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[Senate Hearing 112-787]
[From the U.S. Government Publishing Office]

                                                        S. Hrg. 112-787
 
     FIRST, DO NO HARM: IMPROVING HEALTH QUALITY AND PATIENT SAFETY

=======================================================================

                                HEARING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,

                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                      ONE HUNDRED TWELFTH CONGRESS

                             FIRST SESSION

                                   ON

         EXAMINING IMPROVING HEALTH QUALITY AND PATIENT SAFETY

                               __________

                              MAY 5, 2011

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions

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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                       TOM HARKIN, Iowa, Chairman

BARBARA A. MIKULSKI, Maryland
JEFF BINGAMAN, New Mexico
PATTY MURRAY, Washington
BERNARD SANDERS (I), Vermont
ROBERT P. CASEY, JR., Pennsylvania
KAY R. HAGAN, North Carolina
JEFF MERKLEY, Oregon
AL FRANKEN, Minnesota
MICHAEL F. BENNET, Colorado
SHELDON WHITEHOUSE, Rhode Island
RICHARD BLUMENTHAL, Connecticut

                                     MICHAEL B. ENZI, Wyoming
                                     LAMAR ALEXANDER, Tennessee
                                     RICHARD BURR, North Carolina
                                     JOHNNY ISAKSON, Georgia
                                     RAND PAUL, Kentucky
                                     ORRIN G. HATCH, Utah
                                     JOHN McCAIN, Arizona
                                     PAT ROBERTS, Kansas
                                     LISA MURKOWSKI, Alaska
                                     MARK KIRK, Illinois
                                       

                    Daniel E. Smith, Staff Director

                  Pamela Smith, Deputy Staff Director

     Frank Macchiarola, Republican Staff Director and Chief Counsel

                                  (ii)

                            C O N T E N T S

                               __________

                               STATEMENTS

                         THURSDAY, MAY 5, 2011

                                                                   Page

                           Committee Members

Harkin, Hon. Tom, Chairman, Committee on Health, Education, 
  Labor, and Pensions, opening statement.........................     1
Enzi, Hon. Michael B., a U.S. Senator from the State of Wyoming, 
  opening statement..............................................     2
Mikulski, Hon. Barbara A., a U.S. Senator from the State of 
  Maryland.......................................................     4
    Prepared statement...........................................     5
Bennet, Hon. Michael F., a U.S. Senator from the State of 
  Colorado.......................................................    19
Whitehouse, Hon. Sheldon, a U.S. Senator from the State of Rhode 
  Island.........................................................    20

                            Witness--Panel I

Clancy, Carolyn M., M.D., Director, Agency for Healthcare 
  Research and Quality, U.S. Department of Health and Human 
  Services, Rockville, MD........................................     6
    Prepared statement...........................................     8

                          Witnesses--Panel II

Charles, Timothy, President and CEO, Mercy Cedar Rapids Hospital, 
  Cedar Rapids, IA...............................................    25
    Prepared statement...........................................    27
Mehler, Philip S., M.D., Chief Medical Officer, Denver Health, 
  Denver, CO.....................................................    30
    Prepared statement...........................................    32

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.:
    American College of Surgeons.................................    45
    National Transitions of Care Coalition.......................    47
    Roundtable on Critical Care Policy, Submitted by Stephanie 
      Silverman, Executive Director..............................    49

                                 (iii)

     FIRST, DO NO HARM: IMPROVING HEALTH QUALITY AND PATIENT SAFETY

                              ----------                              

                         THURSDAY, MAY 5, 2011

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 10:02 a.m. in 
Room 430, Dirksen Office Building, Hon. Tom Harkin, chairman of 
the committee, presiding.
    Present: Senators Harkin, Mikulski, Franken, Bennet, 
Whitehouse, Enzi.

                  Opening Statement of Senator Harkin

    The Chairman. Good morning everyone. The Committee on 
Health, Education, Labor, and Pensions will come to order.
    We have convened this hearing to discuss a new strategy and 
initiative recently announced by the Department of Health and 
Human Services to improve the quality of health care by 
emphasizing patient safety and reducing medical errors.
    In addition to saving tens of thousands of patients' lives, 
the department estimates that this new effort will save up to 
$35 billion in healthcare costs, including up to $10 billion 
for Medicare alone.
    In the late 1970s, a group of researchers began to examine 
the reports of patients' deaths and injuries caused by 
anesthesia. They found wide variation in quality and a 
disturbing incidence of medical errors leading to 6,000 deaths 
or serious injuries annually. ABC's 20/20 news program covered 
the study, and the modern patient safety movement was born.
    But the urgency and importance of this cause was brought 
into sharpest focus by the Institute of Medicine's landmark 
1999 study, To Err is Human, it was called. It sent a shockwave 
though the medical establishment. The Institute of Medicine 
found that almost 100,000 preventable deaths and many times 
that number of injuries occurred annually in the Nation's 
hospitals.
    Since then, conscientious and innovative providers, 
scholars, and public officials have made great strides in 
improving quality of care for all Americans. Our witnesses 
today will talk about some of these life-saving innovations.
    For example, CEO Tim Charles will describe how Mercy 
Medical Center in Cedar Rapids, IA has achieved extraordinarily 
low re-admission rates by sharing information and best 
practices with competitors and by establishing a free clinic 
for uninsured patients. These practices led the Commonwealth 
Fund to name Mercy a high performing hospital, and also the 
Institute for Healthcare Improvement also named Mercy a high 
performing hospital.
    As chief medical officer, Dr. Philip Mehler will tell us 
how Denver Health System has created a quality assurance system 
of incentives, centralized leadership, and focus on high risk 
populations. As a result, it is ranked first among 112 academic 
medical centers for patient safety.
    The Affordable Care Act makes the greatest single 
investment in quality improvement in history, building on 
models like those I just described. It is on these vital 
investments that our hearing will focus today. For the first 
time, the law gives public officials, providers, payers, and 
other stakeholders the tools to reward high quality, not high 
volume care. And perhaps most importantly, the law stops 
payment for bad care. So I am pleased to see that the 
Administration is using these tools to aggressively attack 
weaknesses in our healthcare system.
    In March, the Department of Health and Human Services 
released a comprehensive National Quality Strategy that 
promises to drive broad quality improvement across both public 
and private markets. And in mid-April, the administration 
announced a patient safety initiative, the Partnership for 
Patients.
    As Dr. Clancy will describe, the Partnership's aims are 
ambitious: to reduce preventable hospital acquired conditions 
by 40 percent by 2013, to reduce hospital re-admissions by 20 
percent by 2013. In addition to the patient lives that will be 
saved through these efforts, HHS estimates that reducing 
medical errors will save up to $35 billion, as I said earlier.
    We need bold action. Just last month a study published in 
the journal Health Affairs used a detection tool created by the 
Institute for Healthcare Improvement, and found that on average 
a third of patients admitted to hospitals suffer a medical 
error or other adverse event, which is 10 times greater than 
previously thought. Findings like these show that the new 
quality improvement tools come just in time and cannot be 
implemented too quickly.
    I look forward to hearing our witnesses' perspectives on 
this national challenge.
    I will yield to our Ranking Member, Senator Enzi.

                   Opening Statement of Senator Enzi

    Senator Enzi. Thank you, Mr. Chairman.
    We can probably all agree that our current health care 
system often fails to deliver high quality care and rewards 
inefficiency. I support policies that will create real 
incentives for healthcare providers to improve the quality of 
care they provide to their patients.
    I'm deeply skeptical, however, of any government initiative 
that claims it can save 60,000 lives and $35 billion over the 
next 3 years by improving the quality of care provided to 
patients. This is especially true for a proposal that relies on 
voluntary grants to hospitals and other providers to encourage 
them to modify long standing behaviors which are often 
encouraged by current government payment systems.
    The new Partnership for Patients will spend $1 billion to 
fund new research at the Center for Innovation at CMS and 
provide grants to hospitals and other interested parties to 
reduce the number of patients readmitted to hospitals to treat 
the same or related conditions.
    The AHRQ Partnership Initiative is providing grant monies 
to encourage providers to do the very things they should 
already be doing for their patients. While this may be 
physically attractive because it wins the support of all the 
stakeholders who will receive grant funds, I see very little 
evidence that it will actually change the fundamental problems 
that exist in the current system. Unfortunately, the Federal 
Government does not have a very good track record in 
implementing such reforms.
    The agency charged with carrying out these policies, the 
Centers for Medicare and Medicaid Services, CMS, has a long 
record of missed deadlines and failures to implement policies 
that were intended to reduce Medicare spending. Further, we 
have seen little evidence that the program will have rigorous 
standards for accountability, which would create both 
incentives and penalties for providers who will fail to 
fundamentally improve their performance.
    The Administration's witness today, Dr. Carolyn Clancy, has 
also seen firsthand the challenges of getting providers to 
modify their clinical practices. Her agency has been publishing 
best practices guidelines for years, but efforts to 
fundamentally transform systems of care to promote quality and 
lower costs remain almost an aspirational goal.
    I am not alone in expressing skepticism about the 
effectiveness of these types of proposals. In March 11, 2010, 
in a letter to Senate Majority Leader Reid, the Congressional 
Budget Office estimated the direct revenue and spending effects 
of proposals to develop new patient care models, including the 
new CMS Innovation Center, and the Community-Based Care 
Transition program, would produce a net cost to the government 
of $200 million over 5 years.
    In short, according to the Congressional Budget Office, the 
types of proposals we are discussing today will not produce any 
savings for the foreseeable future, on the contrary, they will 
have a net cost.
    I believe that healthcare providers like Dr. Charles and 
Dr. Mehler, who will testify at our second panel, should be 
applauded for their efforts to promote quality and improve 
care, even without these incentives. I look forward to learning 
more about the specific policies and practices they have 
implemented to improve the care they provide. Hopefully their 
testimony can help inform us about the types of actions the 
government could take that actually will encourage providers to 
make the changes that are necessary to really improve the care 
they provide their patients.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Enzi.
    I would like to yield also for a statement by Senator 
Mikulski, who was the leader of our effort. When we did the 
Affordable Care Act, we broke up into teams and she led the 
team on this very issue of quality improvement and did an 
outstanding job of putting that together for the Affordable 
Care Act. I will yield to Senator Mikulski.

