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IOM Rosenthal Lecture

Washington, DC
May 2, 2011

Remarks as prepared for delivery

Good morning. I want to thank Harvey for that kind introduction and for his decades of work to improve health care for all Americans. I also want to thank all of you here today who make the IOM such an indispensable resource. One of my goals as Secretary of Health and Human Services has been to make sure our policies are guided by the best science and medical research, and your work helps us do that every day.

We’re here today to continue a conversation that the IOM helped start twelve years ago with your historic report To Err is Human. That report was the alarm bell that woke America up to how common medical errors were in our health care system. It grabbed the attention of health care providers, policy makers, and patients with a startling fact: more Americans die each year from the care they receive in hospitals than from all but a few of the diseases that send them there.

Just as important, the report – and the 2001 report that followed – made it clear that the problem was not indifferent or poorly-trained health care providers. America has the best doctors and nurses and the finest hospitals in the world. Instead, the report showed that good people became trapped in bad systems. To improve patient safety, we had to fix these systems.

Over the last 12 years, hospitals have worked to do just that. And as I’ve traveled across the country, I’ve been fortunate to see some incredible success stories.

In February, I visited Virginia Mason Hospital in Seattle, where they’ve studied the world’s best manufacturers to learn how to deliver more consistent care. By applying these lessons, they’ve reduced patient falls by 25 percent and bed sores by 75 percent.

In March, I met with hospital, community, and business leaders in Ohio who have formed a partnership to improve care. Today, they’ve prevented 3,600 infections and medicine complications for Ohio children, while already saving $13 million in reduced health care costs.

I know David Pryor is here today from Ascension Health. Over the last seven years, they’ve reduced preventable deaths by more than 1,500 a year, and I’m looking forward to learning more when I visit Seton Medical Center, an Ascension hospital in Austin, this Friday.

Every day, these hospitals are proving that better, safer, and, in many cases, more affordable care is possible.

In the past, some questioned whether it was possible to bring these results to scale. They wondered whether providing high-quality care was like playing in the NBA, limited only to a select few with exceptional natural ability. But what we’ve found is that it’s more like shooting a free throw. Anyone can do it with the right commitment and the right support.

The reason we know this is because we’re beginning to see some of these pockets of excellence spread. A great example is central line infections in intensive care units. First, researchers developed a checklist that significantly reduced the occurrence of these infections. Then that checklist was taken to Michigan, where they saved 1,500 lives and reduced health care costs by $200 million in just 18 months.

And today, with the support of our Department, these best practices are spreading across the country. Between 2001 and 2009, ICU central line infections fell 63 percent nationally.

That’s an incredible accomplishment. Because of this effort, thousands of Americans are still living happy lives, going to work, seeing their grandchildren. Everyone who played a part should be incredibly proud.

But I want you to consider exactly how limited an achievement this is. This was not all healthcare-associated infections; it was infections associated with one procedure. It was not even all central line infections; it was just those in ICUs. And it was not a 100 percent reduction or even an 80 percent reduction. It was just over a 60 percent reduction.

The truth is that despite the successes we see around the country, injuries from care are still far too prevalent. In fact, one recent study found that as many as one in three hospital patients are harmed by their care.

So as we look back at the last twelve years, we can say two things: we have made some progress, and it is not nearly enough. Let me put it in even stronger terms: if we only improve care as much in the next decade as we have in the last, we will have failed.

The good news is that bigger and faster improvements are within our reach. Not only do hospitals that want to improve care today have more examples to follow, they also have access to better research on quality and better metrics for measuring it.

Even more important, there is a growing urgency behind improving care. Medicare spending alone is expected to rise 91 percent over the next decade, and families and businesses are expected to see similar increases. People are realizing that we will be forced to slow health care spending somehow and we will have two choices: less care or better care. And if we want to improve care, we need to start now.

I saw this urgency last month when the Administration helped launch a new patient safety coalition we call the Partnership for Patients. We recruited doctors, nurses, pharmacists, hospital leaders, health plans, employers, and patients to work with us to achieve two ambitious goals for the next three years: reducing preventable injuries in hospitals by 40 percent and reducing hospital readmissions by 20 percent, by targeting those that should never have happened.

