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S. HRG. 112–554 

NEXT STEPS FOR PATIENT SAFETY: ASSURING 

HIGH VALUE HEALTH CARE ACROSS ALL SITES 

OF CARE 

FIELD HEARING 

BEFORE THE

SPECIAL COMMITTEE ON AGING 

UNITED STATES SENATE 

ONE HUNDRED TWELFTH CONGRESS 

SECOND SESSION 

HARTFORD, CT 

JULY 2, 2012 

Serial No. 112–19 

Printed for the use of the Special Committee on Aging 

( 

Available via the World Wide Web: http://www.fdsys.gov 
(II) 

SPECIAL COMMITTEE ON AGING 

HERB KOHL, Wisconsin, Chairman 

RON WYDEN, Oregon 

BILL NELSON, Florida 

BOB CASEY, Pennsylvania 

CLAIRE MCCASKILL, Missouri 

SHELDON WHITEHOUSE, Rhode Island 

MARK UDALL, Colorado 

MICHAEL BENNET, Colorado 

KIRSTEN GILLIBRAND, New York 

JOE MANCHIN III, West Virginia 

RICHARD BLUMENTHAL, Connecticut 

BOB CORKER, Tennessee 

SUSAN COLLINS, Maine 

ORRIN HATCH, Utah 

MARK KIRK III, Illinois 

DEAN HELLER, Nevada 

JERRY MORAN, Kansas 

RONALD H. JOHNSON, Wisconsin 

RICHARD SHELBY, Alabama 

LINDSEY GRAHAM, South Carolina 

SAXBY CHAMBLISS, Georgia 

CHAD METZLER, Majority Staff Director 

MICHAEL BASSETT, Ranking Member Staff Director 
(III) 

CONTENTS 

Page 

Opening Statement of Senator Richard Blumenthal ............................................ 1 

PANEL OF WITNESSES 

Statement of Alice Bonner, Director, Division of Nursing Homes, Survey 

and Certification Group, Centers for Medicare & Medicaid Services, U.S. 

Department of Health and Human Services, Baltimore, MD .......................... 3 

Statement of Jean Rexford, Executive Director, Connecticut Center for Patient Safety, Redding, CT .................................................................................... 14 

Statement of David Blumenthal, Chief Health Information and Innovation 

Officer, Partners HealthCare System, Boston, MA ........................................... 17 

Statement of Susan Davis, Chief Executive Officer, St. Vincent’s Medical 

Center, Bridgeport, CT ........................................................................................ 22 

Statement of Jamesina Henderson, Chief Executive Officer, Cornell-Scott Hill 

Health Center, Hartford, CT ............................................................................... 25 

Statement of Scott Ellner, Director of Surgical Quality, Saint Francis Hospital 

and Medical Center, Hartford, CT ...................................................................... 28 

APPENDIX 

WITNESS STATEMENTS FOR THE RECORD

Alice Bonner, PhD, RN, Director, Division of Nursing Homes, Survey and 

Certification Group, Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services, Baltimore, MD ............................... 38 

Jean Rexford, Executive Director, Connecticut Center for Patient Safety, Redding, CT ................................................................................................................ 51 

David Blumenthal, MD, MPP, Chief Health Information and Innovation Officer, Partners HealthCare System, Boston, MA ................................................. 54 

Susan Davis, Chief Executive Officer, St. Vincent’s Medical Center, Bridgeport, CT ................................................................................................................. 60 

Jamesina Henderson, Chief Executive Officer, Cornell-Scott Hill Health Center, Hartford, CT .................................................................................................. 64 

Scott Ellner, Director of Surgical Quality, Saint Francis Hospital and Medical 

Center, Hartford, CT ............................................................................................ 68 

ADDITIONAL STATEMENTS SUBMITTED FOR THE RECORD

American Society of Consultant Pharmacists, Alexandria, VA ........................... 70 

Gail R. Simon, East Haven, CT .............................................................................. 81 

(1) 

NEXT STEPS FOR PATIENT SAFETY: ASSURING HIGH VALUE HEALTH CARE ACROSS 

ALL SITES OF CARE 

MONDAY, JULY 2, 2012 

U.S. SENATE, 

SPECIAL COMMITTEE ON AGING, 

Hartford, CT. 

The Committee met, pursuant to notice, at 1:06 p.m. in the Legislative Office Building, 300 Capitol Ave., Hon. Richard 

Blumenthal, presiding. 

Present: Senator Blumenthal [presiding]. 

OPENING STATEMENT OF SENATOR RICHARD BLUMENTHAL 

Senator BLUMENTHAL. Good afternoon. I have the great pleasure 

and honor of convening this special field hearing of the Committee 

on Aging, and I want to welcome everyone here, all of the advocates, the experts, the citizens and elected officials. I see one here, 

Senator Edith Prague. Thank you for being with us today. 

[Applause.] 

Certainly one of the experts, advocates, and great citizens of our 

state on this issue and so many others. 

We are going to begin with a video that the Hamilton family 

very, very graciously has helped us put together, and then I’ll make 

an opening statement. We’re then going to ask Alice Bonner of the 

Department of Health and Human Services to speak to us, and 

then take a second panel consisting of some experts whom I will 

introduce at the time. 

So why don’t we begin with the video? 

[Videotape played.] 

I thank the Hamilton family again for sharing that story with us. 

Anybody who knows about T. Stewart Hamilton knows that his 

granddaughter was actually quite modest about his achievements 

and his stature in the community. For many, many years he was 

well known as a leader in the profession and an advocate for better 

health care in all of Connecticut, as well as an administrator at the 

Hartford Hospital, and I want to thank his family for so graciously 

sharing the story of their grandfather, T. Stewart Hamilton, who 

leaves a legacy and a story. I think he would have supported and 

approved of what we’re going to do and what we’re going to hear 

today. 

I want to thank Alice Bonner for making the trip, as well as my 

brother, David Blumenthal, who are from outside of Connecticut. 

But the reason for having this hearing in Connecticut is that our 
2 

hospitals and our providers really have been at the forefront of caring about this issue of patient safety. As you’ll hear from Susan 

Davis and others, our hospitals and our providers have made patient safety a priority. So I can think of no better place to have this 

hearing, and I’m very proud to do it here. 

At the same time, one of the reasons we’re doing it here and one 

of the reasons that Connecticut hospitals and providers and doctors 

have been so foresighted and vigorous in this effort is that we have 

so far to go. We have a lot of work to do. Some of the statistics nationally are absolutely staggering. 

Today, an estimated 100,000 people die every year from hospital- acquired infections, at an estimated cost of $28.4 to $45 billion. 

That’s billion, with a B. Medication errors alone harm an estimated 

1.5 million people every single year, costing $3.5 billion in extra 

medical expenses. One in four seniors will be discharged to a nursing home and then readmitted to a hospital within 30 days, costing 

Medicare more than $4 billion every year, and 50 percent of all 

those readmissions are avoidable. The costs can be saved. 

The Office of the Inspector General of the U.S. Department of 

Health and Human Services found in 2010 that one in seven Medicare patients are injured during hospital stays. One in seven Medicare patients nationwide are injured in hospital stays. That’s a 

staggering number. An average of one in five Americans, 22 percent, report that they or a family member have experienced a medical error of some kind. 

When we’re talking about patient safety, we’re talking about a 

problem that affects every family, literally every person in Connecticut and the country, and the work ahead should have the kind 

of priority that Connecticut providers and hospitals are giving it. 

Those kinds of numbers do not capture what you’ve just seen about 

a single man, a single person, a family that bears the burden and 

the grief and struggle of patient safety problems. 

It really isn’t about numbers; it’s personal. It’s not only about 

statistics. It’s individual lives lost and suffering created. It was personal to T. Stewart Hamilton’s granddaughter, as you’ve seen, who 

was brave enough to share her story. It was personal to Lorraine 

Purowski of South Windsor, whose husband underwent successful 

surgery for cancer, only to later pass away from an infection acquired afterwards. He had successful surgery for cancer. He passed 

away from the hospital-acquired infection afterwards. And it was 

personal to Marilyn Jasmine, an insulin-dependent diabetic who 

acquired a treatable infection after surgery, but the nursing home 

misplaced doctor’s orders for antibiotics. She lives with the consequences of an infection that spread out of control before the mistake was realized, and she was severely hurt as a result. 

We all have a stake in this problem. The Affordable Care Act and 

the HITECH Act are two measures designed to help address these 

issues, and the witnesses today who will have speak to us can 

speak not only to the problem but also to the solutions, because 

there are things we can do that will make a difference. 

Every single hospital in the State of Connecticut is now part of 

an initiative begun by the Administration in April called the Partnership for Patients, which commits to dramatic reductions in hospital infections and readmissions. They believe that the Partner-
3 

ship’s efforts alone will save 60,000 lives and 10 billion in Medicare 

dollars in the next three years, and more than 50 million Medicare 

dollars over the next 10 years. 

So these problems, those savings of 50 billion—not 50 million— 

50 billion Medicare dollars are achievable. The kinds of efforts that 

we can document in this state that we can achieve can be a model 

for the country. Again I want to thank the experts who are here 

today to talk about them, beginning with Alice Bonner, who is Director of Survey and Certification for Nursing Homes at the Center 

for Medical and Medicaid Services. She will open our discussion on 

an area that is particularly relevant to our Baby Boomers. She has 

a background in this area, a distinguished resume, and a background including expert work in many of the areas that are relevant here. 

Her work now is to oversee certification and review of all Medicare-participating nursing homes in the United States. She has 

also been a geriatric nurse practitioner for the past 20 years, and 

she has focused her research efforts on both nursing home quality 

and development of patient safety culture in health care organizations. 

Thank you very much for being with us. 

[Applause.] 

STATEMENT OF ALICE BONNER, DIRECTOR, DIVISION OF 

NURSING HOMES, SURVEY AND CERTIFICATION GROUP, 

CENTERS FOR MEDICARE & MEDICAID SERVICES, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, BALTIMORE, 

MD 

Ms. BONNER. I brought with me some photos that are 30 years 

old, from when I was a nursing assistant, which is how I got started working in nursing homes. So when you say it’s personal, even 

though I’m representing CMS today, I want you to know that this 

is very personal for me as well in my 30-year journey in nursing 

and nursing homes. 

So thank you, Senator Blumenthal, for the opportunity to appear 

today to discuss CMS’ efforts to improve patient safety in nursing 

home residents. Nursing homes play an important role in health 

care today. More than 3 million Americans rely on services provided by nursing homes at some point during the year, and 1.4 million Americans reside in the nation’s 15,800 nursing homes on any 

given day. Those individuals and an even larger number of their 

families and friends must be able to count on nursing homes to 

provide safe, reliable, high-quality care. 

To ensure that nursing homes meet both Federal and state 

standards, CMS conducts initial and ongoing inspections of all facilities participating in the Medicare and Medicaid programs. The 

survey and certification process plays a critical role in ensuring 

basic levels of quality and safety for Medicare and Medicaid beneficiaries by monitoring nursing home compliance with Federal and 

state requirements. 

Within the survey and certification group, the Division of Nursing Homes focuses on optimizing the health, safety, and quality of 

life for people living in nursing homes through close collaboration 

with other divisions as well, and over 5,000 Federal and state sur-
4 

veyors conduct on-site surveys of certified nursing homes each year 

to assure basic levels of quality and safety for beneficiaries. 

So prior to becoming the Director of the Division of Nursing 

Homes, I did work as a nurse practitioner in clinical practice in the 

State of Massachusetts for 20 years, and I’m very well aware of the 

importance of interdisciplinary partnerships in nursing home care 

where safe, reliable care depends on these close collaborations 

among nurses, nursing assistants, physicians, therapists, pharmacists, really the entire interdisciplinary team, most importantly 

the residents and families at the center of that care. 