                     Statement of Senator Mikulski

    Senator Mikulski. Thank you very much, Senator Harkin, for 
convening this really important hearing, and what I think is 
one of the most important issues on how we can save lives and 
save money, which is our emphasis on practical health quality 
endeavors.
    You are exactly right, when Senator Kennedy asked us to 
take on various aspects of the healthcare initiative, he asked 
me to take on the quality issues, and we did it, and we all 
worked as a team.
    The Patient Protection and Affordable Care Act had 
important quality provisions. It had four guiding principles, 
and I think it would go very much to some of the points made by 
Senator Enzi.
    One, we wanted to make sure we introduced health IT, that 
it really provided a new way of keeping track of patients and 
keeping track of care. We also wanted to have health 
interoperability, so we wouldn't have a techno disaster.
    Second, we wanted to apply best practices and evidence-
based medicine to care for delivery. We looked initially at the 
famous Institute of Medicine report, To Err is Human.
    The third was to improve care coordination, and then the 
fourth, of course, was that all quality ultimately rests not on 
technology, but on our workforce who operates the technology.
    We emphasized evidence-based practices, like the famous 
Pronovost Checklist developed by Dr. Pronovost of my hometown 
at Johns Hopkins. Practical, low tech, but empowered nurses, 
could, in the hospitals just by emphasizing basic Florence 
Nightingale hygiene principles, save lives by preventing 
infection.
    We could go through a whole list of these things, but our 
whole idea on quality was it doesn't have to be expensive. It 
doesn't have to be shock and awe medicine. In fact, often shock 
and awe medicine is part of the problem, an overuse of 
antibiotics that makes us drug resistant, and low-tech problems 
like not washing hands.
    I look forward to hearing the testimony today from the 
witnesses. I know Dr. Clancy comes with a very distinguished 
background--has been an award winner.
    But I must say, in looking at the Administration results so 
far, for $1 billion I find it a bit thin. And perhaps it is 
only in the materials that I have read, or that we are at the 
initial stage, but I give $1 billion a year to the National 
Institutes of Standards. They employ 4,000 people in 
Gaithersburg, and they develop the standards for every major 
product that comes on from new tech, to what should be the 
building standards so we don't have another collapse like at 
the World Trade Center. I think for $1 billion, either this is 
in the beginning or not, but we could be getting a lot more 
value in this area. Perhaps I don't have enough knowledge or 
information.
    I look forward to hearing from you, Dr. Clancy, because you 
have a history of being steadfast and persistent in achieving 
quality objectives.
    Thank you very much, Mr. Chairman, for your ongoing 
oversight in this important matter.
    [The prepared statement of Senator Mikulski follows:]

                 Prepared Statement of Senator Mikulski

    Thank you, Chairman Harkin and Ranking Member Enzi, for 
calling this hearing to discuss implementation of health 
reform's quality provisions and to hear from hospitals who have 
been successful in cutting costs and reducing waste, while 
enhancing the quality of patient care.
    I remember when this committee began our work on health 
reform, and I remember when Senator Kennedy asked me to lead 
the quality working group. He asked me to work with members of 
this committee, both Republicans and Democrats, to craft 
sections of our new health reform law that work to improve the 
quality of health care in our country. For all the controversy 
and drama that surrounded the health reform debate, I believe 
that, with respect to the quality provisions, this committee 
largely came together in bipartisan fashion to ensure that our 
law contained robust provisions that work to improve care for 
all patients and reduce unnecessary costs. That is something we 
should all be proud of.
    The Patient Protection and Affordable Care Act includes 
important quality provisions, which support the four priorities 
that were most important to me throughout the health reform 
process: it provides comprehensive and health IT 
interoperability, it applies best practices and evidence-based 
medicine to care delivery, it improves care coordination, and 
it strengthens the health workforce.
    Using these four quality priorities as a roadmap, we 
ensured that provisions included in the final health reform law 
will prevent medical errors, reduce hospital re-admissions, 
help better manage chronic conditions, strengthen the health 
workforce and reduce health disparities.
    We worked to prevent medical errors and improve care by 
expanding the Pronovost checklist Nationwide. In Michigan, the 
checklist saved 1,500 lives, $75 million in 18 months, and 
virtually eliminated costly and deadly intravenous infections.
    We worked to reduce preventable hospital re-admissions, 
which cost the government an estimated $17 billion per year, by 
mandating comprehensive discharge planning. This will reduce 
re-
admissions within the first 30 days by 30 percent and improve 
patient health outcomes.
    We included provisions to simplify administration 
procedures and enrollment into health and human services 
programs with new technology standards. As a result, the 
administrative savings could be more than $200 billion per 
year.
    We ensured that the final law helps better manage chronic 
conditions through better coordination and integration of care. 
Treatment costs for chronic conditions are $277 billion. We 
created community health teams to support medical homes and to 
coordinate and integrate care. The community health team model 
saved North Carolina approximately $260 million in a single 
year.
    The final law includes important provisions, which require 
dissemination of comparative effectives research, so that 
providers and patients know what's most effective and have all 
the information necessary to make educated decisions about 
their care.
    The final law also included a requirement that the Food and 
Drug Administration (FDA) look into requiring drug fact boxes 
to help consumers understand the benefits and risks of the 
drugs they are considering.
    These are only a small subset of the quality provisions 
included in our health reform law. I look forward to hearing 
today from Dr. Carolyn Clancy, Director of the Agency for 
Health Care Research and Quality, about the Partnership for 
Patients Initiative, which will work to reduce hospital-
acquired infections and decrease preventable hospital re-
admissions. I am particularly interested in how this initiative 
will achieve these goals for pediatric populations who face 
unique health challenges that are very distinct from adults.
    I am also interested in hearing more about the National 
Strategy for Quality Improvement. Particularly, how it will 
work to combat our Nation's high rates of premature birth and 
how it will help encourage adoption of the Pronovost checklist 
nationwide.
    Finally, we are fortunate to have witnesses from innovative 
and forward-thinking hospitals. I look forward to hearing about 
the successes they've had to improve patient care and reduce 
health care costs.
    Thank you again, Mr. Chairman.

    The Chairman. Thank you, Senator Mikulski for your great 
leadership in this area. And we all, of course, look to you for 
your guidance and direction since you did such a great job in 
putting this in the bill.
    Now we will have two panels. Our first panel will be Dr. 
Clancy. Dr. Carolyn M. Clancy, M.D., was appointed director of 
the Agency for Healthcare Research and Quality on February 5, 
2003, reappointed in February 2009. Prior to that, Dr. Clancy 
was director of AHRQ Center for Outcomes and Effectiveness 
Research, a graduate of Boston College and University of 
Massachusetts Medical School. Before joining AHRQ in 1990, she 
was also an assistant professor in the department of internal 
medicine at the Medical College of Virginia. Dr. Clancy is a 
member of the Institute of Medicine, was elected a master of 
the American College of Physicians in 2004, and 2009 was 
awarded the William B. Graham prize for health services 
research.
    Dr. Clancy, welcome to the committee. Your statement will 
be made a part of the record in its entirety, and if you could 
sum it up in several minutes or so, we would be most 
appreciative.

  STATEMENT OF CAROLYN M. CLANCY, M.D., DIRECTOR, AGENCY FOR 
HEALTHCARE RESEARCH AND QUALITY, U.S. DEPARTMENT OF HEALTH AND 
                 HUMAN SERVICES, ROCKVILLE, MD

