PROs may spearhead error reporting initiative

Critics worry that federal regulators will use PROs to spy on provider operations

Lost in the controversy over President Clinton’s plan to force hospitals to report serious adverse events has been the important question of who’s likely to be in charge of the systematic, nationwide error reporting process. The administration says it wants to take a state-based approach to error reduction, but some experts wonder how the federal government can mandate state action. Hospital Peer Review has learned that the answer probably lies with the nation’s existing network of peer review organizations (PROs).

Taking the lead on error reporting and reduction is a natural extension of the role PROs historically have played in health care, says William Golden, MD, president of the Washington, DC-based American Health Quality Association, which represents the nation’s PROs. "You could look at it a couple of ways. One is that we’re already doing quality improvement and performance measurement assessment. Sometimes, we have done root-cause analysis depending on the nature of what we’re analyzing." Golden adds that, in the past, PROs were very active in performing case reviews, and because they were random, "we could uncover serious episodes of unusual character. That was part of our mission — to take a case review where something dramatic might be found and then work with the facility to ensure that it would not occur again."

But not everyone’s likely to be enthusiastic about a return to the "good old days" of PRO case review. "I think it would be very much resisted," says Sanford E. Feldman, MD, a retired surgeon in Mill Valley, CA, who has published extensively on the subject of medical errors. Feldman also served for several years as medical director of the PRO California Medical Review.

Feldman notes that PROs stopped doing external case review in the first place because of opposition from medical and hospital associations. "The attitude about the PROs from the medical association viewpoint was that it was a police-state kind of thing," he says. The associations objected that not all of the physicians who performed case review on behalf of the PRO were qualified to judge whether a case was mishandled or not. "It got to be a fight over each and every case," he says. "Gradually, HCFA [the Health Care Financing Administration, which administers the PROs] basically gave in to that movement and first reduced the number of cases [the PROs] reviewed and then eventually lessened the pressure to see those cases at all."

Controversy stirred again in late 1998, when HCFA assigned the PROs responsibility for detecting billing errors and reporting those errors to the Health and Human Services’ Office of Inspector General and other enforcement agencies. At the time, some providers contended that the plan would poison the relationship between providers and PROs, and even Golden’s organization opposed the idea, contending that PROs should maintain their newfound focus on quality of care. With medical error reduction, however, Golden is convinced that PROs can maintain collegial relations with providers by putting their error reduction activities "more into a quality improvement kind of mode, rather than a gotcha’ kind of mode."

Indeed, Golden says that PROs’ generally positive relationship with hospitals is a big part of the argument in favor of allowing PROs to coordinate the national error reduction effort. "A lot of this in terms of error reduction is education, outreach, and communication," he says. "Obviously, if you go in there like a stern parent, people will be turned off. Over the past several years, because of our quality improvement activities, people have become used to how we’ve approached them. Most facilities and professionals want to do the right thing, and if they are given an environment where they are treated as professionals, to respond and then to make changes in safety systems, then I think that problem would not be a major issue."

Steven Shea, RHIA, MBA, senior consultant with Sheasp Healthcare Consulting in Winchester, MA and sponsor of the World Wide Web site, concedes that using PROs to spearhead error reduction and reporting activities represents "a logical model. Instead of creating another bureaucracy, it would be a reasonable thing to do." Nevertheless, he remains concerned about the issue of government control of the error reporting process. "Doctors and hospitals are going to say, Wait a minute, you guys are just another arm of HCFA. You’re just going to send in the HCFA police if problems exist."

Golden argues, however, that PROs are the logical choice to handle error reporting activities because the PRO program has built-in peer review protections — something health care advocacy groups like the Chicago-based American Medical Association and American Hospital Association are strongly pushing for. "Right now, you can say very clearly that errors reported for Medicare patients to PROs would have peer review protection and would not be subject to Freedom of Information [requests] or subpoenas," Golden says. "That would fall under the Peer Review Protection Act."

Golden adds that "if you want to have a constructive program [that emphasizes] error reduction as opposed to punishment, then that’s going to be an essential piece of the whole operation. And if other entities need to be doing this work, then you’d have to extend peer review protection to [them]. But the PRO program can do it right now."

Even peer review protections, however, won’t necessarily protect all providers who report errors, Shea contends. He notes that even if such protections were in place, they would be easy enough for investigators to get around. "You can still get all the information you want about a case, about the events, and about the analysis, just by deposing people," he says. "You know a case occurred, you know Dr. X was involved, you get a copy of the medical record, and you just go through and start picking out some names and chatting to people. I don’t think there are any protections that will keep [investigators] from deposing those people and getting the information on the case anyway. So the idea that peer review protection is going to give you an absolute barrier from people being aware of an event, it’s just not true."

Shea says that no matter what structure the government devises to collect and analyze data on medical errors, hospitals’ best defense is to set up a strong internal system to identify serious adverse events, conduct thorough root-cause analyses, and institute effective action plans that result in true improvement in patient care and services — very much the approach hospitals already should be taking with regard to the sentinel event reporting policy of the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations.

The larger issue, however, is whether the industry should be rushed into a mandatory error reporting system at all, says Martin Merry, MD, a health care quality consultant and associate professor of health management and policy at the University of New Hampshire in Exeter. Noting that the president’s proposals came in response to a widely publicized report late last year by the Washington, DC-based Institute of Medicine, Merry says, "It’s interesting that so much attention has focused on mandatory reporting, when another part of the report [advocated] creating a culture of safety. What we really need to do is to change the whole culture of health care to one of safety and excellence and get away from this kind of witch-hunting of the worst end of the quality [spectrum]."

Further, Merry says, the regulatory focus of the recent discussion of medical errors "represents a bankruptcy of more creative ideas about how to move the whole system forward." He adds, "I’m reminded of the old saying that if you’re a hammer, everything looks like a nail. If you’re a regulator, and [mandatory] reporting is the only thing you can think of, you pound a little harder on the reporting. My concern is that all this attention we’re giving to regulatory processes might actually detract from the energy we should be putting in moving the whole quality curve forward."