I’ve also seen firsthand the importance of balancing safety with 

autonomy and choice, and an ability for residents to really have a 

say in their daily routines and basic human rights. 

So CMS encourages facilities to examine their organizations’ values and structures and practices so that, as a nation, we can transform these very institutional settings that they’ve been for so long 

into person-centered environments where individuals are really recognized and respected. We know that that will improve the resident’s and family’s experience of care, and may also reduce staff 

turnover and improve care practices as well. 

So today I’d like to highlight some recent specific activities that 

CMS has undertaken to improve quality and safety for nursing 

home residents in the areas of dementia care and anti-psychotic 

medication use, managing fall risk, nursing home oversight of special focus facilities, quality assurance and performance improvement, and care transitions. 

So in terms of dementia care and anti-psychotic use, CMS has 

implemented substantial improvements to the survey and certification process to help address concerns about over-utilization of 

anti-psychotic medications. CMS revised guidelines in 2006 clarifying a number of aspects of medication management and emphasizing that residents have the right to be free from being prescribed 

unnecessary medications. 

Current work on surveyor training focuses survey teams on a 

number of key processes, including the requirement that providers 

must try non-pharmacologic interventions first in order to manage 

behaviors before using medications to address them. 

On May 30th, CMS announced the CMS National Partnership to 

Improve Dementia Care: Rethink, Reconnect, Restore. So rethink 

means rethinking how we approach dementia residents in nursing 

homes; reconnect means connecting with them as an individual, as 

a person, so you know enough about them to prevent some of these 

behaviors; and restore means restoring quality of life. 

This initiative includes raising public awareness, strengthening 

regulatory oversight, providing technical assistance and training to 

nursing homes and prescribers, improving public reporting to increase transparency, and conducting research. And we’ve set a national goal to reduce the use of anti-psychotic medications in longstay residents with dementia by 15 percent by the end of December 

2012. 

In terms of managing fall risk, CMS is attempting to reduce the 

number of injurious falls sustained by nursing home residents. A 

new quality measure on nursing homes this summer will report the 

percentage of falls with serious injury in nursing home residents by 
5 

facility. These data will enable professional associations, culture 

change coalitions, quality improvement organizations and others to 

target technical assistance and fall risk reduction in these facilities, 

so tailoring those programs to see what the problems are related 

to falls, which is a multi-factorial problem. And surveyors will review resident falls and will continue to enforce requirements for 

safety around accidents and supervision. 

In terms of nursing home oversight of special focus facilities, 

CMS created the special focus facility program in 1998, and it was 

part of the Nursing Home Oversight and Improvement Program 

under the Clinton Administration. The purpose of the SFF program 

is to decrease the number of persistently poor performing nursing 

homes by directing more attention to nursing homes with a record 

of poor survey performance. Through collaboration with the states, 

CMS is working to continually improve the SFF program, and improvements since 2004 include increasing the number of facilities 

that are on the program, providing more data to the states so they 

can target the facilities to come into the program, and posting data 

on Nursing Home Compare so that consumers have information 

about which facilities are special focus facilities. 

In terms of quality assurance and performance improvement, another initiative under the Affordable Care Act, the Affordable Care 

Act directed CMS to mobilize best practices in nursing home quality and to identify technical assistance to enhance nursing home 

quality and performance using a systems approach. CMS is currently working to roll out a new national initiative that includes 

development of QAPI standards and technical assistance that will 

enable facilities to implement those standards. QAPI tools, resources and technical assistance, including an interactive website, 

are currently being tested in a demonstration project and will be 

available to all nursing homes later this summer. A new QAPI regulation will enable the surveyors to then go and see if the nursing 

homes are implementing their QAPI plan, whether it’s adequate 

protection for patient safety. 

And finally, in terms of care transitions, currently transitions in 

care from one setting to another are very often fragmented. So 

someone in the hospital sending a resident to the nursing home 

doesn’t necessarily transfer the information that the nursing home 

needs to take care of that person; and similarly, somebody going 

back to the hospital from the nursing home, the hospital emergency 

department doesn’t always get the information that they need to 

really care for that person. 

So in terms of this lack of communication, it’s certainly responsible for medication errors and other adverse events, and as you 

mentioned, the unnecessary re-hospitalizations that we see. 

So the survey and certification group is currently revising our 

guidelines and regulatory requirements for resident transfers so 

that we can better focus on what is the information that we need, 

and working with the Office of the National Coordinator so that the 

elements of data that we really require are being looked at, and 

what nursing homes need is part of that entire discussion. So the 

Division of Nursing Homes is also working with its partners to develop new quality measures that will track 30-day hospital readmissions on newly-admitted nursing home residents. 
6 

So in conclusion, we appreciate the work of the committee and 

the support in terms of improving quality and safety for all of our 

individuals across the country in every health care setting, but particularly the work that you’re doing around nursing homes. So, 

thank you very much. 

Senator BLUMENTHAL. Thank you for that statement. While I 

was reading the prepared text last night, one of the thoughts that 

occurred to me was whether, in the course of those site visits, is 

there any kind of notice given before you actually arrive there? 

What’s the standard procedure? 

Ms. BONNER. The standard procedure is that there is not notice 

given. These are supposed to be visits where the facility should be 

doing the same thing all the time for all their residents to promote 

safety. It shouldn’t make a difference when the regulators come in. 

However, it’s important that these visits be unannounced. So because they have to occur on a cycle—in other words, they’re annual 

visits—the facilities have some sense of what they sometimes refer 

to as ‘‘the window.’’ So within a period of months, they have a 

sense that the regulators are likely to be coming. However, they’re 

not supposed to be announced visits because, again, we want facilities—and facilities and providers are teaching, the associations are 

teaching their own members that the care should be the same, the 

quality should be the same all during the year. 

Senator BLUMENTHAL. And how many people go to visit each of 

the sites? 

Ms. BONNER. So the typical survey team—it’s a team, and there’s 

a team leader, and there are three to four for an average size facility, a 150-bed facility or so. A very small facility, there might be 

two or three surveyors on the team. But it’s important, the way the 

survey works, some people go and look at the kitchen, some people 

look at infection control, some people look at the medication paths. 

So it does take a team of people, and also they’re looking to make 

sure they get out on all of the different units, and then they come 

back and compare notes. 

So there’s a period of time at the end where there’s a conference 

and people say, well, did you see a problem with falls on your unit? 

And someone else says, yes, I saw that on my unit. That leads 

them to sometimes expand the number of cases they would look at. 

So it’s very important to safety that that team collaboration happens. 

Senator BLUMENTHAL. And the team’s report then goes to someone at CMS, or—— 

Ms. BONNER. It first goes back to the state survey agency, and 

I know Barbara Cass is here today. She is the director of the agency in Connecticut. So it would go back to the agency, and some 

managers would review it, and that’s where the enforcement piece 

comes in, and I’m glad you mentioned that because we really try 

to have enforcement be consistent and credible across states and 

across the regions. 

So the surveyors bring back what they saw and they discuss it 

with their managers. If there’s still a question, then sometimes it 

gets referred to the regional offices, and then ultimately to the central office where we are if it’s a policy question or a particularly 

complex case, which they very often are. 
7 

Senator BLUMENTHAL. Is it always a state team, or does it have 

state representation for these 5,000 site visits, which is a lot of visits? 

Ms. BONNER. So we contract with every state, and every state 

does have a survey agency. And then the Federal surveyors are required, under the statute, to go in and do a sample as an oversight, 

as a quality assurance, if you will, measure. So the Federal regions 

will send in surveyors to do a 5 percent sample, and they go in a 

few weeks after the state surveyors and they repeat the survey to 

see if the findings are the same, if they determine any problems, 

any areas for retraining with the state. 

And there’s also an observational survey which is done. So that’s 

where the Federal surveyors go with the state surveyors and actually see them interacting. How do they do the interviews? How do 

they do the observations? So that serves to really do just-in-time 

teaching with those surveyors, whereas with the comparative, 

there’s a little bit more of how is the state survey agency doing 

overall and are there any issues. So it’s our own quality improvement. 

I would like to mention that CMS has been working for the last 

7 to 10 years on a computer-assisted, data-driven model called the 

Quality Indicator Survey. So in about half of our states now, the 

surveyors have laptops that they take with them. So if they’re 

interviewing a physician or they’re interviewing a resident, they’re 

entering data. The algorithms in the computer help to drive the 

surveyors to the areas that may be the most problematic and target 

that so the surveys can be more efficient and effective. 

So this new computer system also generates reports. So if Barbara, who is here in a state where they do the quality indicator 

survey, wanted to know information about one of her survey teams 

or one of her surveyors—are they citing enough, are they an 

outlier—with this new program, we can do it. We were not able to 

do it nearly as well with the traditional survey. 

So this program really needs continued development, but we’ve 

had several years now of study, and we’re learning more about it 

all the time. We think it’s extremely valuable in improving the survey process. 

Senator BLUMENTHAL. Who makes the enforcement judgments 

based on the data that you collect through the survey? Is that done 

in Washington, or is it done at the state level? 

Ms. BONNER. It’s done at the state level. When there are the 

most egregious deficiencies cited, immediate jeopardy and serious 

harm, very often those will go to the regional offices for discussion. 

And then, again, the regional office, because they are overseeing 

several states, four or five states, can really try to make sure that 

those decisions are consistent. There is a grid that is used for 

things like civil money penalties and what we call scope and severity, how many people were affected and how severe was this problem. 

So we continue to try to make those systems more reliable and 

implemented more reliably throughout all the states and the regions. 
8 

Senator BLUMENTHAL. If there are problems indicated at a particular nursing home, do you accelerate the re-review or the re-survey, the visits in that case? 

Ms. BONNER. That definitely can happen. Also, if it’s particularly—if it continues to happen in a facility, that will probably 

drive the data to have that facility on a list for potentially getting 

into the special focus facility program that I mentioned. So either 

the surveyors can certainly make the decision to go back sooner. 

We also work very closely with the ombudsman, and the ombudsman can go into the facility quite often, and that’s another set of 

eyes and ears. So we have really stepped up our partnership with 

the ombudsman program because with safety, the more sets of eyes 

that you have on the problem, the better. 

So the ombudsman can go in. The state survey agency absolutely 

can go back in sooner, and they do that when there’s the most egregious situation. They sometimes will not leave the facility if they 

really believe that people are at risk. The surveyors will call their 

managers and say that they want to stay there until the situation 

is resolved. 

Senator BLUMENTHAL. And what is the most serious enforcement 

efforts that you can take, and has the level of enforcement increased in severity and frequency? 

Ms. BONNER. The most significant enforcement remedy that we 

have is termination from the Medicare and Medicaid program. We 

also have civil money penalties. So those are fines, and we can give 

those on either a per-day or per-instance basis. So we can fine up 

to a certain amount per day for the most serious infractions. We 

can also say that there is a denial of payment for new admissions, 

and sometimes that’s even more effective with facilities because if 

you are not going to be able to be paid by Medicare and Medicaid 

for any new admissions, it means you’re not going to take any new 

admissions in most cases. 

Senator BLUMENTHAL. And how often have you used each of 

those remedies? 

Ms. BONNER. We have some data on that, and I don’t have those 

numbers but I can work with you and your staff to let you know 

what those are. 

Senator BLUMENTHAL. That would be helpful, if you could. 

Ms. BONNER. Absolutely. 

Senator BLUMENTHAL. You know, I imagine the argument for the 

push-back given to you is if you deprive us of resources, it’s just 

going to diminish the level of care. As attorney general, I found 

that argument given frequently when funding cutoffs or reductions 

in funding were suggested. You must find it as well. 