    Dr. Clancy. Thank you. Good morning, Senator Harkin and 
members of the committee, and thank you for inviting me today 
to talk about our Administration's efforts to improve the 
quality and safety of healthcare.
    The bottom line is that patients should not go to a 
hospital afraid and with a realistic fear that they could get 
sicker, rather than better. Healthcare professionals 
desperately want to provide the highest quality, safest, most 
appropriate care for all of their patients. Unfortunately, with 
the complexity of health care, deficiencies in the systems in 
which they practice, needed improvements in teamwork and 
communication, and impaired information flow, high quality, 
safe healthcare can be perceived as a significant challenge.
    The scope of that challenge is staggering. Last November 
the HHS Inspector General reported that one in seven Medicare 
beneficiaries is seriously harmed during his or her care in a 
hospital stay, and less serious harm is equally common. Much of 
this harm is avoidable and the cost is at least $4.4 billion in 
Medicare spending every year. And according to the CDC, at one 
point in time, 1 in 20 inpatients will have a healthcare 
associated infection.
    We are making progress in quality, but overall across all 
settings and populations, it is much too slow. Data from my 
agency most recently finds a somewhat glacial pace of 2.3 
percent a year improvement.
    I am here today to tell you about two very exciting 
initiatives recently announced by my department, the National 
Quality Strategy for Quality Improvement in Healthcare, called 
for under the Affordable Care Act, the first effort to create 
national aims and priorities to guide and inform local, State, 
and national efforts to improve healthcare quality. And the 
Partnership for Patients, a landmark effort launched last month 
with two basic, fundamental goals. One is to prevent patients 
from being harmed in the hospital and the second is to reduce 
the number of preventable re-hospitalizations so that we can 
catch up to what is going on in your State and that you will be 
hearing about in the second panel.
    I don't want to go into what is in the written testimony 
already, what I want to do is emphasize three themes. No. 1, 
the Administration has wasted no time in pursuing activities to 
improve the quality and safety of healthcare.
    At the end of the day, healthcare is very local, so 
developing strategies to improve quality have to be local. We 
have been working extensively with States, local communities, 
and private sector organizations to improve healthcare quality 
and develop tools that could be scaled and used by others. We 
have supported some of the efforts, we at AHRQ, ongoing at 
Denver Health that you will be hearing about.
    These efforts were ongoing even before these initiatives I 
am here to talk about today, and for both the strategy and the 
partnership we were very careful because we wanted to get 
extensive feedback from the private sector. A national strategy 
has to be a public/private partnership. But we have been 
working on this for years, as Senator Enzi noted, and there are 
efforts underway across the administration focused on improving 
healthcare quality.
    The second theme I would like to present is both the 
national strategy and the Partnership for Patients build on a 
strong foundation of quality improvement. We can and will learn 
from the people like the witnesses that you will be hearing 
from in the second panel.
    And Mr. Chairman, I just want to thank you for your 
leadership in providing resources and the foundation for our 
efforts to combat healthcare associated infections. This 
funding has allowed us to extend the project Senator Mikulski 
noted at Hopkins across the country and we are seeing, for 
those participating hospitals, almost the same dramatic 
reductions in these deadly infections. There are other 
activities underway throughout the administration. VA has made 
some very dramatic successes in cutting their infection rates.
    The third theme is that the success of these initiatives is 
shared goals, but a lot of flexibility and innovation and in 
the solutions that are used to achieve those goals. In a 
nutshell, our improvement efforts do not trickle down from big 
government, but rather consist of national aims which can be 
supported and spread with Federal investment.
    We know that different communities have different assets 
and needs. What will work in Iowa, in Des Moines, for example, 
may be very different than what is likely to succeed in a small 
town in Wyoming. We would expect those communities to take 
different paths to achieve common goals.
    The role of the Federal Government is to help assure that 
these local efforts remain consistent with shared national aims 
and priorities. The success of the partnership will similarly 
be based on flexibility and supporting and spreading local 
innovations.
    CMS will commit up to a billion in new funding from the 
Affordable Care Act toward achieving these goals. Half of that 
funding is associated with a demonstration on community 
transitions in care, improving transitions that is a separate 
section from the sections that support the Center for 
Innovations.
    Already more than 1,200 hospitals have pledged their 
commitment and support to this partnership for patients and in 
the months to come we expect that to grow. And it is not just 
hospitals. It is physicians. It is patients and families. It is 
many, many organizations, and it is employers and those paying 
for care in the private sector.
    In keeping with the idea that healthcare is local, many 
hospitals have already shown that it is possible to deliver 
better care, and you have picked two outstanding examples for 
today. We can greatly reduce or eliminate many types of patient 
injuries by helping doctors and other healthcare professionals 
to do what they want to do, which is to provide care that is 
reliably safe. We are partnering with many public and private 
sector groups and encouraging them to work together to achieve 
these national goals.
    I want to emphasize again that while the new Center for 
Innovations, AHRQ, and other Federal agencies have a bit role 
to play, we know that a top down solution where government 
employees go into hospitals and tell doctors, nurses, and 
others what to do to is not the road to success. Success will 
come from a shared energy, commitment, and teamwork at the 
local level to improve the quality and safety of healthcare. 
And frankly, we look forward to learning from their efforts.
    Thank you, again, for inviting me to discuss national 
efforts to improve the quality and safety of our Nation's 
healthcare system, and I look forward to your questions.
    [The prepared statement of Dr. Clancy follows:]
             Prepared Statement of Carolyn M. Clancy, M.D.
    Good morning, Senator Harkin and members of the committee. I am 
very pleased to be here today to talk to you about our Administration's 
efforts to improve the quality and safety of health care.
    The title of this hearing--``First, Do No Harm: Improving Health 
Quality and Patient Safety''--is very fitting. It is one of the 
earliest lessons that a medical student learns, and it is a promise 
that a medical student makes when he or she receives a white coat on 
becoming a doctor.
    But not doing harm is just the bare minimum for health care; we all 
strive for so much more.
    Health care professionals go to work every day wanting to provide 
the highest quality, safest, most appropriate care for their patients. 
The bottom line is that patients should not go to a hospital or other 
health care setting with a fear that they will get sicker not better.
    Unfortunately, with the complexity of health care, deficiencies in 
the systems in which they practice, needed improvements in teamwork and 
communication, and impaired information flow, high quality, safe health 
care may be perceived as a challenge.
    We have made progress in engaging doctors, nurses, patients and 
others involved with our health care system in working together to make 
the challenge less daunting and high quality, safe health care a 
reality. However, we have a lot more work to do.
    Before I outline two exciting new initiatives recently announced by 
the Department of Health and Human Services (HHS) to address these 
challenges, I would like to describe briefly a snapshot of the quality 
of our health care system to help frame our discussion today.
                          scope of the problem
    The 2010 National Healthcare Quality Report, released earlier this 
spring by my agency, the Agency for Healthcare Research and Quality 
(AHRQ), found that improvements in health care quality continue to 
progress at a very slow rate--about 2.3 percent a year.
    Data from other sources also highlight the problems:

     In a report last November, the HHS Inspector General found 
that one out of every seven hospitalized Medicare beneficiaries is 
seriously harmed in the course of their care and less serious harm is 
equally common. Almost half of the events are preventable. According to 
this report (http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf) this 
doesn't just produce anguish and tragedies for families and patients, 
it wastes over $4.4 billion Medicare dollars every year.
     According to CDC, at any one point in time 1 in 20 
patients in U.S. hospitals will have a healthcare-associated infection 
www.cdc.gov/about/advisory/pdf/ACD
_Minutes_04_12_10_Final.pdf.

    These results are simply unacceptable because we know we can do 
better. And we must do better.
      the national strategy for quality improvement in health care
    We need to accelerate our overall efforts to improve quality and 
focus specific attention on areas that need the greatest improvement.
    In March, the U.S. Department of Health and Human Services released 
a roadmap that will guide us to making lasting, measurable improvements 
in the quality and safety of health care services for all Americans.
    The National Strategy for Quality Improvement in Health Care, 
commonly referred to the ``National Quality Strategy,'' was called for 
under the Affordable Care Act and is a significant step in creating 
national aims and priorities to guide efforts to improve the quality of 
health care in the United States.
    The fundamental objective of the National Quality Strategy is to 
promote quality health care that is focused on the needs of patients, 
families, and communities. At the same time, the strategy is designed 
to move the system to work better for doctors and other health care 
providers--reducing their administrative burdens and helping them 
collaborate to improve care.
    Before I provide you with a broad outline of the National Quality 
Strategy, it is important to note that it was developed based on 
evidence-based results of the latest research. Moreover, it was a 
collaborative, transparent process that included input from a wide 
range of stakeholders across the health care system, including Federal 
and State agencies, local communities, provider organizations, doctors 
and other health care professionals, patients, businesses, employers, 
and payers. In addition, I would like to note that we are working 
closely with the developers of the National Prevention Strategy.
    This process of engagement will continue in 2011 and beyond. The 
National Quality Strategy is designed to be an evolving guide for the 
Nation as we continue to move forward with efforts to measure and 
improve health and health care quality. HHS will continue to work with 
health care providers and its other partners to create specific 
quantitative goals and measures for each of these priorities. While the 
strategy articulates common goals, it is not intended to specify how 
those goals are achieved. Rather, the strategy explicitly recognizes 
the importance of encouraging and learning from local innovations in 
improving care.
    At its core, the National Quality Strategy will pursue three broad 
aims. These aims will be used to guide and assess local, State, and 
national efforts to improve the quality of health care. The aims are:

     Better Care: Improve the overall quality by making health 
care more patient-centered, reliable, accessible, and safe.
     Healthy People/Healthy Communities: Improve the health of 
the U.S. population by supporting proven interventions to address 
behavioral, social and, environmental determinants of health in 
addition to delivering higher-quality care.
     Affordable Care: Reduce the cost of quality health care 
for individuals, families, employers, and government.

    To advance these aims, we plan to focus initially on six 
priorities. These priorities are based on the latest research, input 
from a broad range of stakeholders, and examples from around the 
country. They have great potential for rapidly improving health 
outcomes and increasing the effectiveness of care for all populations.
    The six priorities are:

     Making care safer by reducing harm caused in the delivery 
of care.
     Ensuring that each person and family are engaged as 
partners in their care.
     Promoting effective communication and coordination of 
care.
     Promoting the most effective prevention and treatment 
practices for the leading causes of mortality, starting with 
cardiovascular disease.
     Working with communities to promote wide use of best 
practices to enable healthy living.
     Making quality care more affordable for individuals, 
families, employers, and governments by developing and spreading new 
health care delivery models.

