Partnership for Patients: 'It's about time,' say quality experts

CMS predicts that the program will help save 60,000 lives

Hot on the heels of the release of its proposed rule to govern the operation of Accountable Care Organizations, the Centers for Medicare & Medicaid Services has unveiled its Partnership for Patients, a program whose main goals include the reduction of preventable harm in hospitals in the U.S. by 40% by 2013, and a reduction of hospital readmissions by 20% by the same deadline date.

While the Accountable Care Organization rule drew mixed reviews, the "Partnership" has been met with nearly universal acclaim. Organizations issuing statements in support of the initiative included The Leapfrog Group, the American Hospital Association, The National Patient Safety Foundation, and the Premier Healthcare Alliance, to name just a few.

"This is tremendous; it's really the first time the federal government has put substantial funding into capacity building around adverse events and preventing readmission," says Robert M. Wachter, MD, professor and associate chairman of the Department of Medicine at the University of California, San Francisco, and a recognized patient safety expert. "It's ambitious in that it recognizes the feds can't do it by themselves, but they need to form partnerships with all stakeholders. And it dovetails nicely with all the transparency and payment initiatives that will roll out over the next five years."

"I think it's very exciting that CMS is exerting leadership on patient safety," adds Leah Binder, CEO of The Leapfrog Group. "Unfortunately, we still have what I would call a crisis level of safety problems at U.S. hospitals, and it's time for the federal government to begin addressing this with more of the tools in its toolbox. It's also exciting that it is reaching out to the private sector and partnering, and moving forward in some kind of unity to address this crisis."

According to CMS, participants in the "Partnership" will include hospital leaders, employers, health plans, physicians, nurses, and patient advocates — as well as state and federal government. The Department of Health and Human Services will invest up to $1 billion in new funding provided by the Affordable Care Act. In a statement announcing the new initiative, the department indicated the investments would be apportioned as follows:

  • "Preventing Harm: The new Innovation Center at the Centers for Medicare & Medicaid Services (CMS) will dedicate up to $500 million to test different models of improving patient care and patient engagement and collaboration in order to reduce hospital-acquired conditions and improve care transitions nationwide. The Partnership will target all forms of harm to patients but will start by asking hospitals to focus on nine types of medical errors and complications where the potential for dramatic reductions in harm rates has been demonstrated by pioneering hospitals and systems across the country, including preventing adverse drug reactions, pressure ulcers, childbirth complications and surgical site infections."
  • "Improving Care Transitions: The new Community-based Care Transition Program at the CMS Innovation Center will provide $500 million in funding to community-based organizations partnering with eligible hospitals for care transition services that include timely, culturally, and linguistically competent post-discharge education, medication review and management, and patient-centered self-management support within 24 hours of discharge. Starting April 12, 2011, eligible community-based organizations and acute care hospitals that partner with community based organizations can begin submitting applications for that funding. Those interested in applying should visit: www.cms.gov/DemoProjectsEvalRpts/MD/itemdetail.asp?itemID=CMS1239313."

CMS claims that more than 500 stakeholders have committed to support the new initiative; you can find the list at partnershippledge.HealthCare.gov. It predicts that the program will help save 60,000 lives and "has the potential to save up to $35 billion, including up to $10 billion for Medicare."

Structuring partnerships

With the initiative just being announced, observers are not yet clear on how the partnerships will unfold — but that doesn't mean they don't have their own visions. "What we'd like to see is employers setting up value-based purchasing programs that are consistent with goals of value-based purchasing that CMS is involved in, so hospitals and others providers are given consistent messages about the performance they should seek," says Binder. "That does not mean we want the same exact incentive structures as CMS — I'm not even sure that's a good idea — but, for example, if CMS is focused on central-line infections, employers should also be focused on it. They might decide that if you use a hospital that has a low rate they will waive your deductible, or in contracting negotiations they will weigh those rates heavily. That's what's going to drive real change."

"While the program still has to be rolled out, my understanding is there will be funding available to support hospital networks, regional collaborations, some hospital associations, or even physician professional societies to do this work," adds Wachter. "I think we will soon see RFPs for working to improve safety. Later, when individual hospitals or groups demonstrate they have made real progress, there will be funding available to disseminate their lessons to other hospitals."

There are certainly echoes of IHI in the program, which is not surprising given that the former head of IHI, Don Berwick, is now the administrator of CMS. "They are mostly good echoes — lessons from IHI around campaigns that took hold, and got people enthusiastic around initiatives," says Wachter. "You need to have ambitious but achievable goals, and whether you're a 100-person operation in Cambridge or a million-person government in Washington, DC, you should not do these things alone; you have to try and make it a big boat with a lot people rowing."

"To his credit, in many respects this encapsulates the world view he has promoted his whole career," adds Binder. "That actually gives great vision and power for those of us working with him because of his personal passion; it makes it very exciting for all of us."