Ms. BONNER. Right, and also we have a very clear role in survey 

and certification, which is enforcement. We have regulations and 

requirements for participation, and that’s what we do. But that 

doesn’t prevent us from partnering with and networking with the 

quality improvement organizations, the culture change coalitions 

and other entities, even the professional associations, because they 

can do good quality improvement work that will deter. You know, 

if they build better systems, the enforcement, if it’s effective, will 

promote nursing homes to want to do more quality improvement 

work, and those other agencies can do that with them. 
9 

Senator BLUMENTHAL. You know, you have talked about in your 

testimony various areas, including consumer engagement and four 

others that are very, very important, including enforcement. I wonder if you feel that there ought to be more authority, legislative authority from the Congress, to strengthen your ability either in enforcement or consumer engagement or any of those other areas that 

you mentioned in your testimony. 

Ms. BONNER. I think that in the nursing home reform law, there 

is quite a bit of authority. I think it is a combination of using that 

authority effectively, and one of the most important things that we 

can do to be able to do that is to have Congress support the President’s budget for survey and certification. That appropriation allows us to do the training and implementation and use experts 

such as you have assembled here today, and so forth. 

But it’s really extremely important that Congress supports the 

President’s budget in 2013 for survey and certification. 

Senator BLUMENTHAL. Well, I’m glad that you made that point. 

I should also say, because I’ve neglected it, that the record of this 

hearing is going to be made available to all of my colleagues on the 

Special Committee on Aging, and I hope that they will be advocates 

for the resources that the President is planning to request, because 

my guess is—more than a guess—my feeling is that those resources 

may not be completely adequate even themselves, knowing how the 

process works, and I’m not going to ask you to comment on that 

point. But I know that a lot of my colleagues share that feeling. 

I want to focus on one area in particular, and I will take up your 

invitation to follow up afterwards on some of these other points. 

Anti-psychotic drugs, how are we doing in that area? Obviously, 

they’ve been a problem. They still are a very severe problem in 

many nursing homes, over-use of that kind of medication. How are 

Connecticut and the rest of the country doing in trying to combat 

misuse of anti-psychotic drugs? 

Ms. BONNER. Well, we’re fortunate right now that we have a new 

initiative, the CMS National Partnership, to reduce anti-psychotic 

use and improve dementia care. And through this initiative, we’ve 

been able to work with people in all the states, and one of the 

things that CMS has been doing is contacting state by state anyone 

who is interested in this area and anyone who is working on it. 

So in Connecticut, you’re very fortunate. You have some people 

at Yale University—Dr. Mary Tinetti, Dr. Elsa Weickers and others, as well as Qualidyne, the quality improvement organization 

here. All of these are organizations and individuals who have done 

specific work in this area. 

So we’ve been reaching out to all of the states to find out who 

is already doing work in this area so we can learn from the best 

practices. We have identified at least 150 nursing homes in this 

country that have reduced anti-psychotic use or completely eliminated it, again over a period of years. It’s really changing culture, 

and I know you’re going to hear more about safety culture from the 

other panelists. But changing the culture in a nursing home from 

one where people reach for a medication when someone has a behavior like yelling or wandering or kicking or anything like that, 

as opposed to a person-centered approach, really changing that culture takes some time. 
10 

But we are now aligned with all of these different agencies 

throughout HHS. We’re working with AHRQ that has a number of 

programs I know people are aware of for prescriber education, and 

we have SAMHSA and HRSA and other agencies that are also 

working in this area. 

So again, on these state calls, we’ve been impressed that there 

is some work. There is a tremendous amount of work left to do. 

The public reporting we believe is going to be very helpful. We’ve 

been hearing from people around the country that they want the 

data. So Connecticut wants to know what their rate of use is so 

they know what kind of improvements they need to make. 

But the 15 percent reduction is a national number. So some 

states may have a lot farther that they can go to be able to reduce 

anti-psychotics, and other states are already doing a better job. So 

we’re sharing that information back to the states, working with the 

state agencies, regional offices, QIOs, individual researchers, and 

this really resonates with people, there’s no question. We’ve had 

folks who are nursing home residents speak with us. We’ve had 

family members come and be part of the precedents with CMS in 

Baltimore. So people are really coming together around this initiative, and we have a lot left to do. 

Senator BLUMENTHAL. I know that you’re working on it, and yet 

I was struck by some of the statistics in your testimony, an increase of 12.6 percent to 14 percent of the facilities with these 

kinds of problems. And 19.2 percent, I think, in 2011 and 2012 two 

out of five cognitive impairment and behavioral, or I should say individuals who experienced cognitive impairment and behavioral 

problems received anti-psychotic drugs without any diagnosis of 

psychotic conditions, and those are very recent numbers, I gather, 

from your testimony. So there is really a need to address this issue, 

in my view, much more aggressively, and I take it from your testimony you agree. 

Ms. BONNER. Absolutely, and I didn’t mention what we’re doing 

on the surveyor side. So the survey guidance was updated in 2006– 

2007, but as you know, clinical practice changes very quickly, so we 

are looking at that again. We have some experts who are pharmacists from across the country. By focusing the surveyors on this 

on every survey, we’ve said to the surveyors we expect that on 

every single survey, whether you think this is a problem in a particular nursing home or not, that you will be asking the nursing 

home administrator and the director of nurses what are you doing 

to reduce anti-psychotic use in this nursing home, how do you approach it. 

By doing that, the surveyors will get a sense very quickly of 

whether or not they are approaching dementia care with non-pharmacologic approaches, individualized care. Does staff take the time 

to get to know a resident? Do they figure out what works for an 

individual and pass it along to others on other shifts, and are the 

direct care workers really involved? Because historically, again, the 

issue is we haven’t considered safety culture, and so we haven’t 

made sure that nursing assistants who know the residents best are 

at the care planning meetings, and that families are involved in 

care planning meetings. They get invited, but is there a real effort 

being made to involve them, particularly when someone has de-
11 

mentia and has these behaviors? Does someone say, you know, tell 

me about your father? 

If you were the patient, I would say to your family, tell me about 

what was Senator Blumenthal most proud of? What did he write 

about in the Yale Law Journal? And maybe they would bring in 

some articles that you worked on or some cases. So I would learn 

enough about you that you would start to trust me as a caregiver 

and we would have a relationship. So on the days that you were 

feeling anxious or upset about something, I would know something 

to talk about with you that even if you didn’t remember what you 

had for lunch that day, you would probably remember some of 

those things that are really hard wired. 

Dementia care is like cracking a code sometimes. It’s like really 

getting to that one thing that will still work with someone even 

when their brain is very diseased, and that’s what the facilities 

that have been successful have been able to do, and they’ve really 

involved the direct care workers and the rest of the team. 

Senator BLUMENTHAL. Well, I would be interested in that list of 

150, and especially if any of them are in Connecticut. Maybe we 

can use them as models for what should be done elsewhere. I agree 

that part of it is culture, but enforcement against abuse or misuse 

also sends a signal about the importance of changing culture and 

changing standards. 

Preventable falls, maybe you could comment a little bit about the 

work that’s being done there, which I gather is not unrelated to the 

overuse or misuse of anti-psychotic drugs. 

Ms. BONNER. Right. When people are on high doses of anti-psychotic drugs, obviously that’s one of the many factors in falls. So 

falls is a really complicated problem because it’s multi-factorial. 

There can be issues in the environment that lead to falls. There 

can be medications, disease processes, things like Parkinson’s and 

diseases that affect balance, vision, activities, all manner of things. 

So there are many, many fall risk factors, and falls are one of the 

top deficiencies that are cited by surveyors. 

One of the things that we’re doing that we think will be important is through our public reporting and increased transparency on 

Nursing Home Compare, we’re going to be posting this summer a 

new quality indicator, a quality measure. That will be the percentage of residents who have sustained a fall with a serious injury. 

We’re not necessarily trying to prevent everyone from every single 

fall. Some falls are not injurious, and we don’t want to tie people 

down, as we did in the past. 

So this new measure of serious or injurious falls will again allow 

a facility to look at their own data and use a data-driven system 

to improve quality, and this is also what we’re teaching in the 

Quality Assurance and Performance Improvement initiative. So 

through quality assurance performance improvement we’re developing a set of tools in technical assistance that the QIOs can use, 

the professional associations can use, and they will be available on 

a CMS website in the next several months. So facilities will be able 

to see, oh, here are some tools that we can use to reduce the risk 

of falls in our facility, and then along with the public reporting, it 

helps us because consumers go on Nursing Home Compare and 
12 

they see what’s on the website. So if they’re considering a nursing 

home, now they have information. 

So they can go to the nursing home administrator and say, you 

know, I went on Nursing Home Compare and I saw that your nursing home had a high rate of falls. Can you tell me about that? And 

there might be an explanation in terms of the types of residents 

that that nursing home takes, but it’s a very good question to ask 

a nursing home administrator. So it gets that dialogue going. 

So we’re really trying to get consumers more involved, nursing 

home residents more involved. I know Brian Capshaw is here 

today. He’s a nursing home resident in Connecticut. He’s done 

some work with us, and he’s a good student of the regulations and 

helps remind us about things very often. But in terms of falls prevention, consumers being really well educated and asking good 

questions is something that CMS very much is in favor of. 

Senator BLUMENTHAL. And I gather the Quality Assurance and 

Performance Improvement program is aimed at all of these problems. It is also aimed at something that I think is also very important: establishing a partnership with hospitals so as to reduce premature discharges or readmissions that are so expensive to CMS 

and to states. 

Ms. BONNER. Right. Almost any clinical issue involves some sort 

of care across that transition, whether it’s a pressure ulcer and 

someone is left on a stretcher for too long and it gets worse, or an 

anti-psychotic that was prescribed in the hospital and then is no 

longer needed but the information doesn’t get transferred, so the 

person is just continued on the anti-psychotic in the nursing home, 

and all of these transfers back and forth. 

So absolutely, the QAPI program requires a plan on the part of 

the skilled nursing facility, and it’s got to be systemic. It’s got to 

address problems across every component of the skilled nursing facility. It’s not just about nursing. It’s the maintenance department 

and the housekeeping department and the business office, across 

all of those areas, and it’s also got to make sure that the nursing 

home knows how to use data and is managing with data, that leadership is involved, and that projects—you know, small tests of 

change. So testing out a project to see what—let’s take fall prevention. 

They might say, well, we’ve got a problem with falls. We’ve 

looked at our data. Let’s try one thing with just a few of our staff 

on one of our units and see if we can reduce the falls on that unit 

through some interventions. Maybe regular pharmacy rounds of the 

medications would be an example that a number of facilities have 

tried. And then they would look back and see if there was improvement, and if there was, then they might expand it to the rest of 

the facility. 

But those systemic kinds of approaches in their plan is what the 

QAPI program is about. 

Senator BLUMENTHAL. Among the nursing homes that have been 

particularly active on anti-psychotic drugs or on preventable falls, 

can you give us an idea whether any are in Connecticut? That is, 

the good guys, so to speak, who have done really pioneering work 

on these issues. 
13 

Ms. BONNER. There are definitely a number of homes in Connecticut that have done pioneering work in a number of areas, not 

only anti-psychotics and fall reduction. Again, with Dr. Tinetti at 

Yale, and Dr. Baker also, and those programs around Warfarin 

use. Warfarin is an anti-coagulant that leads to bleeding and is a 

very high-risk drug. It’s very often associated with morbidity and 

mortality, and there are some programs, some pilot programs in 

Connecticut that have looked at how nurses in nursing homes monitor a high-risk drug like Warfarin, and the principles were the 

same as monitoring similar, an anti-psychotic high-risk drug as 

well. So there has definitely been some very good work in Connecticut. 

Senator BLUMENTHAL. Well, I’d like you to give me a list of them 

because I’m going to go visit them. 

Ms. BONNER. I’m glad you want to go visit the good ones. 

Senator BLUMENTHAL. Well, I’m going to go visit some of the bad 

ones as well. 

But I really want to thank you for your being here today. It really means a lot, and we have a lot of areas that I would like to pursue with you. I think you may know my staff, Rachel Pryor, who 

deserves credit for helping to put this hearing together, and when 

we’re all back in Washington I’d like to make a point of getting together again and getting some of that additional information. 