    These priorities can only be achieved with the active engagement of 
health care professionals, patients, health care organizations, and 
many others in local communities across the country. Since different 
communities have different assets and needs, they will likely take 
different paths to achieving the six priorities. This Strategy will 
help to assure that these local efforts remain consistent with shared 
national aims and priorities.
    Over time, our goal is to ensure that all patients receive the 
right care, at the right time, in the right setting, every time. The 
United States leads the world in discovering new approaches to prevent, 
diagnose, manage, and cure illness. Our institutions educate and train 
exceptional doctors, nurses, and other health care professionals. Yet 
Americans don't consistently receive a high level of care. Achieving 
optimal results every time requires an unyielding focus on eliminating 
patient harms from health care, reducing waste, and applying creativity 
and innovation to how care is delivered. The National Quality Strategy 
provides the framework to achieve this.
    Another important component of the National Quality Strategy is 
that it aligns and coordinates the wide range of interests and efforts 
to move quality forward. Everyone involved in health care has an 
important role in promoting high quality care. It starts with health 
care providers, but employers, health plans, government, advocates, and 
many others also have an interest in improving the quality of care. 
Employers and other private purchasers, for example, have been leaders 
in demanding better quality by pushing provider organizations to 
achieve new levels of excellence.
    The National Quality Strategy outlines a common path forward for 
all these groups and aims to make high quality, affordable care more 
available to patients everywhere.
    The Strategy will be updated annually and will provide an ongoing 
opportunity to identify and learn from those providers and communities 
that are leading the way in delivering high quality, affordable care. 
It is our hope that this national strategy creates a new level of 
collaboration among all those involved with health care delivery who 
are seeking to improve health and health care for all Americans.
    The Affordable Care Act calls on the National Quality Strategy to 
include HHS agency-specific plans, goals, benchmarks, and standardized 
quality metrics where available. By design, the Strategy does not 
include these elements in the first year, in an effort to allow them to 
be developed with additional collaboration and engagement of the 
participating agencies, along with private sector consultation.
    We believe nation-wide support and subsequent impact is optimized 
when those needed to implement strategic plans participate fully in 
their development. We have begun implementation planning across HHS and 
have established a mechanism to obtain additional private sector input 
on specific goals, benchmarks, and quality metrics in 2011.
    As implementation proceeds, we will monitor our progress in 
achieving the Strategy's three aims, along with other short- and long-
term goals, and will refine the Strategy accordingly. Our goal is to 
keep this Strategy open and inclusive. One way in which we hope to 
achieve this goal is to provide updates annually.
    The National Quality Strategy is available at www.HealthCare.gov/
center/reports. Additional background information can be found at 
www.ahrq.gov/working
forquality/.
    It is hoped that other public and private groups seeking to promote 
better health and health care delivery will also use the National 
Quality Strategy to hold themselves accountable. The Agency for 
Healthcare Research and Quality is tasked with supporting and 
coordinating the implementation planning and further development and 
updating of the Strategy.
         the partnership for patients: better care, lower costs
    As I noted during my introduction, we need to make sure that 
patients feel safe going to the hospital and other health care 
settings.
    Ensuring the safety of patients is integral to the National Quality 
Strategy and a significant priority for this Administration.
    Hospitals are showing that it is possible to deliver better care. 
We can, over time, eliminate many types of patient injury. The way to 
do that is to improve the care systems to allow doctors, nurses, and 
others to do what they desperately want to do: deliver safe care.
    And what's clear is that no one can do this alone. America's 
doctors and nurses are already doing their best to take care of their 
patients. Simply telling them to solve this problem on their own would 
be both unfair and unproductive.
    To that end, the Department is bringing together leaders of major 
hospitals, employers, health plans, physicians, nurses, patient 
advocates and others in a shared effort to make hospital care safer, 
more reliable, and less costly for all Americans.
    Last month, we launched The Partnership for Patients--a landmark 
initiative with two basic but fundamental goals: Prevent patients from 
being harmed while in the hospital, and reduce the number of 
preventable rehospitalizations that occur after patients are discharged 
from the hospital.
    The specific objectives under these goals are challenging, but we 
believe that they are achievable, and we have set a goal that by the 
end of 2013, we can reduce cases of preventable harm by 40 percent 
compared to 2010, and reduce re-hospitalizations within 30 days of 
discharge by 20 percent compared to 2010 by targeting preventable re-
admissions.
    The rewards are worth the challenges we may face.
    Our estimates are that the process of reducing preventable 
hospital-acquired conditions by 40 percent will prevent 1.8 million 
injuries and avert 60,000 deaths of hospital inpatients over the next 3 
years.
    A 20 percent reduction in hospital re-admissions would result in 
eliminating 1.6 million unnecessary rehospitalizations. Reaching both 
these targets would save up to $35 billion across our health care 
system over 3 years, including up to $10 billion for Medicare. Over 10 
years, the reduction in Medicare costs could be around $50 billion.
    This initiative has been developed over the last several months 
under the leadership of HHS and its agencies, including my own (AHRQ), 
the Centers for Medicare & Medicaid Services (CMS), the Centers for 
Disease Control and Prevention, the Office of the Assistant Secretary 
for Health, the Food and Drug Administration, the Health Resources and 
Services Administration, the Administration on Aging, and the Indian 
Health Service, as well as with our colleagues at the Department of 
Veterans Affairs Veteran's Health Administration, and the Department of 
Defense's Military Health System.
    CMS will commit up to $1 billion in new funding from the Affordable 
Care Act towards achieving the goals of the Partnership for Patients. 
Since the program was announced, the CMS Administrator, Dr. Donald 
Berwick, has been leading the program through CMS's Center for Medicare 
and Medicaid Innovation and has interacted with thousands of health 
care providers, hospital leaders, and others at in-person meetings and 
on national conference calls.
    Under the initiative, we are providing hospitals and physicians 
with an unprecedented range of resources about what other health care 
providers have already done, and are doing, to improve patient safety. 
Already more than 1,250 hospitals across the country have pledged their 
support as well as clinicians and other care providers, health plans, 
unions, employers, and consumers and patient organizations. In the 
months to come, we expect that number will continue to grow.
    The Partnership for Patients is pursuing a variety of activities to 
make significant improvements possible nationwide. Three of these 
activities are:

     One, we are developing, testing and making available 
specific and useful tools that are based on the best research to date 
on what works to prevent adverse events and rehospitalizations. These 
include a tool to help prevent pressure ulcers in hospitals (http://
www.ahrq.gov/research/ltc/pressureulcertoolkit/) and another tool to 
avert dangerous blood clots that can occur after surgery. (http://
www.ahrq.gov/qual/vtguide/).
     Two, we are continuing to support efforts to spread 
successful innovations that have worked well in one or a few hospitals 
to larger and more diverse settings. This will build off of HHS's 
previous experience in these areas:

          One of the best examples is a project in Michigan to 
        reduce central line-associated bloodstream infections in 
        hospital intensive care units. This resulted in at least a 45 
        percent reduction in these dangerous infections in less than 18 
        months. These reductions have been sustained for more than 5 
        years. Currently, there is an ongoing, nationwide effort to 
        implement the quality improvement program that yielded these 
        results, and we are excited to report that 22 States are seeing 
        similar reductions in these life-threatening infections.
          Another very successful initiative involves the 
        prevention of unnecessary re-admissions through the Re-
        Engineered Discharge Project, known as Project RED. Patients 
        who have a clear understanding of their after-hospital care 
        instructions, including how to take their medicines and when to 
        make followup appointments with their doctors, are 30 percent 
        less likely to be readmitted or visit the emergency department 
        than patients who lack this information.

     Three, we are identifying private sector initiatives that 
have led to useful tools or generated exemplary results. Some examples 
of promising private sector initiatives are the recent toolkit 
developed by the March of Dimes to help prevent harm to mothers or 
infants during the birth process and work published by Ascension Health 
on how that hospital system has greatly reduced obstetrical adverse 
events.

    Public-private partnerships are critical to the success of the 
Partnership for Patients. The Federal Government is partnering with 
other public- and private-sector groups to encourage patients and 
families to participate in their care to improve transitions between 
hospitals and home and securing the active involvement of other 
organizations representing patients, families, and consumers, in 
efforts to prevent unnecessary rehospitalizations.
    We know that the new Center for Medicare and Medicaid Innovation, 
AHRQ, and the other participating Federal agencies have a collaborative 
role to play with stakeholders to achieve these ends, and that a top-
down solution is not the road to success.
    Success will come as health care providers and hospital leaders 
adopt or develop, and then actually implement, methods that have been 
shown to be effective. As we recommend and implement new methods to 
improve patient safety and care transitions, the new Center for 
Medicare and Medicaid Innovation will test how to introduce national 
models known locally to improve care and reduce costs.
    In the coming years, it is our intent that a greater portion of 
Medicare's hospital payments will be tied to quality results and to 
reward those that deliver the best care.
    We know that the type of change we are talking about today will not 
come easily. But we also know it can be done if we work together. By 
assembling this Partnership for Patients and by committing to its 
ambitious goals, we are sending a clear message that we can no longer 
accept hospital care in which safety and efficiency is not the norm. We 
need a cultural change in our health care system to make safe, high 
quality care our top priority.
                               conclusion
    Mr. Chairman, thank you again for inviting me to discuss National 
efforts to improve the quality and safety of our Nation's health care 
system.
    Through the National Quality Strategy and the Partnership for 
Patients, we are committed to working closely with our Departmental 
colleagues, States, and the private sector to ensure that all patients 
get high quality, safe, appropriate and affordable health care.
    I appreciate this opportunity and look forward to answering any 
questions.

