanted to know what methodology will be adopted in order to create a culture of continuous improvement.  Steve Karp emphasized the importance of improving communication, not only between providers, but also between providers and patients.  Todd said that studies have proven that when family members spend time at hospital bedsides, quality improves.  Involving patients and family members helps to eliminate errors simply by keeping more people aware of what’s going on.  Nelson said that every patient should sign a form designating who could discuss important issues for the patient in the event the patient is too sick to do so.  It was decided that this concern should be included in patient empowerment.  John Lynch said that a concept to add to the list is dedicated resources.  Hospitals have entire units dedicated to patient safety and quality whereas this doesn’t exist in the outpatient world.  For example, if there is a safety issue, there needs to be a team of experts available to resolve the issue.  A few patient safety organizations in CT were mentioned.  Vicki Veltri said that patients need to be able to make informed decisions.  She suggested that SustiNet could provide a resource for people to obtain independent information, perhaps using a website.  An unidentified speaker pointed out there is currently work being done to establish a health information exchange (HIE).

Jean opened the discussion on patient empowerment and education, saying that it is difficult to educate patients.  It is hard to determine the lines of authority, responsibility and accountability.  Language used by healthcare professionals isn’t always understood by patients, so data needs to be translated for patient understanding.  Jean suggested that SustiNet consider using independent patient advocates as many hospitals are doing.  Jeff Walter said that this is where family involvement and access to a medical home fit in.  Robert McLean said that he didn’t think billing fraud should be included here and Jean agreed to remove it.  Claudia Gruss said that small private practices are very different from hospitals, and this Committee should develop a system for providing resources to private offices, being mindful of language and cultural differences.  An unidentified speaker said that programs should be tailored to local communities using local resources.  Mike Hudson said that when patients leave the hospital, they are often on their own, which underscores the importance of providing resources for small providers (inaudible).  Alison Hong’s comments were inaudible.  An unidentified speaker said that many patients have no concept of healthcare costs.  Jean said that often when people can’t understand billing, they become suspicious, which doesn’t help with compliance.  She said that compliance and transparency of costs would be added as concepts of patient safety after figuring out where they would best fit.  Jean’s next comments were inaudible, as were Jody Rowell’s.        

Steve said that SustiNet’s online directory should indicate languages that providers are fluent in so that patients can seek providers who speak their language.  Mike said another advantage to using an HIE would be that it would help to identify people who are at risk (the rest of his comments were inaudible).  Linda said that the individual patient advocate needs to be a concept beyond hospitals.  Advocacy and responsibility for advocacy should help patients manage medical care across their life spans and not just focus on costs and acute problems.  There are problems with safety and quality in every clinical setting that should be addressed.  Nelson spoke of patients going from one facility to another, often having tests repeated unnecessarily at great expense, showing the need for greater communication among providers.  An unidentified speaker said that an HIE would improve this.  Margaret said there are pilot HIEs beginning soon.  She also said that for 30 days after hospital discharges, there should be someone available to ensure that follow up occurs.  (Many inaudible comments were made here).  An unidentified speaker said that using translators or interpreters is very expensive for providers.  Todd mentioned shared decision making as a model of engaging people in assessing risks and alternatives, saying that this should be included in SustiNet (inaudible). 

Jean said that in approaching reporting systems of errors, she looked at the work of two gurus of safety, Dr. Lee and Dr. Don Berwick.  Claudia Gruss quoted from “To Err is Human” about how medical errors are usually caused by faulty systems, processes and conditions rather than individual recklessness.  This is an important concept that has been embraced by the hospital sector.  Claudia also recommended a voluntary reporting system in addition to the mandatory system already in place.  She also spoke of laws that would protect the confidentiality of certain information collected, ensuring that providers who participated in voluntary reporting systems were protected from lawsuits.  This is necessary to avoid errors being pushed underground, and needs to be done in a proactive, positive way and not a punitive way or people will not participate.  Information collected needs to be de-identified so that errors are looked at as part of entire systems and acted upon broadly.  Jean said she had used the term “just culture” in describing error reporting, hoping to emphasize the need to de-identify.  She said that error reporting is a controversial area.  John said that by focusing on errors, to some extent the other end of the equation, best practices, gets missed.  The focus should be on the positives of identifying the best practices in these reporting systems and then creating and disseminating them. 