We could spend a lot more time here but we have another panel 

afterward, and they are busy. I’m sure you have places to go as 

well, and I just can’t thank you enough for the good work that 

you’re doing, and your colleagues at CMS as well, in this very difficult and challenging area. It is so critically important not only for 

saving dollars, which will be a priority going forward as the Affordable Care Act is implemented, but also for stopping the kinds of patient safety violations that are so negatively impactful on people’s 

lives. 

So thank you for your great work, and thank you for being here. 

Ms. BONNER. Thank you. We look forward to those further meetings. 

Senator BLUMENTHAL. Sure. Thank you, Director Bonner. 

[Applause.] 

Senator BLUMENTHAL. I’m going to ask our next panel to come 

forward. 

While they’re doing that, I would like to thank other public officials who are here today. I said hello earlier to our Commissioner 

of Public Health who is here. 

Jewel, if you could please stand up? Thank you so much for being 

here. 

[Applause.] 

Dr. MULLEN. If I could just note that Margaret Hath, the Director—— 

Senator BLUMENTHAL. Any of your staff you’d like to introduce, 

please stand up. 

Dr. MULLEN. They are also going to go out and survey, if you 

would like to join them. 

Senator BLUMENTHAL. Okay. Vicki Veltri, who is the health care 

advocate, I saw her earlier. Thank you for being here. 

[Applause.] 
14 

And I think I saw Nancy Shaffer, who is the state ombudsman. 

Thank you for being here. 

[Applause.] 

Thank you. And I also saw Jeannette DeJesus, who is special advisor to the governor, Governor Malloy. I know he’s very interested 

in this issue. 

Are you still with us, Jeannette? 

[No response.] 

Maybe not. 

But thank you all for being here, and I introduced before Edith 

Prague, who is still with us. 

For the next round, and if you could please come forward, we 

may need to get some chairs for the members of the panel. 

We are, by the way, distributing cards to the audience so that 

you can ask questions of this panel. And what we may have to do— 

I’m not sure how the microphone will work, but we’re going to 

begin with Jean Rexford, and then as we go from one panel member to another, we can have you take a seat in front of the microphone. 

We’re going to begin with Jean Rexford, who is a long-time friend 

and partner in these efforts of mine, and I want to thank her for 

the great work that she’s done in this area. She founded the Connecticut Center for Patient Safety in 2004 and currently serves as 

its executive director. Her organization works to promote consumer 

involvement in patient safety efforts. She was previously chair of 

the Connecticut Health Foundation, and she has represented consumers on the National Committee for Quality Assurance and the 

National Quality Forum. 

Jean, do you want to begin? 

STATEMENT OF JEAN REXFORD, EXECUTIVE DIRECTOR, 

CONNECTICUT CENTER FOR PATIENT SAFETY, REDDING, CT 

Ms. REXFORD. Good afternoon, Senator Blumenthal, and thank 

you for the opportunity to provide testimony today about patient 

safety and for bringing attention to this serious public health issue. 

According to the Inspector General’s November 2010 study, it can 

be estimated that there were 950 Medicare beneficiaries in our own 

state that died in our hospitals, and you can probably add another 

22,000 people who got an infection from a facility that same year. 

Behind each statistic there is a name, a family, a story of sorrow. 

For some, it’s medical bankruptcy. For others, it is unemployment. 

But for all patients harmed by the health care system, there is a 

physical and emotional pain, a profound broken trust and disbelief 

that while being treated, they had been harmed by preventable 

medical errors. 

The Connecticut Center for Patient Safety was formed in 2004 to 

be the voice of the consumer patient. We are determined not to be 

forgotten collateral damage in a terribly broken health care system. 

Today we are joined by other advocacy groups in the national patient safety movement. Loosely organized through Consumer’s 

Union Safe Patient Project, we work together to promote patient 

safety, improve quality, and protect patients’ rights. 

In Connecticut, we are working with another patient-focused advocacy group called Jump Start. We are trying to shine a spotlight 
15 

on the need to put the patient first and foremost in this vast medical-industrial complex and the regulatory agencies that have in 

the past not always put the patient first. 

We began our work with hospital infections. When I learned in 

2005 that there were just two infections reported across 31 hospitals in Connecticut, I knew that it was a good issue to tackle. We 

were told by hospital executives with whom we spoke that most infections were expected, which revealed to me a fundamental gap 

between consumer and medical facility perspectives. I can assure 

you that no health care consumer expects to visit a licensed medical facility and acquire a deadly infection as a result of receiving 

care. It was not difficult to amass stories of patients and families 

and what had happened to them when they had acquired an infection. Keith lost his job. Mary will never walk again after a hip replacement. 

We brought these stories to our legislature, and legislators added 

their own. Twenty-six states now have legislation requiring public 

reporting of hospital-acquired infections, and the Federal Government has paid attention. There is an impressive nationwide effort 

to begin to address infections and needless suffering and costs. But 

think of the individuals who have died and their family’s loss because medical facilities were slow to react without legislative intervention. 

We have learned over the years that legislation has limitations. 

The health care consumer will never get all that we want or deserve. There is absolutely no road map for the consumer patient 

safety movement, and only meager funding for our advocates. 

When funding is awarded for patient safety improvements in the 

clinical setting, there is never a requirement for consumer representation on medical facility commissions, panels, and 

workgroups studying patient safety, innovation and quality improvement. Most funded endeavors exclude patient voices altogether. 

While we have worked hard to collaborate with hospitals to get 

a seat at the table to solve the patient safety epidemic, we concurrently faced obstruction by the industry’s powerful and well-funded 

lobbyists serving profit motives first. We realize we had to think 

more creatively and decided that nurses can make an enormous 

difference in the quality of care in keeping patients safe. So we 

started an outreach program to nursing schools. Collaborating directly with providers instead of institutions seemed a far more 

positive way to work. 

Our nursing education program has been successful and continues to grow. Some doors have now opened, and we regularly participate in state and national efforts. However, there is much work 

to be done to bring awareness to an issue that for too long has been 

accepted by the medical community, overlooked by regulators, unknown to the vast majority of the general public and unsuspecting 

patients, and out of the realm of consumer protection. 

Without transparency and accountability, patients will continue 

to be harmed by medical facilities that tolerate errors at a rate unheard of in any other safety-sensitive industry. We are eager to 

work with medical facilities and the health care system and have 

just recently begun collaborating with innovators that welcome our 
16 

participation. Testimony provided later today will provide an example of islands of excellence that have begun to take shape and 

make progress. But why aren’t these islands the norm instead of 

the exception? 

Nineteen months ago the Federal Government launched the 

Partnership for Patients. It was an important initiative for health 

care providers, but it wasn’t with patients. It was for patients. 

After nearly two years, we were finally contacted, advocates across 

the country, and invited to Washington. The next week after we 

were excited about showing up, we were told not to come. There 

was no money. There was no money for the patients, for the advocates. We were, sadly, an afterthought. 

Patients and patient safety must be a reflex. Only when we become an equal partner will we begin to see safe, patient-centered 

care. 

Thank you, Senator Blumenthal, for your never-ending commitment to ensure that patients and consumer voices are heard. 

Senator BLUMENTHAL. Thank you. 

[Applause.] 

I am going to ask each of the witnesses in order just a couple 

of questions, and then we’ll take questions from the audience. 

Jean, thank you very, very much. You know, I remember last 

night reading your reference to a patient safety epidemic. Do you 

think that’s an accurate description of the extent and severity of 

the problem? 

Ms. REXFORD. Absolutely. In fact, this morning on the news there 

was a helicopter where four people died. Dr. Lucien Leaf talks 

about the jumbo jet of Americans that die on a daily basis from 

failures within our health care delivery system. These are huge 

numbers. And so it’s not only the toll of the suffering, but it is the 

cost to the industry. 

I have been frustrated in that we’re always talking about access, 

we’ve got to have access, and I believe that. But we need to talk 

about what we are accessing. We want to provide safe, reliable 

care. It’s the only—you know, every once in a while they’ll say we 

provide experience-based medicine, and I’m thinking, we weren’t 

doing that before? It is of concern that the patient isn’t always put 

first. 

Senator BLUMENTHAL. And what has been the response since you 

were invited to Washington? Have you found greater receptivity 

since then? 

Ms. REXFORD. Well, I think people are really trying. The FDA recently asked consumers to come and spend a day at the FDA to 

begin communication. There were 200 people in the room. I would 

guess I was one of three consumers that was non-conflicted, and 

that has been the challenge, to find people that don’t have financial 

ties to the industries that make up health care. Many of the other 

consumers were representing disease groups, whether it was Parkinson’s or AIDS, all of which have heavy funding from the pharmaceutical industry. 

So the non-conflicted voice is of critical importance. When I do 

serve on national panels, I am always thanked because I am able 

to say what providers really want to say, but they can’t. 
17 

Senator BLUMENTHAL. Thank you very much, and we’ll be coming back to you. 

I’m going to invite the next panelist, Dr. David Blumenthal, who 

is Samuel O. Thier Professor of Medicine and Professor of Health 

Policy at Massachusetts General Hospital and Partners Health 

System and the Harvard Medical School. He serves as Chief Health 

Information and Innovation Officer for Partners Health System in 

Boston. From 2009 to 2011, he served as National Coordinator for 

Health Information Technology under the President of the United 

States, Barack Obama, and in that role he was charged with building an interoperable private and secure nationwide health system 

supporting widespread use of health information technology to improve patient outcomes. 

There’s more that I could say, but I am a somewhat conflicted 

observer. 

[Laughter.] 

To use the word that Jean Rexford did. 

Thank you for being here, Dr. Blumenthal. 

STATEMENT OF DAVID BLUMENTHAL, CHIEF HEALTH INFORMATION AND INNOVATION OFFICER, PARTNERS 

HEALTHCARE SYSTEM, BOSTON, MA 

Dr. BLUMENTHAL. Well, Senator Blumenthal—— 

[Laughter.] 

It’s a pleasure for me to be here. This is a unique opportunity 

for me to testify before you in your home state and bring you greetings from the neighboring State of Massachusetts. 

I’m going to talk about patient safety from a particular point of 

view, and that is from the point of view of one of the important pillars of patient safety, the availability of accurate and timely health 

information. We need to supply our key decision-makers in health 

care with the best possible information they can have at the time 

they need it, accurate information. Inaccurate information is an important cause of safety problems. Up-to-date scientific information, 

when it is lacking, is another important cause of safety problems. 

This vital lifeblood of patient care and of safety, good information 

is one of the most critical resources that clinicians have in their 

care of patients on a day-to-day basis. The best circulatory system 

for that lifeblood in the 21st century is electronic information systems. Virtually every blue-ribbon panel and every expert that has 

looked at patient safety has enumerated a long list of things that 

we need to do, and invariably one of them is to improve information through better information systems using modern technologies, 

which are almost inevitably electronic. 

So, this apparently very complicated topic of information technology is actually very simple. It’s about empowering people to do 

the right thing by enabling them to know what the right thing to 

do is. 

So, we’ve made a lot of progress on that topic since the Obama 

Administration came into office and since the Congress passed the 

Health Information Technology for Economic and Clinical Health 

Act (HITECH), which you mentioned in your opening remarks. 

This 2009 piece of legislation, which was part of the stimulus bill 

passed at that time, put aside many billions of dollars to reward 
18 

physicians, hospitals, and other caretakers for becoming meaningful users of electronic health records, which also have to be certified by the Federal Government. 

Since that law was passed, very dramatic changes have occurred. 

The proportion of American physicians and hospitals with electronic health records has doubled. The numbers of meaningful 

users of electronic health records, both doctors and hospitals, is 

now approaching 100,000. The Federal Government has spent over 

$5 billion in incentive payments through the Medicare and Medicaid programs to reward them as stipulated by law. 