And today, I’m proud to say that more than 2500 partners have signed on, including more than 1200 hospitals. But what really sets this partnership apart from previous efforts is how eager they were to join. There was negotiating or arm twisting. When we reached out, the typical response was: where do I sign up?

If we are going to bring excellence to scale in our health care system, we’ll need all of these partners to play a part. But we know that government has a particularly important role to play.

When it came to eliminating central line ICU infections, for example, many hospitals only got serious when Medicare added them to the “no-pay list.” But for too long this kind of leadership was the exception. I’ve talked to many employers and hospitals over the years who felt that when it came to improving care, Medicare and Medicaid lagged behind. We knew that needed to change.

So the first thing we did is encourage the President to get Don Berwick, who helped write the IOM report, to come lead Medicare and Medicaid and work with Carolyn Clancy and our other leaders to figure out how we could use the world’s largest insurance company to drive change.

Next, we started putting the unprecedented tools and resources we got in the Affordable Care Act to work. For example, we’re backing the new Partnership for Patients with up to $1 billion in funding to support local efforts to promote best practices and help leading hospitals take their efforts to the next level.

We also recently launched an initiative that ties payments to quality for 3,500 hospitals across the country beginning in 2012. Over time, even more money will be paid out on the basis of quality, creating powerful incentives for improvement.

Referring to some of these changes, one Georgia hospital CEO said: “It isn't just good to do quality. It is going to be necessary to do quality.” We hope that attitude spreads.

We’ve also provided guidance to help doctors and hospitals form Accountable Care Organizations where they share the savings if they keep their patients healthy. And we’ve established a new Innovation Center in Medicare and Medicaid that will test new approaches for improving care.

The best hospitals have adopted a philosophy of continuous improvement. With the Innovation Center, we are setting the same goal in Medicare and Medicaid.

By preventing injuries and the unnecessary care that goes along with them, these reforms will also free up critical resources. We estimate that the Partnership for Patients alone could reduce costs by $50 billion in Medicare over the next decade. And these reforms will have an even bigger impact when they are adopted and supplemented by other payers, creating powerful incentives for improving care across the health care system.

My pledge to you today is that we will continue to be active partners in improving health care. But ultimately, this transformation will happen one hospital and health system and community at a time. We can provide support and establish incentives, but you are the ones who will have to do the hard work of putting better systems into practice.

Many of you in this room have already been national leaders in this effort. But today, I want to ask you to go further.

Shortly after I was sworn in, I got a letter from a woman in Maine. Her father had gone to the hospital with a fractured ankle and a mild urinary tract infection. But while he was there, he was infected with MRSA pneumonia.

A day and a half after he came home, he collapsed and never walked again. He lost fifty pounds and eventually got so weak he couldn’t sip water through a straw. A few months later, he died.

If you asked his daughter what an acceptable rate of preventable injuries was, she would say zero. And if you asked any of us what rate of injuries we would accept for our own parents or children or spouses, we would give the same answer. That needs to be our goal: to do no harm. And we can’t confine our efforts to a few kinds of errors. We must strive to reduce all types of harms, including harm to those who provide care. Today, a nurse in Maine is more likely to miss a day of work because of injury than a logger in Maine. So this is an area that needs more attention.

In its 1999 report, the IOM sought to, quote, “break the cycle of inaction.” Today, we have broken that cycle. We are moving forward. But we are not going fast enough. Every day, new treatments and therapies are introduced, bringing benefits for patients, but also adding to the complexity that breeds medical errors.

If we want a safer health care system, we will need to speed up the rate of improvement, and we will need the leaders in this room to show the way. I want to thank you for all your hard work and courageous leadership over the last 12 years. We would not have gotten to where we are today without it. And whether we cross the next frontier – to elimination of harm and complication – once again lies in your hands.

We’re poised to take a great leap towards the day when every American who walks into a doctor’s office or hospital receives the best possible care. I look forward to working with you to make it happen.

Thank you.