    The Chairman. Thank you very much, Dr. Clancy.
    I understand from your testimony that really the 
partnership is going out and doing at least a couple things 
here. You are stimulating certain hospitals and places to look 
at how they might and how they could address this infection 
problem, re-admission rates, and then you are also going out 
and finding those who have done those things effectively and 
taking those models and what, spreading them out around the 
country, informing others? For example, you mentioned one about 
Michigan with the central line infections reduced 45 percent, I 
think, within a year or so.
    Dr. Clancy. And they have sustained it after the project 
was over, which is really remarkable.
    The Chairman. Well so then you tell me--what do you do with 
that information on how they did that? How does a hospital in 
Wyoming, or Maryland, or Iowa, or anyplace else, find out what 
steps they did to do that?
    Dr. Clancy. What we are doing based on the success of 
Michigan, and this is an AHRQ-sponsored project, although the 
partnership will build on that, is actually working with the 
American Hospital Association, they have a research technical 
assistance arm and the team at Hopkins, we couldn't possibly 
leave them out of it, and spreading this across the country to 
all 50 States and DC. So far we have gotten to 22. Somewhere 
between a quarter and a third of hospitals are voluntarily 
stepping up to participate, but they are seeing the same, 
dramatic reductions.
    Essentially the intervention is relatively low tech, as 
Senator Mikulski noted. It is a checklist. But a checklist is 
easy, what you need is a commitment to teamwork behind it. The 
teams also collect a very limited amount of data and they get 
regular feedback about how they are doing. People start to 
connect the dots between their day jobs and the goal they are 
trying to achieve, and if you ever meet anyone from Michigan 
who is part of this, they are still kind of euphoric with the 
results that they were able to achieve.
    The Chairman. I guess that is what I am wondering, because 
as you said in your statement that what they do may be OK for a 
hospital someplace, but maybe not for a small hospital 
someplace else. I just don't know how you take that example and 
scale it for different hospitals.
    Let me just try one other thing here and that is, what are 
the important ways that the partnership will improve how 
doctors and hospitals treat patients as they move between 
settings of care? That is also a big problem. They come in, 
admissions, they do the analysis and then there is the 
preoperative, there is postoperative, there is acute care, then 
there is rehab care. There are all these different settings 
that they go in, and if I am not mistaken, that is where a lot 
of problems arise. So how do you address that issue of 
coordination between the different settings?
    Dr. Clancy. A major component of this partnership will be 
focusing on technical assistance to hospitals. And learning, 
like through the leaders you have here as part of the second 
panel, how do you do that. How do you do it and how can we 
apply it here?
    The checklist that you just asked me about with the State 
of Michigan was designed so that it could be flexible enough to 
be adapted by very small, rural hospitals, but also used in the 
ICUs at the University of Michigan, where there is probably, I 
don't know, a double digit number of them.
    Same thing for re-admissions. The technical assistance 
provided to hospitals, physicians, and other healthcare 
professionals will build on and leverage investments that have 
already been made, so one specific set of tools that we have 
supported and tested at AHRQ relates to something called the 
Re-Engineered Discharge, or Project RED. Fairly low tech, very 
focused attention from a nurse and a pharmacist at the time of 
discharge, and very importantly, focused attention, phone calls 
to the patient a day or two afterwards to make sure they have 
got their medications aligned with the right ones, that they 
have gotten them filled, that they have got their followup 
appointments, and so forth.
    Not rocket science, but it hadn't been happening. Achieving 
it is rocket science. And that initiative alone reduced re-
admissions in the first 30 days by 30 percent. We know this is 
possible and the question is how do you inspire that shared 
energy and commitment and so forth?
    The Chairman. My time has run out. Thanks, Dr. Clancy.
    Senator Enzi.
    Senator Enzi. Thank you, Mr. Chairman.
    Dr. Clancy, I want to note first that I didn't get your 
testimony until 9 o'clock last night and that doesn't fit with 
the committee rules, and it doesn't give us time to prepare 
anything, and I would like your commitment that that won't 
happen in the future.
    Dr. Clancy. You have it.
    Senator Enzi. Thank you. Now, from what I was able to get 
out of it in the short period of time, it is the 
Administration's claim that the Partnership for Patients 
program will save $10 billion for the Medicare program over the 
next 3 years. We communicated with the actuary of CMS and they 
confirmed that they haven't done an actual estimate of the 
budget impact on the program, that they were given a couple 
assumptions and had to come up with numbers based on those 
assumptions. The two assumptions were that over the next 3 
years the program would reduce hospital acquired infections by 
40 percent and decrease preventable compilations by 20 percent.
    When assumptions are given to an actuary it kind of seems 
to me like that would be like assuming that I would grow to 6 
feet four inches and be able to run the 40 in 4 seconds flat, 
and therefore be a starting linebacker for the Redskins next 
year. It's not going to happen and I'm pretty sure that these 
numbers aren't going to happen and when they are--especially 
when they are just based on a couple of assumptions like that.
    I want to ask CBO and the CMS actuary to perform real 
estimates rather than just looking at limited assumptions that 
would drive an answer. They know the real world challenges the 
CMS faces and they have to take that into account when they are 
doing their estimates, and that way we can have a more honest 
debate about the merits of the program.
    I am going to be writing a letter to the Chief Medicare 
Actuary, Richard Foster, later today asking that he provide me 
with a real estimate for how much money that program will 
actually save. And I would ask you to work with Mr. Foster to 
provide that real cost estimate as soon as possible. Would that 
be possible?
    Dr. Clancy. Absolutely. In fact the information that your 
staff received actually was--some of the assumptions come out 
of published literature and my colleagues have already been 
working with Mr. Foster's colleagues as well. So we would be 
happy to continue that.
    Senator Enzi. OK. Can you identify a single time that CMS 
has implemented a program that fundamentally changed hospitals, 
the way they provide care, and produced those kinds of savings?
    Dr. Clancy. CMS has implemented a number of demonstrations 
that have had impressive results. One is the Premier 
demonstration, led by a collaborative of hospitals, which is 
continuing to this day and taking on more and better efforts. 
And they have resulted--I would have to get back to you for the 
record, and would be happy to, in terms of how many hospitals 
are now involved. But the infrastructure and support that they 
have built for the hospitals is very, very impressive and, in 
fact, some senior folks at HHS actually kind of, occasionally 
give them assistance in terms of how does this fit with other 
things.
    There was another very large demonstration, because there 
were a lot of important demonstrations that were part of the 
Medicare Modernization Act, that was about improving 
physician's care, a value-based purchasing approach, which also 
had very, very positive results, but we would be happy to send 
you a summary of that.
    Senator Enzi. Thank you. Doesn't Medicare also pay Quality 
Improvement Organizations, QIOs, about $400 million a year to 
do many of the exact things this program is supposed to do? I 
know in the most recent statement of work, the QIOs were 
specifically directed to work with providers to reduce 
unnecessary re-admissions. Won't the new partnership program 
exactly duplicate the work the QIOs are already doing?
    Dr. Clancy. There has been quite a bit of discussion about 
that, about the need for very close coordination. I think you 
are right about the numbers and the investment and the quality 
improvement organizations, but I think it is also fair to say 
that in many States they can't get to all hospitals. And so the 
partnership will effectively expand and enhance what the QIOs 
scope of work has already indicated that they will be doing.
    Senator Enzi. OK. Medicare is already said to begin 
reducing payments to hospitals to discourage hospital acquired 
infections. The new value-based purchasing program, pay for 
performance initiatives, and other delivery system changes are 
going to address most of the things that the Partnership 
Program is supposed to address. Isn't this program simply 
paying hospitals and outside groups up to $1 billion to do the 
things that they are already going to have to do to continue to 
get paid by Medicare?
    Dr. Clancy. No. What it is doing--I am sorry, I didn't mean 
to cut you off.
    Senator Enzi. That is OK. Go ahead.
    Dr. Clancy. It is not paying them to do what they are 
already supposed to do. It is actually paying and supporting 
technical assistance to hospitals, to healthcare professionals, 
and also to patients and families, who can be a big part of 
this. My father, a Medicare beneficiary, about a year ago had 
an avoidable hospitalization, so this would have been one of 
the bad outcomes that we count because of a miscommunication 
about the use of his blood thinner.
    Senator Enzi. How will the program avoid paying for the 
things that the hospitals are already planning to do?
    Dr. Clancy. What they are hoping to do is to have to avoid 
paying for the harms and the consequences of the poor 
practices. In my father's case, if they had been more careful 
about communicating what the dose was. What happened was a 
nurse said to my stepmother, give him two. She meant 
milligrams. My stepmother thought she meant pills and in about 
3 days he had to be admitted. We are talking a 3 or 4 day 
admission with lots and lots of tests. He did fine after that. 
But the point is this goes on sort of constantly across the 
country.
    The Partnership will pay for technical assistance and 
support, but also will provide support to patients and families 
so that they can be more active partners, because many of them 
want to do that. And we know from all the studies we have 
supported that oftentimes individuals and their families pick 
up things that our other methods of looking for avoidable harm 
don't. They see what is going on, they are right there and so 
forth.
    Senator Enzi. The example you give makes me think that we 
are going to be paying for things that hospitals would normally 
do to keep from being sued. Thank you.
    The Chairman. Senator Mikulski.
    Senator Mikulski. Thank you.
    Dr. Clancy, I want to pick up on some of the main things we 
wanted to achieve in the legislation and address some of the 
excellent points raised by Senators Harkin and Enzi.
    First of all, one of the big things we want to improve is 
health outcomes for patients. That is our large, bipartisan, 
public policy goal.
    We find we spend a lot of money, but we rank 37th 
nationally in health outcomes, and that is not from Senator 
Barb, that is from our own business roundtable and other 
demographic and epidemiological studies. So then we said, 
``Well, what are we getting for our money?'' What we saw is 
that we get a lot of intensive, acute care medicine, but a lot 
of bad things happen in a hospital, and a lot of magical 
things, and miracle things. What we identified in the hospital 
was that it wasn't maybe an impaired physician who made a 
mistake, that goes to the malpractice situation, but it was the 
systemic practices of hospitals around cleanliness, deployment 
of staff, and so on that resulted in medical errors. Am I 
correct in that?
    Dr. Clancy. Absolutely.
    Senator Mikulski. So it wasn't the individual act where 
either an accident or malfeasance or whatever occurred. This 
isn't the malpractice issue. This is a systemic failure to 
identify with these practices.
    Now if you come with me to Hopkins, in addition to the 
Pronovost Checklist, you see low-tech things like why do all 
the docs wear bow ties? You know why they wear bowties? This is 
one of the filthiest things you can bring into a patient's 
room.
    [Laughter.]
    Senator Mikulski. Not you, Tom.
    The Chairman. I'm sure not.
    Senator Mikulski. But you would flunk----
    Dr. Clancy. Absolutely.
    Senator Mikulski [continuing]. Hospital quality because 
what does a doctor do, or a nurse? They're touching other 
people and other things and then they touch a patient, so 
therein lies the infection. If you have had ankle surgery, like 
I had, you worry about a bone infection, an incision infection, 
and other kinds of things. Am I correct?
    Dr. Clancy. Absolutely.
    Senator Mikulski. So now, the whole idea is people were so 
intent on the delivery of high tech and high touch medicine 
that they weren't looking at the negative consequences to that. 
Now is that what you are trying to achieve?
    Dr. Clancy. Absolutely. There is Senator Harkin----
    Senator Mikulski. To do practical things.
    Dr. Clancy. Yes, absolutely practical things and trying to 
not only identify those practical steps, but identify 
approaches that make those the defaults every time we do the 
right thing.
    Senator Mikulski. Now, I want to come back to acute care, 
which is highly visible, highly regulated, highly monitored. I 
want to focus on when patients get ready to leave and when they 
go home. Our task force on quality during the debate was 
focused on hospital re-admission, the terrible problems of 
being admitted within 10 days and within 30 days.
    We found in our hearings that there was a big gap. While 
you got high tech and high touch, you didn't get a lot of 
information when you were ready to leave about what you needed 
to do to comply with the medical regime. Once you left, you 
were in an unregulated atmosphere and often you were 
unmonitored for months at a time. Call me in a month or 6 
weeks.
    People would leave. They wouldn't know how to take their 
drugs. There was no checklist or sequencing on their drugs. The 
synergistic thing, like don't take a drug with orange juice 
kind of tip that you need with certain kinds of drugs. There 
was no discharge planning where you are going home to something 
where you could comply, and this is say post-cardiac surgery, 
post-ankle surgery.
    Now what are you doing about that? Our whole idea was you 
need to have a plan. You needed to teach the plan to both the 
patient and another responsible adult, because patients don't 
always hear because we are scared when we go home. The 
monitoring once they went home, 72 hours, 1 week, 1 month, 1 
year.
    Then the whole idea was that we would make sure they were 
complying with their medical regime. And that was going to be 
assisted through health IT. Are you doing that?
    Dr. Clancy. Yes. We at AHRQ are supporting a number of 
projects on that and all of that information, where we have 
seen a local success at the particular institution who applied 
for funding and so forth, is already being shared with the 
Innovation Center so that they can take it and many, many 
others across the country, through their support for technical 
assistance, can use it to make it right.
    One of the things that happens a lot, in addition to your 
brilliant description of all that doesn't go wrong. People are 
scared, oftentimes not enough time is devoted at the time of 
discharge. Sometimes health care professionals, besides being 
in a rush, are talking over the heads of patients and their 
families, who are scared and sometimes actually just want to 
get out of there, because they have kind of had enough of the 
hospital. And some people don't think a lot about this until 
they get home.
    The project I mentioned to you, this Re-Engineered 
Discharge actually had that followup call, which seems to be 
very, very helpful to a lot of people, but those are the kinds 
of practical tools that will be very important.
    Senator Mikulski. But isn't one of the failures to comply a 
lack of information and lack of follow through, and a lack of 
actual news that you could use, tips for the practical thing, 
and the failure--it is usually around the taking of their drugs 
and their pharmaceutical regime?
    Dr. Clancy. Absolutely. The information is shared, but it 
is not shared in a way people can hear it and use it.
    Senator Mikulski. I know my time is up, but to my 
colleagues, Senator Harkin and Enzi, and others, if you live in 
Baltimore, you have Hopkins, you have University of Maryland. 
For my ankle, I was at Mercy, which is a university affiliated 
community hospital, lots of monitoring, lots of teaching, lots 
of stuff. Then, when you get out to suburban, ex-urban, and 
rural communities, that is often where they are not getting the 
latest and the greatest about how they could change their 
system to empower staff, and actually Dr. Pronovost told me 
this really improves clinical satisfaction.
    Doctors are thrilled that a year later everybody has not 
only gotten better, but stayed better. It is the doctor-nurse 
satisfaction. But the big challenges are what happens in 
community-based, university distant hospitals in remote areas?
    And I thought we would like to--my time is up. You can't go 
into that, but to me, it is not only in these high tech, high 
knowledge area--facilities, but then what happens as we go out?
    But anyway, I am going to stop. Mr. Chairman, you have been 
indulgent. These materials are dense and wonky. I am a straight 
talker here and I am such an admirer of your work, but this is 
like what we are getting out of healthcare, generally. We have 
spent money. We have very clear policy goals that we are agreed 
upon, and yet this does not have the clarity and the vitality 
of just what you have told us here.
    So we have to tell our story to garner public support in a 
very frugal atmosphere. This might be the last billion you get, 
unless we really show results. That is not a threat, it is an 
analysis.
    At the same time, we need news that you could use for both 
patients and then those people in what I call distance learning 
situations. So please, help us help you help improve the health 
outcomes for people.
    Dr. Clancy. We will do that. Thank you.
    The Chairman. Thank you very much, Senator Mikulski. That 
was refreshing.
    Senator Bennet.