So, we are definitely on a new trajectory, but more could be done. 

Specifically on the topic of this hearing and the topic of your committee, the Special Committee on Aging, there is one particular 

oversight that needs to be corrected under the HITECH Act, and 

that is that the HITECH Act does not support long-term care providers, home health providers, or rehabilitation facilities for the 

adoption and meaningful use of electronic health records. 

This is not a wise choice. We need to do better. Of course, covering the full continuum of care is essential, and the information 

that’s necessary to care for patients in long-term care, home care, 

rehabilitation, and other areas outside the acute care setting is 

every bit as important as in the acute care setting. 

This is especially true for the 5 percent of Americans who account for 50 percent of our spending, patients with multiple chronic 

conditions, with chronic illnesses, the kinds of patients who one 

finds among the elderly and in long-term care facilities. For these 

patients, coordination of care is especially important to avoid safety 

problems; knowing what patients have received in the way of care 

in the past, knowing what drugs they’re on, knowing what their allergies are. All of this information needs to be part of the care 

that’s provided in long-term care settings, as well as in acute care 

settings. 

The HITECH Act didn’t cover those other facilities I think in 

part because it needed to start somewhere. It needed to set bounds 

around the level of expenditure. But as we plan for the future, it’s 

clearly the case that the umbrella of the law has to extend to include those kinds of caretakers and those kinds of facilities as well. 

As the law is implemented, there’s another area where I think 

that Congress needs to be attentive and careful, and that has to 

do with the level of performance that we demand of users of these 

modern information systems. There are two basic, important things 

that information systems do. The electronic health record itself is 

not a powerful tool. It’s just a repository for information. The power 

of these tools derives from two uses of the information. One is to 

exchange it, to enable the information to follow patients, to move 

wherever the patient moves; and the other is to use it to make clinicians smarter and caretakers smarter. 

The latter is done through embedded algorithms, reasoning logic 

that takes the best information that is available to medical science, 

as well as information about patients, and wraps it up in a way 

that presents it to clinicians in a way that they can use most effectively. 

Health information exchange and clinical decision support are 

the waves of the future, and they are both incorporated into the 
19 

meaningful use framework. The meaningful use framework encourages the use of these techniques but they are demanding, more expensive, and they require things of the profession and the health 

care institutions that are not straightforward. As they come into effect, especially as the Center for Medicare and Medicaid Services 

and the Office of the National Coordinator promulgate increasingly 

demanding regulations for compliance with meaningful use, I fully 

expect that there will be efforts by my colleagues in the health care 

industry to postpone, mitigate, and reduce the demands associated 

with the meaningful use framework. I hope the Congress will stand 

firm in supporting the Administration as it tries to push the frontier on making good use of information for improving patient care, 

for improving quality of care, for improving safety and reducing the 

cost of care. 

The last point I would make, following a consumer representative I feel I have to make, is that one of the things that health care 

consumers do care a lot about is the privacy and security of information that’s in medical records. They care about it in the nonhealth care world, in their finances and in the personal choices 

that they make on websites and over the Internet. But there’s 

something special about health care. 

So, I think that the Congress needs to reexamine, and the Administration needs to reexamine the current privacy and security 

framework, because it is not currently adequate to provide the security and enable the trust that we need to make sure that patients and their families are trusting of and fully cooperating with 

the collection and distribution of information using electronic technologies. 

So with those comments, Senator Blumenthal, I will conclude my 

remarks. I’d be happy to take a few questions. 

Senator BLUMENTHAL. I promise only a very few. 

Dr. BLUMENTHAL. None of them personal. 

Senator BLUMENTHAL. In your written testimony—by the way, 

I’m going to ask that all of the written testimony be made a part 

of the record. I know that the witnesses understandably shortened 

what they had to say, and without objection I’m going to ask that 

it all be made a part of the record, and we’ll distribute it to my 

colleagues. 

You mentioned in your written testimony the radiology order 

entry as an example of how IT can save the system from errors or 

make for better and more effective treatment. That’s just one example. Maybe you could just describe that. 

Dr. BLUMENTHAL. Sure, sure. So this is a story that comes from 

my personal experience, 35 years as a primary care physician, and 

that I told frequently when I was working in the Federal Government. At my home institution at Massachusetts General Hospital, 

where I practiced for many years, we had a fairly advanced information system, and one of the things that we had was a form of 

clinical decision support. I mentioned it in my remarks, a way of 

making clinicians smarter. 

What this system did was, it was called radiology order entry, required that you enter some information about the patient in support of ordering a high-cost imaging study, a magnetic resonance 

image study or a computerized CAT scan study of the head or the 
20 

chest or the abdomen, whatever the body part might be. And after 

you’d entered this information electronically, it would then do two 

things. 

First, it would compare your test ordering and the patient’s information to the guidelines of the American College of Radiology. This 

it did in real time. So you would get feedback in milliseconds on 

whether your decision conformed to the recommendation of the nation’s best thinkers about ordering tests. 

The other thing it did—both these systems, by the way, were 

home grown—is it looked back through the patient record, and if 

the same test or a similar test had been ordered within three 

months, it would essentially say are you sure you want to do this, 

because either you or somebody else had just ordered this test, and 

you might be able to get the information you need without doing 

this high-cost test. 

And we found, I found personally and I know that many of my 

colleagues found, that either they weren’t aware that something 

had been ordered or their logic may not have been in accord with 

expert opinion, and often this meant changing a test to order a different one, either adding something to it or taking something away. 

Sometimes it meant canceling the test altogether because a similar 

test had been done and the information was available. 

So what this did is it actually reduced the collective costs across 

the health system, the collective amount of high-cost images that 

were ordered over time. There was a very dramatic reduction in 

the rate of increase in those tests, and I often think of this as kind 

of health policy nirvana. What it did was it got physicians to 

change their behavior in a way that made the care higher in quality, reduced the cost of care, prevented unnecessary radiation exposure for patients, and prevented them from being inconvenienced 

by the need to come back to get a test. Often we would end up 

sending patients to outlying facilities because at Mass General our 

facilities were so busy. So, it saved all that inconvenience, and it 

did it with no coercion, no financial incentives. It just made doctors 

better at what they wanted to do, better professionals. 

So that’s sort of the power, I think, of information at the right 

time and the right place. If you’d given that information a halfhour later, it wouldn’t have been worth anything. But because it 

was present at the time the test was ordered, it made a huge difference. We have almost unlimited opportunities to do that using 

information technology. 

Senator BLUMENTHAL. And it saved money. 

Dr. BLUMENTHAL. It saved test ordering, which saved money. 

Senator BLUMENTHAL. You mentioned that 5 percent of the individuals who receive health care are responsible for 50 percent of 

the spending. Is that an inevitable proportion, or are there steps 

that we can take either through long-term care efficiencies, nursing 

homes, rehabilitation, to drive down those costs? 

Dr. BLUMENTHAL. Well, we can drive down, certainly reduce the 

rate of increase in the cost of that 5 percent. I think it’s unclear 

whether you can ever or would want ever to spread those costs 

across a larger proportion of the population. The fact is that as we 

age as a population, we tend to get more people with chronic illness, and they tend generally to be a minority of the population. 
21 

So I don’t expect that proportion, that concentration of cost to 

change, but I think we could care for that group more efficiently. 

Senator BLUMENTHAL. The concern that you raised about privacy 

and security is very much on people’s minds, whether it relates to 

IT or simple paper records, and I’ve actually sponsored a measure 

and have a number of co-sponsors—it’s been reported out of the Judiciary Committee—that would impose requirements for actual systems. Many corporations, including health care institutions, have 

no systems, and it provides penalties in the event that they don’t, 

and provide a private right of action in the event that there are 

breaches, and other remedies in the event that there are breaches. 

But I think you’ve rightly identified the medical care area as one 

where people are understandably and rightly sensitive, and I take 

it that you feel that there is the need for additional protection. 

Dr. BLUMENTHAL. Yes. There is the need in part because though 

we complain in the medical profession and in the health care industry a lot about HIPAA, which has become kind of an epithet as 

an obstacle from different points of view, an obstacle to whatever 

people are setting out to get, the fact is that it was created in the 

pre-Internet age. It was created before the current use of information was ever imagined, before the Internet, with all its benefits 

and all its risks, was considered. 

So there are whole groups of institutions which now are 

custodians of health care data—take Microsoft and Google as two— 

that are not at all regulated under the HIPAA provisions. There 

are also big gaps in HIPAA itself. It’s actually quite porous and 

fairly easy for practitioners to exchange information, to move information around legally, and often necessarily, without getting patient consent. 

So that’s not to say it’s the wrong thing to do, but I do think it 

needs, in the Internet age, to be reexamined. This will require a 

series of things. It requires some of these necessary changes and 

considerations to be done through regulation. You don’t need congressional action. Some will need, though, congressional action because they are part and parcel of the regulation of information in 

commerce using the Internet, and that is a topic that is under active discussion right now. It’s not an area of my expertise, but I do 

understand that you can’t address the health care area in complete 

isolation from all the other uses of the Internet. 

Senator BLUMENTHAL. Susan Davis, who will follow you, talks 

about patient misidentification and the potential with the same 

name, the same birth date, to be misidentified and confused. Is 

that a problem that you saw during the time that you served as 

national coordinator in this area? 

Dr. BLUMENTHAL. It was a great concern. Of course, the less privacy you have, the easier it is to identify people. The ultimate form 

of identification would be some kind of national patient identifier, 

and I was often asked about that. If we all had to have a unique 

number that was incorporated into our medical records, it would be 

from an information standpoint very easy to avoid making errors 

in identifying patients. But that would run afoul of many deeply 

held views about what the role of government is, what it should 

know about people, and I don’t see that as likely. 
22 

Lacking a unique number associated with everybody, we will 

never find a way to identify people that is absolutely perfect and 

secure with 100 percent accuracy. So the challenge is to identify 

the best technical systems that we have to identify people with an 

error rate that’s tolerable, and educating the public about that as 

a risk of information systems inherently is a big challenge. 

It’s not reasonable absent a national identifier, and even to some 

degree with a national identifier, it’s not reasonable to expect that 

we’ll ever have 100 percent certainty in identifying individuals, especially with common names and without very distinguishing physical or medical problems. 

Senator BLUMENTHAL. Thank you, and thank you for your testimony today. 

Dr. BLUMENTHAL. My pleasure. 

Senator BLUMENTHAL. I’m going to ask Susan Davis to take the 

microphone next. She is the CEO of St. Vincent’s Medical Center 

and Market Leader of the Ascension Systems of Hospitals across 

New York, Connecticut, Florida, and Alabama. She has been at St. 

Vincent’s since 2004, overseeing the most ambitious technology upgrade to support patient safety in the medical center’s history and 

indeed probably in the history of our state. She has aggressively 

implemented systems of patient safety reforms that have resulted 

in one of the lowest rates of infection in the nation, and she’s been 

appointed by the Connecticut Hospital Association to lead all Connecticut hospitals through St. Vincent’s model and example. She 

has received local and national recognition for her commitment to 

patient-centered care, and I can say about her as well as others of 

the witnesses today that I’ve been very proud to work with you, 

Susan. Thank you for being here today. 

And I might just mention that I know that many of you have 

other schedules. If you find after your testimony that you need to 

leave, we won’t hold it against you. We’re going to be keeping in 

contact with you, and obviously all of your testimony will be made 

part of the record. 

Thank you for being here. 

STATEMENT OF SUSAN DAVIS, CHIEF EXECUTIVE OFFICER, 

ST. VINCENT’S MEDICAL CENTER, BRIDGEPORT, CT 

Ms. DAVIS. Thank you very much, Senator, and thank you for 

that very gracious introduction. My father would be proud. 