An investment of $1 billion certainly adds to the excitement, but will it truly help to improve quality and safety? "There's already a lot of momentum for quality and safety, built over the last 11 years following the first IOM report [To Err Is Human] and then Quality Chasm," says Wachter. "There's now a deeper understanding of the problems in quality and safety, better understanding, more research, more interest among caregivers and leaders, and more pressure that did not exist before in the form of transparency in public reporting — and now pressures of the payment system coming on line. The pressure was already there, organizations were already trying to figure out how to get the work done, but the partnership says, 'We, the federal government, with a lot of partnership, will do what we can to help.'"

Wachter recognizes that many are skeptical about government involvement, "But in this one the motives are good; they do want hospitals and healthcare systems to be motivated to improve," he says. "So we have a situation where the soil is right, everyone wants to do better, but sometimes they do not know how to prevent readmissions or hospital-acquired infections." If the government had announced a similar initiative five years ago, he adds, "I do not think it would have had the same effect."

Binder is convinced that quality and safety will improve as a result of the partnership. "If your child has a fever at two a.m. and you take them to the ED and they get admitted, you will have far less chance your child will get harmed or even killed by infection, medical error, the wrong medication, or any of a myriad of problems in the system that keep us up at night," she predicts. "There will be less worry when you enter a hospital that you will suffer even more from the visit than from the disease that brings you there."

But are the initiative's goals actually achievable? "Yes, I think they are, but they are ambitious," says Wachter. "Part of the key will be in the definition of what preventable harm truly is. If you look at studies of design to prevent readmissions, you will see results everywhere from a 20%-40% decrease, so the question then is what is the preventable number? There may be some wiggle room, but I like the concept — rather than saying we should prevent all readmissions, or all falls, which is completely unrealistic. I felt 50% was too high, and 20% was too wimpy."

"The goals are achievable, but ambitious," adds Binder. "Let's say this: If we just use this as a PR play and its business as usual it won't work, because it's too ambitious. But if we're bold and transparent in a way that's uncomfortable, it could work." (For more on transparency, see the related story, below.)

[For more information, contact:

• Leah Binder, CEO, The Leapfrog Group, c/o Academy Health, 1150 17th Street NW, Suite 600, Washington DC 20036. Phone: (202) 292-6713. Fax: (202) 292-6813.

• Robert M. Wachter, MD, Professor and Associate Chairman, Department of Medicine, University of California, San Francisco, Chief, Division of Hospital Medicine, Chief, Medical Service, UCSF Medical Center. Phone: (415) 699-1116.

'Transformed' QI leaders take center stage

Whether or not their facility takes the pledge to participate in the Partnership for Patients their role has been transformed in the last few years," says Robert M. Wachter, MD, professor and associate chairman of the Department of Medicine at the University of California, San Francisco, and a recognized patient safety expert, about quality managers. "They've gone from someone who often was there just to meet regulatory requirements and did not get deep involvement or engagement in QI and patient safety from doctors or hospital leaders, because there was relatively little skin in game, to someone who is now central to the hospital not only meeting its ethical obligation to provide high quality but the business survival of the hospital."

What this new initiative does, he continues, "is provide them potentially significant new resources in the form of potential funding for new quality and safety initiatives, and new opportunities for they themselves or people working with them to be trained in best practices and creative new strategies."

"I think they'll be extremely significant, and hopefully, pressure in the form of CMS and all of the partners will help elevate their leverage within the hospital," adds Leah Binder, CEO of The Leapfrog Group. "What they do is extraordinary; when I meet with them I'm extremely impressed with their knowledge, sophistication, and the treasure trove of information they have on how to improve. Sometimes they do not have the voice they deserve, and hopefully this will elevate their stature."


Expert seeks transparency from CMS

Leah Binder, CEO of The Leapfrog Group, is supportive of the new Partnership for Patients initiative unveiled by the Centers for Medicare & Medicaid Services, but she wants more. "I think the next step is for Medicare to publicly release the data it collects on core measures and patient safety indicators in hospitals so that the private sector can begin to analyze that data and publicly report it ourselves," she says. "They now publicly report analysis of data through Hospital Compare, but that just shows that hospitals are mostly average; I believe the public deserves to know what each hospital is reporting, so we are able to frame our own analysis. As we know from our Leapfrog analyses, there is very significant variation among hospitals — and that's not reflected in Hospital Compare or other public reporting."

Progress has been made, she continues. "We've had conversations with CMS, and they did report data on 'never events,' and we're very pleased," she notes. "They will get a lot of stakeholders concerned about too much public reporting, so we will have to continue to ask for it; it's not something other stakeholders will be happy about. However, it goes back to transparency — it will be very, very important in maintaining this partnership of trust. We need full transparency of what we learn in the performance of hospitals so the public, employers, and other purchasers, as well as government agencies will be able to share that information and use it productively together."