                      Statement of Senator Bennet

    Senator Bennet. Thank you. Thank you, Mr. Chairman. I will 
try to continue in a nonwonky, news-you-can-use way here, 
because I agree also.
    Dr. Clancy, I am very pleased to see you here. Throughout 
the healthcare debate we were very focused on the community-
based care transitions program that is included in the 
Partnership for Patients. It reflects a lot of work that is 
already being done in Colorado. In fact, some of the people in 
Colorado helped draft that part of the healthcare bill because 
we recognized when the rate of Medicare patients being 
rehospitalized nationwide was 20 percent and our government was 
spending $17 billion a year on this, places like Grand 
Junction, CO were having re-admission rates of less than 2 
percent at the same time, in their case, by using health care 
coaches to coordinate and to make sure that patients knew what 
they were doing when they were leaving the hospital.
    The nurse from Denver Health, which provides $400 million a 
year in uncompensated care annually still manages to stay in 
the black and have some of the best outcomes in the country. We 
have seen it in our State and I think it could be fairly 
described in some ways as the end State you would want to see, 
high quality at a much lower cost through the reduction, among 
other things, in this case of re-admission rates.
    I wonder if you wouldn't mind in the nonwonky way, talking 
a little bit about this savings question. Where do you expect 
to see the savings? How big might the savings be and what can 
we do, or what can you do to make sure we accelerate these 
savings as much as possible, because we are now in an 
environment where we know we have to change what we are doing 
if we are not going to bankrupt the Federal Government, the 
State and local government? Could you take that on?
    Dr. Clancy. Sure. We have made some fairly cautious 
estimates of savings. I think there is some uncertainty about 
how rapidly they will accrue, but I will also tell you, and my 
colleagues are right here behind me who labored over this long 
into many nights, and worked with Rick Foster's team, that the 
estimates are fairly cautious. They are based on the best 
published literature we have, so they have been tested very 
carefully. I don't think it is the limits of what is 
achievable, which I think is the good news.
    To be able to prevent hospitalizations, the recent study in 
Health Affairs that talked about one in three hospital patients 
having an adverse event, almost one of the three is actually 
something that happened in outpatient care that could have been 
prevented, or was an avoidable harm that then required 
hospitalization, so that is where the savings will come from.
    We would be happy to provide you more detail on sort of 
what those ranges might be, I don't have that with me today. 
But I know I have terrific colleagues who have a great deal of 
information on that.
    Senator Bennet. I think that would be useful to the 
committee. I certainly would like to have that.
    But there is a lot of discussion around there about 
projections, CBO projections, the CBO projections, is that--but 
what this really is going to come down to is the quality of the 
implementation.
    Dr. Clancy. Absolutely.
    Senator Bennet. And I wonder if you can talk a little bit 
about what you're doing to try to make sure that the quality 
and the implementation is both high and accelerated.
    Dr. Clancy. Some of what we are doing is actually building 
tools that hospitals and other organizations can use themselves 
to do the tracking internally. The genius of the Keystone 
Project, in my view, was they made data collection light, very 
easy, but unlike many systems where it is really easy to take 
data in and suck in a lot of information, getting it back out 
is much, much harder, but theirs was designed to let people 
know how they were doing.
    Now there was a little bit of, how would I say this, 
persuasion. In Michigan the Michigan Blue Cross plans, if 
hospitals forgot to send in their information, they would get a 
reminder letter from the Hospital Association and the Michigan 
Blues. I mean Dr. Pronovost could write to them, but, that 
probably wouldn't have meant a lot. Getting a letter from Blue 
Cross, got to the right people's desks and mysteriously 
information started flowing thereafter. So part of this 
Partnership for Patients is going to be enlisting that kind of 
local leadership similar to what Pronovost did in Michigan to 
make that happen.
    But at the end of the day, when we submit to you all every 
year our national reports on quality, it is a little bit of a 
reaction that'd like, wow. I mean for many people, when I 
present this to different audiences, which says, ``Gee, I 
thought we were doing better than that.'' Thank goodness it is 
not us. Right? I mean the data that really, really matters is 
what is going on in this hospital, this community, and so 
forth. That is part of what we are going to be helping 
institutions build, including taking very well-defined and 
reviewed ways of measuring common, avoidable harms, medication 
adverse events, for example, falls, and so forth, and we are 
now working with vendors to have those put into electronic 
records. It becomes very easy for hospitals to track them as 
they are happening and respond appropriately, rather than 
getting a report from the Inspector General a year, a year and 
a half later. I mean that is informative, but it is not nearly 
as informative as that timely feedback of how we are doing.
    Senator Bennet. Thank you, Mr. Chairman.
    The Chairman. Thank you.
    Senator Whitehouse.