The point that you made about my role with the Connecticut 

Hospital Association is perhaps one of the responsibilities that I am 

very proud of. We heard our consumer advocate speak about the 

need for hospitals taking patient safety seriously, and I’m proud to 

say that the Connecticut Hospital Association agrees and is working together with every hospital in the State of Connecticut to put 

aside our competitive issues that we have in our communities and 

work together to create a culture of safety by building in reliable 

behaviors amongst the health care workers. 

Our objective is to eliminate serious safety events and make our 

hospitals collectively in the state, and I believe it’s the only state 

in the country that has made this commitment to provide our patients and our communities a safer environment. And I’m pleased 

to say, Jean, that this initiative was developed with a consumer as 
23 

part of our planning group, so you’re teaching us well. Thank you 

very much. 

But patient safety is my passion, and what I am going to speak 

to today is not the issue of safety from the standpoint of serious 

safety events or building a culture of safety and reliability, but 

from the IT side. 

I feel a little—is Dr. Blumenthal still here? Good. 

[Laughter.] 

I feel a little bit overwhelmed by his presence, but I’m going to 

try to give you a perspective from the health care side. 

Senator BLUMENTHAL. He’s much more imposing than I am. 

[Laughter.] 

Ms. DAVIS. Not so. 

[Laughter.] 

But as you know, St. Vincent’s is part of Ascension Health, which 

is the largest Catholic health system in the country and has undergone a number of initiatives around the country to create an IT 

platform that will enable us to use information technology to improve the delivery of care across the continuum, because it’s not 

just about hospitals. As we move forward with the Affordable Care 

Act, the exciting part of it is we’re going to be looking at payment 

for value and also payment across the continuum. In order for us 

to be able to do that, we need to be able to transport information 

and data about the patient across that continuum. 

Unfortunately, that’s not the case today. The Bipartisan Policy 

Center in Washington, which I’m sure you’re familiar with, issued 

a report that highlighted a number of issues that need to be addressed if we’re to be successful in building an electronic infrastructure to support quality, value, and the care across the continuum. 

Our delivery systems and payment reforms must promote quality 

and value, but they require providers to deliver care and bring important health care information about the patient to the point of 

care. And while the High-Tech Act has been very significant in exacerbating the adoption of electronic health records, we have two 

major issues that I’d like to speak to. One is the interoperability 

of our information systems, and the second is the unique patient 

identifier. 

On the interoperability of our health care systems, I’d suggest 

that there needs to be standards and certification requirements associated with CMS’ Medicare and Medicaid EHR programs, and 

they should be expanded at Stage 2 because we need to be required 

to transmit additional data across providers and in different settings, and that’s not the case today. Clinical IT vendors have proprietary standards which prevent easy data exchange between systems, and frankly, those proprietary practices are barriers. 

Think about the fact that the U.S. banks have figured this out 

long ago. Without standards, investments in HIT are minimally optimized and increases the overall cost to the health care delivery 

system. 

The second point I’d like to raise is one that you discussed with 

Dr. Blumenthal, and that is the unique patient identifier. Again, 

the Bipartisan Policy Center issued a report titled ‘‘Challenges and 

Strategies for Accurately Matching Patients to Their Health Data.’’ 
24 

In Harris County, Texas, there are 2,400 people named Maria Garcia; 231 of them have the same birth date. In that county alone, 

there are almost 70,000 pairs of patients who share both names 

and birth dates. That’s not unique to Harris County, Texas or the 

State of Texas. That happens across this country, and patient 

misidentifications vary from 8 to up to 20 percent and have significant impact on medical errors. 

While we need to be conscious and concerned about patient privacy, we also have to find a way to move closer. I understand that 

Dr. Blumenthal said that we will never have a unique patient identifier, but we have to move closer on that continuum to eliminate 

this problem of duplication of names and birth dates to improve the 

safety of the health care we provide to patients. 

Hospitals have developed workarounds, but those workarounds 

are dependent on people. Human error occurs, and people need to 

be added to health care systems to do this manual work, and that 

only adds cost to the health care system. 

There is one additional point I’d like to make in closing, and that 

has to do with the alignment of Federal quality measures. CMS 

has offered three ways for providers to begin moving to provide accountable care under its newly-created Accountable Care Organization program, Medicare Shared Savings, Pioneer ACO, and Advanced Payment Initiative. These are very, very exciting opportunities for hospitals. 

One of the best parts of those three initiatives is the fact that 

the measures across the various payers, either Federal, state or 

local, are required to be consistent measures. It enables those participants in those three programs to pull data that is the same for 

each of those initiatives. We are really appreciative of CMS’ efforts 

to standardize data and data measurements. However, it has to go 

broader than to those providers that are participating in these accountable care organizations. 

The broader U.S. health care system needs to align both its payment and technology processes to assure high quality and high 

value. Health IT and provider adoption of EHR technologies must 

become an integrated component of the health care system transformation that is grounded in policy which facilitates provider access to secure patient health information. 

I welcome the opportunity to serve as a continuing resource to 

you in your important work, and thank you for inviting me to be 

part of this testimony. 

Senator BLUMENTHAL. Thank you, and we certainly will take advantage of your offer to be a continuing resource. 

You mentioned that the effort has to be broader than the ACO, 

the accountable care organizations. Can you expand on that a little 

bit? 

Ms. DAVIS. Yes. I’ll take it from a local perspective. We provide 

measures on almost 75 indicators. Now, I’ll make two points on 

that. First, we have got to move from process measure to outcome 

measures because that’s the value that we provide, the outcome to 

the patient. Patients can still get bedsores even if we’re being 

measured and the fact that we document turning patients every 

two hours. The definition of those outcomes are different when 
25 

we’re reporting them to insurers, managed care companies, CMS, 

Joint Commission, or statewide agencies. 

So what we need as providers is a consistent definition of those 

outcomes so that we’re able to report it to everyone. We believe in 

transparency, but when you take those 75 measures and put three 

or four different definitions in there, it’s just additional work and 

opportunities for error, and it takes us away from ensuring the outcomes that we want to deliver. 

Senator BLUMENTHAL. Good point. You also mentioned—that one 

of your recommendations is to expand consumer engagement in 

electronic tools. How exactly do you think we ought to do it? 

Ms. DAVIS. Well, you know, I think we’re fortunate to have organizations like Jean’s who really advocate for the consumer; not to 

say that we as providers don’t also advocate for the consumer. But 

it’s amazing to me the amount of information that’s out there that 

consumers do not gain access to, and I think we need to start with 

educating consumers about the information that is available to 

them now to help improve their health outcomes. 

But in addition to that, I think that patient portals that can be 

developed by hospitals, by a health system, and giving patients access to them in an easy, accessible way is one of the best ways for 

patients to get access to their information. But in order to do that, 

we need interoperability, and we need unique patient identifiers to 

protect the privacy of those patients that have duplicate personal 

patient information. 

Senator BLUMENTHAL. And these ideas, I think, really go very 

well with the suggestion that Jean Rexford made, that we need 

partnerships for patients, but even more partnerships with patients so that they are involved and engaged as participants, not 

just the objects of what happens. 

Ms. DAVIS. Absolutely. As health care providers, we sometimes 

think that we know what patients want. We don’t. And unless the 

patient has a seat at the table, we’re not going to move this health 

system along as we need to, to better meet their needs. 

Senator BLUMENTHAL. Thank you. 

I’m going to ask—I wish we had more time for each of our witnesses, but I know that we are limited in terms of time. I’m going 

to ask Ms. Henderson, CEO of Hill Health Center, Connecticut’s 

oldest community health center, to be our next witness. Since her 

arrival, she has directed the rebuilding efforts of a legacy institution with a 40-year track record of innovative patient care. 

I’ve been tremendously impressed by the great work that you’ve 

done there, and thank you so much for being here with us today. 

STATEMENT OF JAMESINA HENDERSON, CHIEF EXECUTIVE 

OFFICER, CORNELL–SCOTT HILL HEALTH CENTER, HARTFORD, CT 

Ms. HENDERSON. Thank you. Thank you so very much, and good 

afternoon, Senator Blumenthal. Thank you for the opportunity to 

contribute to your research on this most important subject. 

I am Jamesina Henderson, CEO of the Cornell-Scott Hill Health 

Corporation, Connecticut’s first federally qualified health center 

and one of its largest. And may I add that each federally qualified 
26 

health center is required to have 51 percent patient participation 

on its board of directors, so there is patient voice. 

We were established in 1968 as a primary care institution, and 

through our 44 years of growth, expansion, and development of 

services in medical, dental, and behavioral health care, we have become the nation’s best example of integrated care. We’re not alone 

in arriving at this conclusion. Linda Rosenberg, the CEO of the National Council of Behavioral Health Care, who visited with us recently and is responsible for leading an association comprised of 

over 1,900 behavioral health care organizations nationwide, stated 

that in all of her experience, we are the best example of integrated 

care that she has ever seen. 

I believe our perspective on care integration is critical to your efforts on patient safety, and I’d like to explain why. 

Throughout our history of providing care to the 33,000 people 

who consider us their medical home each year, we have focused on 

delivering a quality experience, from scheduling to the reception 

desk to the treatment room. One of the challenges we have faced 

is ensuring the appropriate sharing of information between our 

medical, dental, and behavioral health providers. Many of our patient population receive services from all three disciplines, and as 

many of you know, there are many connections between mental 

health and physical health. 

In one of our most recent efforts to tackle this problem head-on, 

which is what we like to do at the Cornell-Scott Hill Health Corporation, we challenged the marketplace to provide what we know 

is the right contributory solution to improve patient care and patient safety, a completely integrated electronic health record structurally built on a foundation of information sharing across all three 

care disciplines. We demanded a solution that mirrored our practice of integrated care, and only one solution provider heard our 

call. 

I’m proud to say to this committee that the Cornell-Scott Hill 

Health Corporation, in partnership with General Electric, is leading the transformation of electronic health records. Our system, 

which is now in place at several of our 16 care sites, is likely the 

first in the nation to provide full integration and sharing of information across all care disciplines. 

We know from experience that communication and sharing of information is critical to patient safety, continuity of care, and to an 

enhanced patient experience. Technology aside, there are other 

ways we know this to be true. And like the technology solution we 

are implementing, there are other collaborative and partnership solutions underway in our health care environment equally deserving 

of mention. 

Today we have no less than three programs in place, funded 

through foundations and others, to provide patient navigation services to patients with specific conditions. Just last month we were 

awarded a grant from the Komen Foundation to provide patient 

navigation services to women with breast cancer. What these foundations know and are willing to put their funding behind is the 

true value of communication, information sharing and care management. They know that if patients diagnosed with specific condi-
27 

tions are assisted along the path of the health care continuum, 

they stand a better chance of improved health outcomes. 

Technology cannot do this alone. It is an important, even critical 

component, but the human component is needed. Patients need to 

know they have an advocate fighting for them, working with them 

to ensure their needs are going to be met. This gains increasing importance as the population in general, and our patient population 

specifically, ages. More complex medical conditions and treatment 

regimes, including medication adherence, demand greater attention. 

Patient navigation is a clear success story. With it, we stand a 

better chance of our patients receiving the right care at the right 

time in the right place. Patient navigation can help us reduce nonemergency visits to emergency departments, which of course everyone knows will reduce costs throughout the health care system. 

What makes this a difficult solution to implement is the simple fact 

that patient navigation services are not a reimbursable expense 

from our current payer mix. 

Another challenging aspect of providing this service is the lack 

of training and workforce development opportunities to help us 

transform the existing workforce into 21st century caregivers capable of coordinating care across multiple specialties and institutions 

while simultaneously delivering on our promise of an exceptional 

experience. 

I’d like to make one additional point before concluding with the 

recommendations. All of us in the health care field understand the 

growing complexities in delivering quality care. With the confirmation of the Affordable Care Act, we know the future of health care 

is going to be different tomorrow than it is today. One area we 

know will not be different is the expectation of our patient, high 

quality and safe care from their provider. We believe the vast majority of our patients have elected to make us their medical home 

precisely for that reason. 

