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December 22, 2021
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David Burda
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Outcomes Policy System Dynamics
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AHRQ Swings and Misses on New Patient Safety Report

As I’ve said before, healthcare providers know how to make patient care as safe as possible. They just lack the total commitment and the right financial incentives to do so.  

With that bias in mind, another report destined for an email or file folder is out on how to make care safer. This one is from the U.S. Agency for Healthcare Research and Quality no less, and you can download the 69-page report here

There’s a lot to like in AHRQ’s Strategies to Improve Patient safety: Final Report to Congress Required by the Patient Safety and Quality Improvement Act of 2005 besides its long title. 

One thing to like is its focus on practical strategies and tactics to reduce medical errors and increase patient safety, and it puts all those strategies and tactics in one place. In fact, the report features 28 tables of searchable strategies and tactics on topics like care transitions, diagnostic errors, infection control and patient engagement. If you’re a provider, there’s no excuse for not finding what you’re looking for. It’s there in this report. 

Another thing the report does right is identify ways that help providers to actually use the strategies and tactics. For example, AHRQ recommended that providers:

  • Use “analytic approaches in patient safety research, measurement, and practice improvement to monitor risk”
  • Implement “evidence-based practices in real-world settings through clinically useful tools and infrastructure”
  • Develop “learning health systems that integrate continuous learning and improvement in day-to-day operations”
  • And use “patient safety strategies outlined in the National Action Plan by the National Steering Committee for Patient Safety”

We commented on the National Action plan in a previous post, “Putting the Patient in Patient Safety,” way back in September 2020.

What the report swings and misses on is something we believe at 4sight Health, and that’s the direct link between payment and outcomes. We won’t get the care we want until we start paying for the care we want. And the care we want is safe, as in safe as humanly possible. 

The AHRQ report stops short of making that connection between money and safety and admits it:

“This report does not address mechanisms for setting, incentivizing, and/or enforcing compliance with patient safety-related standards or requirements, or for holding providers accountable, such as professional licensing and discipline and healthcare facility licensing and certification,” AHRQ said.

Further: “Consistent with the framework and purpose of the Patient Safety Act, this report addresses strategies to be encouraged for use in voluntary patient safety improvement activities conducted by, with, and/or for healthcare providers.”

No financial incentives. No regulatory compliance. No provider accountability. 

I wouldn’t go to a restaurant under those conditions. But we have to go to the doctor or hospital under those conditions when we’re sick or hurt. 

Yet another reason why we need a customer revolution in healthcare.

Thanks for reading. 

About the Authors

David Burda

Dave is 4sight Health’s biggest news junkie, resident journalist and healthcare historian. He began covering healthcare in 1983 and hasn’t stopped since. Dave writes his own column, “Burda on Health,” for us, contributes weekly blog posts, and manages our weekly e-newsletter and weekly podcast, 4sight Friday and 4sight Roundup.

Dave believes that healthcare is a business like any other business, and customers—patients—are king. If you do what’s right for patients, good business results will follow.

Dave’s personal experiences with the healthcare system both as a patient and family caregiver have shaped his point of view. It’s also been shaped by covering the industry for 35 years as a reporter and editor. He worked at Modern Healthcare for 25 years, the last 11 as editor.

Prior to Modern Healthcare, he did stints at the American Medical Record Association (now AHIMA) and the American Hospital Association. After Modern Healthcare, he wrote a monthly column for Twin Cities Business explaining healthcare trends to a business audience, and he developed and executed content marketing plans for leading healthcare corporations as the editorial director for healthcare strategies at MSP Communications.

When he’s not reading and writing about healthcare, Dave spends his time riding the trails of DuPage County, IL, on his bike, tending his vegetable garden and daydreaming about being a lobster fisherman in Maine. He lives in Wheaton, IL, with his lovely wife of 35 years and his three children, none of whom want to be journalists or lobster fishermen.

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