                    Statement of Senator Whitehouse

    Senator Whitehouse. Thank you, Chairman and thank you, Dr. 
Clancy for being here.
    To followup a little bit on what Senator Mikulski and 
Senator Bennet have said, particularly with respect to the 
savings issue, and I understand that there is a difference 
between what you as a professional can take a look at, and 
using scientific principles and actuarial principles go out and 
predict, versus what you have said, you said that is not the 
upper limit, we could do considerably better than that.
    My concern is that there are only two ways that we are 
going to get out of this healthcare cost problem that we have. 
One is to fix the system, which is a great way to get out of it 
because it lowers cost while improving both the quality, 
outcomes, and experience of care for American patients. And the 
second is if we fail at that, we are going to have to cut 
programs.
    Dr. Clancy. Exactly. Yes.
    Senator Whitehouse. We already have proposals to basically 
wipe out Medicare a decade from now.
    We are really up against it in this. And I would strongly 
urge you to push up into the administration, to invite them to 
set a goal for you to achieve. Not something you have to 
approve, but a goal that would be directed into the system.
    When President Kennedy decided that we needed to get into 
the space race, he did not give a forgettable speech about 
bending the curve of space exploration. He gave a memorable, 
and consequential speech about putting a man on the moon, and 
bringing him home safely, within a decade, and I think that is 
the kind of ramp up we need. There is enormous administration 
support of this. There is enormous legislative support for 
this. It is bipartisan. You have an incredible number of 
resources at your disposal.
    But what is missing, to go back to what Senator Mikulski 
said, is that kind of capture the moment signal that goes out 
and says what our goal is. It can be a financial goal, and it 
can also be a goal that people relate to in their experience. 
Everybody who has been with a loved one who has been very sick 
has had to navigate for them and knows what a nightmare it is. 
This is not something that is not going to resonate with the 
American people. Everybody who has tried to get paid knows what 
a nightmare the insurance bureaucracy is. That is going to 
resonate with the American people.
    There is a message here to be reached, and to go back to 
what Senator Mikulski said, we have to clarify this, make it 
real for people, but also raise the bar. We can no longer be 
talking about just what we can prove.
    Dr. Clancy. You are exactly right.
    Senator Whitehouse. It is time to be bold and have this 
Administration assert what its goal is here, and do that 
specifically. I would urge you to do that.
    I am from Rhode Island, and we have been doing Pronovost's 
checklist. We have been doing the ICU thing for a while. We 
took it right out of Michigan. We were the first place to go 
statewide. We really get it. We are doing that. Obviously, re-
entry is a big deal. What do you think, as you look forward, 
are the next big opportunities for this kind of quality 
improvement, cost saving, virtual cycle to emerge?
    Dr. Clancy. I think some of the next big opportunities are 
going to be looking at care coordination across multiple 
entities outside the hospital. More and more of Medicare is 
actually being done in ambulatory surgery and we have very 
little idea about the infection rates in those facilities yet 
on a systematic way, how carefully patients who are at some 
risk for bad outcomes are monitored and immediately connected 
to the hospital, and so forth. That strikes me as one likely 
target of opportunity.
    Senator Whitehouse. That sounds like a really good target. 
I think everybody who either has, or has a loved one who has 
multiple conditions is keenly aware of the sense of confusion 
and loneliness that they experience trying to sort through all 
the different specialists, all the different treatments, all 
the different prescriptions. It is not a great place to be and 
I think that is a good opportunity and I appreciate that you 
identified that.
    A lot of people who deal in this world have a lot of really 
good ideas that may be the trigger for broader use and broader 
expansion. Is there a formal way that the Administration has 
for outreach, and for assessing those ideas so that a local 
doctor, or medical practice, or hospital has something? I mean 
if somebody falls in the hospital, you know to call 911. If 
somebody has a great idea in the hospital, who do they call?
    Dr. Clancy. We have a site at AHRQ that invites people to 
submit their innovations. What we are trying to do is hear from 
people who want to solve problems and who--they are not so 
interested in getting a research grant, or writing papers, and 
so forth, but boy, they would like to kind of share what 
worked, or in some cases what didn't, which is also really 
helpful information.
    They actually have to submit a fairly straight forward 
form. I have been sharing some of this with my colleagues at 
HHS recently and I have to say they have been kind of blown 
away. When I described it I don't think I used the right words 
because when they actually saw the specific examples they were 
thrilled.
    The Innovation Center has actually emulated and will be 
replicating something very, very similar, not to take over what 
we are doing, but just to build on that same kind of approach. 
And I know that they have lots and lots of plans for how they 
can reach out.
    Personally, I think one of the greatest things we can do is 
to learn from many, many innovators across the country. You are 
going to be hearing from two fantastic institutions, but they 
are--that is not the end of the world.
    Senator Whitehouse. My time has expired----
    Dr. Clancy. Yes.
    Senator Whitehouse [continuing]. And I don't want to take 
the time from anybody behind me. But I do think--I am glad that 
there is a doorway. I think it might help to put a nice, bright 
light over that doorway so that everybody knows where it is. 
Thank you.
    Dr. Clancy. Thank you.
    Senator Franken. Thank you, Mr. Chairman. Thank you, 
Doctor, for your testimony.
    Atul Gawande brought to light the success of checklists, 
which have been so successful in saving lives and resources, 
which I think is what we--I agree with Senator Whitehouse--this 
is the way we have to go. Gawande wrote an article in June 2009 
that was very influential. It was in the New Yorker and it 
compared McAllen, TX to Mayo Clinic and some other clinics that 
used these sorts of protocols.
    Let me tell you a story about Mayo, and I would like 
Senator Enzi to listen to this, because the average Mayo 
reimbursement for a Medicare patient is about one-half the 
reimbursement per patient of McAllen, TX. And if we are talking 
about saving money, this is how to do it. And Mayo had better 
outcomes than McAllen, TX. And one of the things they do is use 
checklists.
    I was talking to Dr. Noseworthy who is the CEO at Mayo, and 
he was telling me about ABC doing a little documentary--or 
doing a news story, actually--on Mayo, and they told him--he 
got cut out of the piece and the reason he got cut out of the 
piece is that there was a housekeeper there who was cleaning 
one of the rooms and the ABC producer was asking her, what are 
you doing? You're cleaning up the room. She said, ``Well, I am 
saving lives.'' And she said, ``The surgeons have this 
checklist, so I have this checklist too, and I am preventing 
infections, and I am saving lives.''
    And so Dr. Noseworthy was very proud of the fact that he 
had been cut out of the piece and the housekeeper was in it.
    Dr. Clancy. That is great.
    Senator Mikulski. That is the whole thing.
    Senator Franken. That is the whole point here. Now, I want 
to ask how these QIOs will work with the Partnership for 
Patients, because I don't get the impression that there is just 
too much of this in the country that we are just--that this is 
being duplicative and we are just wasting money. I mean I think 
when that starts happening that will be good.
    [Laughter.]
    Tell me how the QIOs will be working with the Partnership 
for Patients.
    Dr. Clancy. I think I would probably do my colleagues the 
most service if I were to get back to you for the record and 
would be happy to do that.
    Senator Franken. OK.
    Dr. Clancy. One area where the Partnership will be working 
that I am pretty certain is not part of the QIOs scope of work 
is in working with patients and families so that they can play 
a more active role.
    So Senator Mikulski was right, it is very scary at the time 
of discharge and so forth, but sometimes having someone with 
you who has got specific tools and knows what questions to ask 
can be very, very helpful. In general, that has not been part 
of the QIOs remit. But we would be happy to provide additional 
information about how these two dovetail.
    Senator Franken. A couple years ago, when I was running for 
the Senate, SEIU asked me to do a Walk in Our Shoes Day and I 
chose to be a nurse's assistant in a nursing home because my 
mom had gotten such great care in the last few years of her 
life and I wanted to do that.
    I spent time in a home for people with severe MS. And I got 
to see the safe patient----
    Dr. Clancy. Right.
    Senator Franken [continuing]. Or the lifting equipment for 
patients, and I saw the nurse assistant who told me this 
equipment is saving nurses' backs, and not only that, but it is 
improving patients' safety. And so I am going to be 
reintroducing a safe patient lifting standards bill this year.
    But the studies show that this pays for itself and more. 
So, what can you tell me about patient safety in terms of 
lifting them and having the equipment that makes it safe?
    Dr. Clancy. My general understanding is that health worker 
injuries, especially in nurses and nurses assistants, are 
definitely on the rise and in some cases are costing hospitals 
and other facilities a lot of money. I am not--my own direct 
knowledge of those lifts actually relates to the fact that my 
uncle has one at home; my aunt uses it for him with some help. 
But we would be happy to look into it more and see what we 
could find out.
    Senator Franken. OK, because I know it definitely is saving 
nurses and nurse assistants from injuries, but also as far as 
patient safety, it is important too. Thank you.
    Dr. Clancy. Yes.
    Senator Franken. Thank you, Mr. Chairman.
    The Chairman. Dr. Clancy, thank you very much for being 
here today and thanks for your testimony. We'll leave the 
record open, of course, for additional questions from other 
Senators, or any who are here. Thank you very much, Dr. Clancy.
    Dr. Clancy. A pleasure. Thank you.
    The Chairman. Now we will turn to our second panel.
    To begin our second panel I am delighted to welcome Mr. 
Timothy Charles to Washington. Mr. Charles is president and CEO 
of Mercy Medical Center in Cedar Rapids, IA. Mr. Charles has 
significant healthcare experience. Before coming to Mercy he 
was CEO of a large community hospital in Texas. Earlier this 
spring Mercy was recognized by the Commonwealth Fund as a high 
performing healthcare organization because of its low re-
admission rates for heart attack, heart failure, and pneumonia.
    Mr. Charles, we thank you for your commitment, and for your 
being here today, and your testimony. And for purposes for 
introduction, I'll yield to Senator Bennet.
    Senator Bennet. Thank you, Mr. Chairman and it really is an 
honor today to introduce a fellow Coloradan employed by a 
world-renowned healthcare system that I have had the privilege 
to work with for many years, Dr. Philip Mehler, who is the 
chief medical officer at Denver Health.
    Dr. Mehler has been at Denver Health since completing his 
residency there in the early 1980s, and served as chief of 
internal medicine and associate medical director before 
reaching his current position. Dr. Mehler is also professor of 
medicine at the University of Colorado, Colorado Medical School 
and holds the Shana Glassman Endowed Chair of Medicine. He is a 
national expert on the medical treatment of eating disorders, 
such as anorexia nervosa, and bulimia, as well as issues 
related to healthcare quality and patient safety. He has been 
named one of the best doctors in America for the last 13 years 
and is currently serving a 4-year term on the Colorado State 
Board of Health.
    I would like to welcome Dr. Mehler to Washington and look 
forward to hearing his testimony.
    Mr. Chairman, I would like to thank you very much for 
inviting him to testify today. Thank you.
    The Chairman. Very good. Thank you very much, Senator 
Bennet. And we welcome you both here.
    Your statements will be made part of the record in their 
entirety. We will start with you, Mr. Charles, and if you could 
sum up your testimony in several minutes. Then we will go to 
Dr. Mehler and then we will open it up for questions.
    Mr. Charles, welcome.