A medical home is more than a label. It is an affirmation of expectation and of value. And underpinning that expectation and acceptance of a medical home is trust. The simple and powerful truth 

is that our patients place their trust in us, all of us in the health 

care field, to do what is best for them. A successful handoff or 

transfer of a patient and their clinical information builds trust, and 

when coupled with the overt acceptance of responsibility for an individual’s care, then and only then have we all succeeded in transforming health care. 

My recommendation to you, Senator Blumenthal, and to your colleagues on this committee and in the Senate, is to draft legislation 

that supports our efforts to provide seamless, accountable, and beneficial patient navigation across the health care spectrum. With it, 

we can improve patient safety, achieve better outcomes, and reduce 

costly interventions. 

Once again, thank you for the opportunity to share my thoughts 

on this most important issue. 

Senator BLUMENTHAL. Thank you. And by that recommendation, 

I assume you would also recommend that patient navigation be a 

reimbursable expense. 

Ms. HENDERSON. I certainly do. 
28 

Senator BLUMENTHAL. And how would you, if you were to make 

that argument, or elaborate on it I should say, talk about how cost 

effective it will be, that the investment is worth the savings, the 

improved effectiveness of health care. 

Ms. HENDERSON. Well, I think it’s well known the cost of the improper use of emergency departments, and the reason people do 

that is because they are directed by the system to go to the emergency room. That structural guidance needs to change, and we 

need more people. As much as we applaud the electronic health 

record, there is nothing like an actual person helping to assist patients go to the right place and encouraging them to transfer information essential to their better health. 

Senator BLUMENTHAL. And that’s what’s necessary to permit and 

foster and promote patient navigation, which is really navigating 

for patients in what is now all too often a maze to them. 

Ms. HENDERSON. Yes. 

Senator BLUMENTHAL. Seemingly a maze of fragmented, different 

stops along the way to health care. 

Ms. HENDERSON. Absolutely, and to encourage their active participation in whatever that acute situation is, and their prevention 

and wellness. We expect to differentiate in the future at the Hill 

Health Center by focusing on prevention and wellness and active, 

proactive engagement of patients. 

Senator BLUMENTHAL. Well, I want to thank you. First, congratulations on having a fully integrated health IT system. 

Ms. HENDERSON. Thank you. 

Senator BLUMENTHAL. And for your use of patient navigation, 

and thank you for being here today. 

Ms. HENDERSON. Thank you very much. 

[Applause.] 

Senator BLUMENTHAL. We’re going to go to Scott Ellner. Dr. 

Ellner is the Director of Surgical Quality and Trauma Surgery at 

St. Francis Medical Center. He completed a Patient Safety Leadership Fellowship with the American Hospital Association and the 

National Patient Safety Foundation. He is co-founder and chairman of the Connecticut Surgical Quality Collaborative, which is a 

statewide data-sharing framework for all Connecticut hospitals to 

learn from each other. 

Thank you for your great work in this area, Dr. Ellner. 

STATEMENT OF SCOTT ELLNER, DIRECTOR OF SURGICAL 

QUALITY, SAINT FRANCIS HOSPITAL AND MEDICAL CENTER, 

HARTFORD, CT 

Dr. ELLNER. Thank you, Senator Blumenthal. It’s a pleasure to 

be here today amongst all the esteemed luminaries on this panel, 

and I’m excited to testify on behalf of a surgeon’s perspective on 

value-based health care delivery. 

As a general and trauma surgeon employed at Saint Francis 

Hospital and Medical Center, I am honored to share with the committee our efforts to improve the value of health care delivered to 

our patients. Value can be equated to health outcomes for every 

dollar spent on health care services. This value proposition redefines the next steps which should be taken toward health care reform and which can be achieved through the full continuum of 
29 

care; simultaneously improving the experience for patients and 

their families, improving the overall health of populations, and reducing the per-capita costs of health care provided. 

Now, Susan Davis had discussed outcomes, and my vision as a 

health care provider is about improving patient outcomes and moving away from studying process measures, but, looking at outcome 

measures, and this can be done through the careful measurement 

of these outcomes. 

It’s a well-known management axiom that if it’s not measured, 

then it cannot be improved. Over the last five years at Saint 

Francis Hospital, my team has collected and reported on 30-day 

post-surgical complications through a risk-adjusted and transparent database. Knowing our outcomes has allowed us to realize 

not only how good we are, but how much better we can be. Over 

this time period using our data, we have implemented specific patient safety initiatives to improve our patient safety outcomes. 

For example, nurse-driven protocols for early removal of in-dwelling urinary catheters resulted in a 62 percent reduction in urinary 

tract infection rates. Improved care bundles in the intensive care 

unit to prevent hospital-acquired pneumonias reduced our pneumonia rates by 33 percent. We developed an operating room team 

training program to effectively implement a surgical checklist to 

prevent safety-compromising events in the surgical setting. This resulted in a 70 percent reduction in post-operative complication 

rates, and I’m proud to say we were recognized by the Joint Commission for demonstrating best practice during our time out for 

universal protocol in the operating room. 

This has a big impact on costs. Knowing our outcomes has allowed us to develop these performance improvement initiatives to 

prevent costly readmissions in health-care-acquired infections. In 

fact, two years ago in one study, we found on average that patients 

who developed the dangerous C–DIFF infection, which is hospitalacquired or health-care-acquired, added up to an excess cost of 

$54,000 to those patients’ care. By obtaining better outcomes, we 

can identify opportunities to eliminate waste and reduce those 

costs. 

Through our electronic health record system, our information is 

now streamlined so we can automate our data collection for realtime monitoring and make adjustments as needed. 

I’ll tell you, this morning I saw 22 patients in my office on my 

electronic health record. All the data was input. I wrote a letter to 

each of their primary care physicians and the patients received a 

summary of care to go home with for them to use for transfer to 

other physicians if they didn’t have the patient portal system. So 

we are implementing the electronic health record to its fullest potential not only to help the patient navigate the system but also 

for measuring our outcomes. 

But, we have to be prepared to change the culture in order to 

make these adjustments, and this starts with medical school training. The behaviors and actions of the doctors today come from the 

core curriculum in the medical schools and the residency training 

programs. We are, in fact, still taught 19th and 20th century management principles for human interaction. Consequently, there is a 

hierarchy or an authority gradient in medicine which exists today, 
30 

and at times this can be intimidating to patients. It can impede 

communication and collegiality among providers: be they doctors, 

nurses, pharmacists, or physician assistants. It’s time to level this 

authority gradient, to remove these behaviors, to better the communication so that we can work together as a cohesive unit for the 

betterment of our patients. 

I’m proud to say that next week at the University of Connecticut, 

School of Medicine, we will be teaching our first course in patient 

safety as part of their curriculum. We are going to be teaching the 

future providers in health care how to be the best advocates for 

their patients and how to work together as a cohesive, integrated 

unit. 

Jean has been an important advocate for her patients, and we 

have reached out to her, and recently, last March at Saint Francis 

Hospital, we had a very successful patient safety awareness day 

with a goal of collaborating with our patients. We brought them in 

from the community and we discussed efforts on how they can safely navigate the system. It was a successful day where patients felt 

like they were listened to, and on the other hand we were able to 

hear what they had to say to help them come to the hospital and 

leave safely. 

One other thing I just want to mention is that Hospital Compare 

is now looking for hospitals to present their outcomes data, and 

what we have done is we have participated in a new pilot, the only 

hospital in Connecticut to report our elderly serious outcomes after 

surgery. 

So with that, I want to thank you for allowing me to testify 

today. It’s been an honor. 

Senator BLUMENTHAL. Thank you for being here. I feel badly—— 

[Applause.] 

I feel badly for taking you away from those 22 patients and others that you would be seeing right now, but your contribution has 

been immeasurable. Quite honestly, those numbers of reductions in 

urinary tract infections and pneumonia and other accomplishments, measureable outcomes, are really extraordinarily impressive. 

I guess my first question is: was it difficult to get support or buyin from the nurses and the doctors and others who are in the 

trenches for the steps that were necessary to achieve those outcomes? 

Dr. ELLNER. Well, I think that one of the challenges that you 

have to face anytime that you’re going up against an embedded culture is to change the mindset from the way we’ve always done 

things to the way we should be doing things on behalf of patient 

safety. 

Because I am a frontline worker, I’m there in the trenches—I 

was there last night operating on a patient with a small bowel obstruction—they know me. They are able to relate to me and understand that if I’m truly passionate about this then this must be important. And so I was able to develop a team of stakeholders who 

understand it. Some of them are here today. Then I was able to go 

to senior leadership, particularly our CEO, Chris Dadlez, who has 

been behind us 100 percent and he understands the importance of 

this. 
31 

I can tell you that if the leadership in your organization understands how important patient safety is, then you’re going to be successful. It aligns the organization. 

Senator BLUMENTHAL. Well, I know your CEO, and I’m very glad 

that you brought some of your stakeholders and your team here 

today because they really show how leadership can get results. 

This is not pie in the sky stuff. This is real-life steps that can be 

taken, can achieve results, and I think it’s a very powerful story. 

I guess the other question I have for you is: do you think that 

the teaching, the curriculum that you developed for the University 

of Connecticut, can be replicated and done elsewhere? 

Dr. ELLNER. I believe it can. We look at the World Health Organization as a model and use some of their baseline teachings to develop the core curriculum, and the goal is to not only roll this out 

here at the University of Connecticut but to implement it in the 

nursing programs and the pharmacy schools so that it’s an interactive process with all health care providers, not just the physicians. 

So ultimately that is our goal. And then on a side note, what 

we’d like to do is make this into a 4-hour certification program for 

all providers, for all personnel within our hospital, so that like you 

have to become basic life support certified, know how to do CPR, 

you have to be patient-certified, patient-safety-certified. 

Senator BLUMENTHAL. Patient safety certified. That would be a 

great qualification to spread more generally among health care providers and institutions. 

Well, thank you very much. 

I’m going to ask questions that have been submitted by the audience, and I guess some of them are general questions, and I’m 

going to ask them in exactly the way they have been written and 

open it to whomever would like to respond if they’re not addressed 

to one person, and identify who has submitted them. 

The first is from Ann Yedlin of New Haven, and the question is: 

‘‘What role does staffing play in patient safety, and how is this 

being addressed? Numbers, training, empowerment.’’ For any of 

you who would like to respond. 

Ms. DAVIS. I’ll try taking a shot at it. I think there are a lot of 

studies that are out there that talk about the relationship of the 

number of registered nurses to patient outcomes, patient satisfaction. So I think that’s got to be an issue amongst all of our hospitals, within all of our hospitals, because there are data there that 

supports it. 

But it’s just not having a person. It’s just not about numbers. It 

really is about the culture in our organizations and the behaviors 

that we all exhibit. We talk about in higher liability of 200 percent 

accountability. I’m accountable for the work that I do, but I’m also 

accountable for the work that Jean does in making sure that if I 

see her forgetting to wash her hands or not putting isolation balm 

on, I stop her; speaking up, creating a culture where employees, it 

doesn’t matter what you do in the organization, whether you’re the 

CEO or a registered nurse or a housekeeper or dietary worker. If 

you see a health care provider doing something that you know is 

wrong, like not washing their hands, or putting a mask on when 

you’re going to put a central line in, you have to empower those 
32 

individuals to speak up, to stop the line, so to speak, and that’s not 

about numbers. That’s about culture. That’s about setting the expectations within the organization. 

Senator BLUMENTHAL. Thank you. 

[Applause.] 

Our next question—I’m asking these in the order that they were 

submitted—is from Maggie Ewald, who is the Long-Term Care Ombudsman. She’s from Columbia, Connecticut. ‘‘How does a patient 

correct or change a previous erroneous diagnosis in his or her, medical record?’’ 

[No response.] 