Jean brought up science based medicine, but her comments were (inaudible).  Lynne Garner spoke of the importance of reporting on safety rather on errors, looking at positives and negatives.  She said there are very good surveys available on safety culture that might prove valuable for this Committee.  Steve emphasized the importance of creating a culture where patients and families feel comfortable filing complaints.  Jean said that “just culture” is a culture where everyone is empowered.  She said that information submitted by hospitals and physicians needs to be accurate and not just random.  Regarding adverse events, Robert questioned the IOM data, (inaudible).

Jean said that in looking at over use, she felt that it was important to determine who is responsible and how this can be changed.  She said that this is rarely talked about but needs to be addressed.  Todd said that studies have shown that in areas of the country with the highest costs, more money has been spent for lower quality treatment/services.  He termed this “toxic assets,” saying that overtreatment is a serious issue.  He mentioned that 2% of cancers in the US are caused by diagnostic radiation, and one CAT scan equals about 500 chest x-rays worth of radiation.  Not a lot of thought is going on about the larger picture.  Todd said that there is a fear of being sued which drives some of this.  Jean said that some of this is from a lack of communication from one hospital to another.  Todd said that is not a big factor, and that every ER wants a CAT scan done for everyone who comes in who has banged his head.  He said that the issues of tort reform, safety and linkage are tough to resolve.  (Inaudible comments.) Jean said that there is also a huge marketing problem.  Robert said that original SustiNet legislation included some tort reform protection, so this would be a perfect place to strongly endorse to the Legislature that this needs to be part of it.  It’s a huge cost driver.  (Inaudible comments.)  An unidentified speaker said that in talking about what an idealized healthcare system would look like, the big question is how to afford it; tort reform could provide an area where potential cost savings could be generated.  An unidentified speaker said that regulatory oversight needs to be coordinated.  Another unidentified speaker said that oversight needs to be simplified.  Claudia said that accreditation should be mandatory.  An unidentified speaker said that in CT most primary care doctors are middle-aged and older, and because of being grandfathered, aren’t required to recertify.  She said that there needs to be a way to educate, measure and build a system that includes private practices.  She said this Committee also needs to focus on the system and not on individuals.

Addressing education, Jean said that she has learned that there is a gap of 17 years from the time science gets published until the time it becomes implemented.  This is something that needs improvement.  Linda agreed, giving as an example the use of n95 masks for flu protection.  Flu is probably one of the most difficult, expensive things to manage, but the science is not yet in place to require hospitals to use the masks.  Because of very powerful interest groups, there is now a requirement to use them.  It’s not about treatment, but rather about (inaudible) and product placement.  Jean said that somehow conflicts of interest have to get out of healthcare because they aren’t good for people’s health.  Lynne spoke of science based medicine, saying that this might provide an opportunity for SustiNet to work synergistically with healthcare reform.  Rob said that he doesn’t think healthcare can ever get away from conflicts of interest.  He said that this Committee can endorse guidelines done by organizations such as US Preventive Services Task Force that tend to be unbiased and are explicitly set up that way.  If the providers in the SustiNet network are following those evidence-based guidelines then they can’t be held liable.  Rob said that this Committee also needs to promote patient education.  Lynne and Jean’s comments (were inaudible).  Jean thanked all Committee members for their input.

To summarize, Todd said that safety goes across the continuum of healthcare and is a team based activity.  SustiNet will need to look at creating a central resource that provides advocacy, cost improvement methodologies that can be taught to small practices, and the promotion of best practices using things such as checklists.  SustiNet needs to promote HIEs and a medical home strategy, both of which could help in improving patient safety.  There is a need for a proactive approach to safety, identifying safety risks and working to lower those risks.  Incentives and a “just culture” would allow reporting in a nonpunitive way.  In time, there should be rewards for safety, perhaps tied to compensation.  There is a link between overtreatment and tort reform.  Science based medicine (inaudible).  Margaret said the Committee should take Jean’s outline and use it to make specific recommendations based on personal perspectives and expertise, focusing on mechanisms for promoting safety, the education of and training of providers and what SustiNet’s role is.

Meeting was adjourned.  Next meeting is May 20, 2010 from 8:00 – 9:30 am.

SustiNet Healthcare Quality and Provider Advisory Committee Regular Meeting, April 15, 2010, Meeting Minutes