PARTICIPANT. Well, I guess they don’t. 

Ms. DAVIS. No, they do. They absolutely do. Most organizations 

have a process for that in their policy that enables that to happen. 

It’s not easy. I will tell you that, because a physician has written 

a diagnosis in a medical record, they’ve made that diagnosis based 

on scientific and qualitative data. 

But there is a way in which you can contact the hospital where 

you believe the erroneous medical record entry is and work with 

the hospital and the physician to have your complaint reviewed 

and potential for changing the medical record. 

I’ve seen it done, it does work, and I’ve seen those from the DPH 

standpoint understand the process. But that is generally the path 

that you should follow to get it done. 

Senator BLUMENTHAL. Next question from Sean Jeffrey of Branford, Connecticut. ‘‘Medication reconciliation between care settings 

is an important source of errors and potential danger for seniors. 

Pharmacists are best situated to make positive changes. However, 

pharmacists need to be recognized by CMS as health care providers 

to ensure they have the ability to work across care settings to incorporate medication data across electronic records to ensure proper communication and make sure the right drug reaches the right 

patient at the right time. The American Society of Consultant 

Pharmacists looks to partner with your office and the Senate Aging 

Committee.’’ 

I guess that’s a comment more than a question. If you wish to 

comment, we would welcome it. 

Ms. BONNER. Thank you for that comment, and I just want to 

add that we are working with ASCP, the American Society of Consultant Pharmacists. Our regulations right now for the most part, 

as you pointed out, are really in silos. We have nursing home regulations, we have hospital regulations, we have home health regulations. One of the things that we’re doing now, CMS is looking to 

see how do the regulations need to change now that we’re looking 

at accountable care organizations and looking at care transitions. 

The pharmacists have played a tremendous role in the anti-psychotic work that we talked about earlier, and we’re very pleased 

that ASCP is a partner with us. So we’d be happy to work with 

them, and Mr. Jeffrey here in Connecticut as well. 

Senator BLUMENTHAL. We have a question from Martin Spriglio 

of Stratford. ‘‘Will there be funding for nursing homes to put electronic health records? All others receive funding—hospitals, doctors, et cetera.’’ 
33 

I guess I will answer that question, but I will open it to others. 

I certainly hope there will be funding for it, and I will support it 

if the President is willing to support it as well. Anyone else who 

wants to comment can, but I think that kind of funding for nursing 

homes is vitally important. 

KATHY TYNAN MCKIERNAN. ‘‘What plans are underway to improve quality of care and disincentivizing quick decisions to hospitalize or re-hospitalize patients in nursing homes?’’ 

Ms. BONNER. There are a number of initiatives that are going on, 

but most recently—— 

Senator BLUMENTHAL. Sorry about the logistics here. 

Ms. BONNER. I’m sorry I have my back to you so that you can 

hear me. There is a recent initiative from the Federal Coordinated 

Care Office of Health, which is the office of the dual eligibles, people who have Medicare and Medicaid, and it is specifically a proposal. They’re reviewing the people who submitted them now to 

look at re-hospitalization, avoidable re-hospitalization of nursing 

home residents. That is one of the primary outcomes, as well as, 

again, the use of anti-psychotic medications, and others. But that 

is one specific initiative where nursing homes are partnering with 

physicians and other groups to come in and provide primary care 

and work together collaboratively on primary care nursing home 

issues to prevent re-hospitalizations. 

CMS is working with a number of partners as well. In Connecticut, there is a particular group in New Haven that was funded 

under the Section 3026 of the Affordable Care Act on care transitions, and that’s again a group that includes skilled nursing facilities, hospitals, community-based organizations to look at unnecessary re-hospitalizations, including those of nursing home residents. 

So a number of the programs under the Community-Based Care 

Transitions section of the Affordable Care Act are looking at that 

as well. 

Senator BLUMENTHAL. Thank you. 

This is a question for Jean Rexford from Brian Capshaw, resident counsel, President of Aurora Senior Living of East Hartford. 

He’s an executive board member of the Statewide Coalition of 

Presidents of Resident Counsels of Connecticut. 

Is Brian still here? 

Mr. CAPSHAW. Yes. 

Senator BLUMENTHAL. Great. ‘‘Connecticut law requires that 

nursing home staffing levels result in 1.90 (second lowest in the 

country) total nurse and nurse’s aide hours per resident per day. 

With this low number, nursing home resident safety is an issue, 

such as falls, because not enough staff is available and residents 

try to do things for themselves. The Federal Government leaves 

this up to each state. Would you support our attempt to change the 

Connecticut law from 1.9 to 2.3 in 2013, and 2.3 to 2.7 in 2014 in 

the next legislative session? The Office of Fiscal Analysis shows little cost to the state.’’ 

Ms. REXFORD. That’s known as being put on the spot. It would 

be certainly something I would be very interested in, and our group 

would be very interested. We have just begun working on nursing 

home issues. As you know, we have focused on hospitals. But over 
34 

the last few years, we’ve had more and more calls about problems 

within the nursing homes. 

Clearly, in some nursing homes it is the same complaint, whether it is medication or falls, that are repeated, and there’s been a 

movement in California particularly that looked at staffing levels 

that was driven by consumers. So it would be definitely something 

we would consider. 

Senator BLUMENTHAL. I’m going to ask Brian’s next question because I think it deserves to be asked, and you can answer it or 

maybe talk to Brian individually since he’s here. But I’d like the 

whole panel to hear it. 

‘‘The last three Connecticut nursing homes that were found to be 

negligent in causing a resident’s death were fined an average of 

$560. Connecticut law says DPH can fine nursing homes up to 

$3,000. With these small fines, there is no incentive for owners to 

provide safe care. I’ve looked at recent cases from 10 other states 

and found the average fine to be $18,000. The Federal Government 

allows states to set their own monetary penalties. In the 2013 legislative session, we will be asking the Connecticut legislature to 

raise the maximum fine to $10,000 and the minimum fine for causing a resident’s death to $2,000. Would you support our effort?’’ 

Ms. REXFORD. We are absolutely looking into this. In fact, this 

past year the Connecticut legislature passed animal cruelty fines. 

The first time is $1,000, and it can go up to $5,000, and criminal 

charges can be filed. One of our members has just done a spreadsheet on what our fines are and what they are in other states, and 

we would be very happy to share that with your office, and I have 

a feeling we’ll be sharing that with the legislature next year. 

Senator BLUMENTHAL. And may I just say, Brian, you’ve asked 

about state law, but perhaps we can talk about changes in Federal 

law and obviously work with Jean and other members of the panel 

that may be appropriate in this area. So thank you for the question. 

The next questions are first from Patricia Kellmer of Farmington, and this one is for Susan Davis. ‘‘Can you elaborate on the 

Connecticut Hospital Association’s plans to bring culture change to 

Connecticut hospitals? What are your goals, and how do you intend 

to achieve them, especially for those hospitals not already willing 

to change?’’ 

Ms. DAVIS. Sure. The Connecticut Hospital Association, through 

its Committee on Patient Care, Quality and Safety, has been working over the past three years to put a plan in place that will involve all the Connecticut hospitals in, first of all, making a commitment, doing education of the leadership, and bringing in a consultant from the nuclear power industry that really does work on safety to teach us about all the principles of changing behavior, because in order to change a culture, you have to start with changing 

behavior. 

The Connecticut Hospital Association has held two boot camps in 

the month of June where we had CEOs, physicians, frontline staff, 

and medical leaders come for a two-day event. Each boot camp was 

two days where they learned about some of the tools that can be 

used and the process for helping to change the culture and create 

a culture of safety and high reliability, looking at serious safety 
35 

events, using tools to monitor the serious safety events and improve the outcomes. 

I can speak to what we’ve done at St. Vincent’s. We have gone 

through this process and we, in fact, have educated all of our hospital employees in a three-and-a-half-hour course that I taught, as 

well as all of our senior leaders taught to every one of our 3,500 

associates about safety and reliability, and we also did the same 

thing for our physicians. That was taught by medical staff. 

So it’s a real commitment. But when you try and answer the 

question that you asked earlier of Scott about how you change this 

culture, it’s easy, because you change it by touching the heart of 

the caregiver. Caregivers come into health care because they want 

to make a difference in people’s lives, and when you can tell stories 

of people that we have harmed, unintentionally harmed, it helps 

the caregiver understand their role better and what they could 

have done differently in order to avoid that medical error. 

Senator BLUMENTHAL. Our last question is from David Shapiro, 

and I think it’s broad enough to be addressed to any of our witnesses. David Shapiro, M.D., West Hartford, ‘‘How can we truly 

achieve ‘collaborative patient safety’ if hospitals are constantly demonstrative of their competitive stance? Billboards, ads, et cetera, 

say ‘we’re the best,’ but it’s less than accurate.’’ 

So that one I will open to any of you. Again, I’m reading the 

questions, I’m not asking them, but I think all of these questions 

really deserve to be asked, and others, because it is the consumers, 

the folks who are here today, who ought to have an opportunity to 

be engaged and involved. So, any of you may choose to answer. 

Ms. DAVIS. I’ll take a shot at it first since I’ve had the opportunity to work through this with the Connecticut Hospital Association. What I would say to you is it’s a journey, it’s not an event. 

But to get all the hospitals in the State of Connecticut together to 

say we’re going to put aside our differences and our competitive nature on issues and work together to share information, share data, 

is a huge undertaking, and it’s a leap of faith, because we did have 

discussions where some hospitals said, well, if I’m sharing my data 

on my serious safety events, I don’t want to see Hospital Y putting 

a billboard up and saying come to us because Hospital X has this 

many serious safety events. 

We as providers have to be bigger than that. That’s what I would 

suggest to you. We have to understand that we’re not doing this 

for a competitive reason. We’re doing it for our patients, and that’s 

what gets us up every day to come to work. 

Senator BLUMENTHAL. Dr. Ellner. 

Dr. ELLNER. I think part of the culture in health care is that 

there’s a zero sum competition right now. There’s no incentive for 

us to display our outcomes. We get paid for quality, whether it’s 

good or bad. So what we have to do is we have to work together 

with CMS or the payers to put our outcomes out there and be 

transparent, because that’s what we’re going to move toward, a 

more transparent outcomes reporting type of system. Unfortunately, this type of competitive or zero sum competition, as Michael 

Porter calls it at Harvard Business School, is not going to work five 

years from now. It has to be based on value, your outcomes and 

the amount that it costs to get those outcomes. 
36 

So part of the collaborative that we have in the state, the Surgical Quality Collaborative, we have 17 hospitals that have come 

together, 17 out of the 30, that are willing to share their data in 

a collegial framework understanding that this is about our patients. It’s not about billboards. It’s about improving our patient’s 

outcomes. 

Senator BLUMENTHAL. Thank you. I think that is a highly appropriate comment on which to end this hearing. If any of our witnesses have anything else they would like to add or any closing 

comments, I’d be happy to entertain them. 

[No response.] 

If not, let me just say how truly thankful I am to each of you 

for being here today. You have added enormously to the information available to us. I can tell you I’ve been in the United States 

Senate for about a year and a half. I haven’t heard a more thoughtful or insightful panel, and I’m very, very proud that it happened 

here in Connecticut. 

I’m very proud also that Connecticut is really at the forefront. 

We have some leaders here, and I think that the more we can add 

to this movement, the better. As Susan Davis said so well, it isn’t 

an event. This hearing is not the end. It really is a journey, and 

I really want to thank all of you on the panel and others who are 

in leadership who have attended today for your really extraordinary work on this very, very important issue. Thank you very 

much. 

We will keep the record open for a week so that anyone who 

wants to submit anything more can do so, and it will be included 

in the record, including, by the way, comments from others who 

may wish to submit them for the record. 

For now, the hearing is adjourned. Thank you. 

[Applause.] 

[Whereupon, at 3:21 p.m., the hearing was adjourned.] 
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