 STATEMENT OF TIMOTHY CHARLES, PRESIDENT AND CEO, MERCY CEDAR 
               RAPIDS HOSPITAL, CEDAR RAPIDS, IA

    Mr. Charles. Senator Harkin, Ranking Member Enzi, 
distinguished members of this committee, thank you very much on 
behalf of Mercy Medical Center for inviting us here.
    One of my intentions this morning is to provide you a 
greater sense of confidence that there actually is 
extraordinary work underway already within community and 
community hospitals like ours that are already having a 
significant impact on the quality of healthcare.
    Mercy was founded by the Sisters of Mercy in 1990 and for 
the past century has devoted itself to the healthcare ministry 
of caring for the sick, and improving the health of the 
communities we serve. And I would be remiss if I didn't say 
that we are as concerned about the vitality of our community as 
we are the health of our residents. And Cedar Rapids is still 
recovering from a devastating flood in 2008 and we continue to 
need your help.
    The themes that thread the ways through the long and 
unbroken history are that we stand upon a ground of 
compassionate service, but we do that through state-of-the-art 
care, the science of medicine that is made possible by 
extremely talented providers, as well as the generosity of a 
community that ensures that we have the very latest and finest 
tools that are necessary to deliver that care.
    Just 1 year after evacuating the hospital as a result of 
the flood and rebuilding it, we were invited by the Institute 
for Healthcare Improvement to present our path and results and 
to achieve its recognition by Don Berwick, along with our 
competing hospital and the medical community, as one of the 
leading providers of high quality and cost-effective care.
    In a subsequent presentation, I shared that Mercy's 
accomplishments were the result of years of dedicated effort 
and discipline. This invitation led to two additional meetings 
in Washington with colleagues from a select group of 
communities chosen as they might offer innovative models to an 
industry desperately in need of reform.
    The recent Commonwealth Fund case study released in March 
and April of this year recognizing Mercy as being in the top 3 
percent of all facilities with respect to low re-admission 
rates is further testament to the relentless commitment to 
quality improvement.
    Looking back, the pace of Mercy's commitment to quality 
improvement accelerated dramatically beginning in 2003 with our 
joining of the Institute for Healthcare Improvement, Dr. Don 
Berwick's initiative, in devoting ourselves to improving the 
health of our community, the patient experience, while also 
reducing costs.
    Today we can also look to the Partnership for Patients 
intention to improve safety, and affordability and I am pleased 
to inform you that Mercy Medical Center is a member.
    Our accomplishment, our communities accomplishment, has 
been the product of a dedicated medical institution functioning 
in a rather unique community where sharing knowledge and 
initiatives that improve quality is common. The cross-
cultivation has assured that all of those best practices are 
distributed to both hospitals, as well as to all providers and 
clinics.
    Specifically, with respect to treatment, the principle in 
play is to get it right the first time, and to ensure that the 
treatment process is managed before, during, and after acute 
care. For example, 100 percent of Mercy's 85 providers--primary 
care physicians are utilizing electronic health record. Health 
coaches are now embedded within these practices to augment and 
enhance the physician's capacity to effectively interact with 
the respective patients to better manage chronic disease, such 
as diabetes, congestive heart failure, and to drive wellness 
and prevention initiatives.
    Additionally, chronic disease management self-help courses 
are held throughout our community led by Mercy trainers, 
supported by a curriculum developed at Stanford.
    Every Mercy employed physician is on an incentive program 
designed to improve compliance with evidence-based practice. In 
the event that acute care is required, a myriad of initiatives 
have been undertaken to ensure top quality. Adopting the 
technology of Lean, the facility is constantly challenging its 
performance and instituting initiatives that are evidenced-
based, standardized, and hard wired.
    We have deployed additional resources to the floors, such 
as pharmacists to work side-by-side with nurses. We have 
actually developed new services within our community. 
Palliative care, we opened a 12-bed hospice house.
    We also have reached out to other organizations to bring to 
Mercy the evidence-based practices that do make a difference. 
For example, the American Heart Association's Get With the 
Guidelines Project, which encouraged us to reach beyond the 
walls of the hospital and to bring the local ambulance company 
into a conversation for how we can improve cardiac outcomes by 
beginning care in the field.
    You may have noticed that a number of the initiatives are 
in some ways reflective of the nine focuses embedded within the 
Partnership for Patients Center for Innovation. With each 
successive year, blending technology and Lean process 
improvement, the hospital environment has become safer and more 
reliable. Process improvement coupled with advance technology 
from robotics in the pharmacy, computerized Smart IV pumps, 
bedside medication verification, and bar-coding vocera 
communication programs, the organization has grown in its 
sophistication.
    The Commonwealth's Funds interests of re-admissions and its 
subsequent identification of leading institutions is an 
important indicator of overall success in managing the clinical 
process. This success, from our perspective, is the cumulative 
consequence of striving for and achieving many varied 
certifications and designations of expertise in specialty 
programs, and I could list a number of those. These 
designations are important for the recognition that specific 
requirements have been met, a high standard of care has been 
measured and verified, and that commitment to excellence has 
been sustained.
    We have also committed ourselves to transparency, sharing 
data, benchmarking, and also research. We have been involved 
with Mayo Clinic for 25 years with cancer research. But once 
the patient departs from the hospital the work doesn't stop. 
Mercy's process improvement teams have been working on two 
specific initiatives, post discharge followup for home care, 
and also, particularly for high-risk patients, and the other is 
the use of home-based monitoring systems that provide data that 
alert clinical teams to patient's progress or deterioration and 
that has actually reduced the re-admission rate within that 
population by 47 percent.
    It is true that Cedar Rapids is somewhat unique. We share 
one medical staff, one group of specialists. Four years ago 
Mercy brought to our community an innovative information 
technology product called PatientKeeper, which enabled us to 
share data. It is an overlay that allows us to communicate 
across all facilities. We are also now developing a patient 
portal, which will enable patients to engage in their care, 
which is particularly important, Senator Harkin, to your 
initiative with respect to health and wellness.
    The future will bring significant investment in information 
technology, increased engagement across the spectrum of 
services, and finally the medical home will be embedded in 
every primary care practice, and that will, in effect, ensure 
that these initiatives are driven home and the results that we 
are committed to are achieved.
    I think that there is an authentic sense of leadership and 
opportunity right now within the medical community, 
particularly within the hospital industry, and I am very 
excited. We are at a tremendous juncture, and I think the 
future is very encouraging and positive.
    Thank you very much.
    [The prepared statement of Mr. Charles follows:]
                 Prepared Statement of Timothy Charles
                                summary
    The Commonwealth Fund recently recognized Mercy Medical Center, 
Cedar Rapids, IA as performing in the top 3 percent of the Nation's 
hospitals in maintaining a low re-admission rate. The committee will be 
provided an overview of the hospital's approach to quality improvement.
    The hospital's commitment to achieving nationally recognized 
quality and safety has been in place for many years. Intensification of 
these efforts occurred in the past decade with Mercy's early adoption 
of the Institute for Healthcare Improvement's 100,000 lives and Triple 
Aim efforts. Instituting a myriad of improvement projects, coupled with 
LEAN, has resulted in improved performance in quality of care, reducing 
waste, reducing harm and dramatically reducing mortality. The success 
of these initiatives has been well-documented and recognized publicly, 
for example, by the Institute for Healthcare Improvement, the Delta 
Group, American Heart Association and The Joint Commission.
    Looking to the future, the hospital will continue the program that 
led to improved management of the patient experience before and after 
acute care. With advances in the Medical Home Model offering improved 
chronic disease management, wellness and prevention services through 
health coaches, the system will strive to reduce the necessity for 
downstream emergency and acute services. Following hospitalization, 
expansion of the home-monitoring project now underway will continue to 
demonstrate the value of close observation of patients upon release 
from the hospital. In other words, the effectiveness of the acute care 
experience is inextricably tied to having an effective medical home and 
to resources made available while at home when recovering.
    Much work must yet be accomplished. Even as the national agenda 
takes shape, we can be confident that the ``Partnership for Patients'' 
is already underway in communities like Cedar Rapids, and is making a 
demonstrable difference.
                                 ______
                                 
    Senator Harkin, Ranking Member Enzi and members of this 
distinguished committee: On behalf of Mercy Medical Center, Cedar 
Rapids, IA, I am gratified to have been asked to present our journey 
toward achieving and sustaining nationally ranked quality and safety.
    Mercy was founded by the Sisters of Mercy in 1900 and for the past 
century has been devoted to a healthcare ministry of caring for the 
sick and improving the health of the communities we serve. The themes 
that thread their way through this long and unbroken history are to 
stand upon the ground of compassionate service established by the 
Sisters; provide the state-of-the art and science of medicine made 
possible by extremely talented providers, and the generosity of 
community members that see to it the organization is equipped with the 
most advanced facilities and technology; and finally, to place the 
needs of our patients and the common good at the center of all 
undertakings.
    In December 2009 we were invited by the Institute for Healthcare 
Improvement to present our path and results and to receive its 
recognition, along with our competitor hospital and the medical 
community, as one of the leading providers of high quality and cost-
effective care. I shared that Mercy's accomplishment was the result of 
years of dedicated effort and discipline. This invitation led to two 
additional meetings in Washington, with colleagues from a select group 
of communities chosen as they might offer innovative models to an 
industry desperately in need of reform.
    The recent Commonwealth Fund case study released in March of this 
year recognizing Mercy as being in the top 3 percent of all facilities 
with respect to low re-admission rates is further testament to this 
relentless commitment to quality improvement.
    The pace of change at Mercy accelerated dramatically in 2003 when 
we became an early adopter of Dr. Don Berwick's 100,000 lives campaign 
and later the IHI Triple Aim: improve the health of the community and 
the patient experience while reducing costs. Today we can also look to 
the ``Partnership for Patients'' intention to improve quality, safety 
and affordability. I am pleased to inform you that Mercy Medical Center 
is now a member.
    From 2003 forward the facility has been in relentless pursuit of 
improved quality while driving down costs--in other words eliminating 
waste. This has come in three ways: decreasing unnecessary utilization 
of services; decreasing harm--through complications and/or unintended 
adverse outcomes; and, standardization of evidence-based practices. 
Long before the Accountable Care Act, Mercy was undertaking its own 
local initiatives.
    This, in no small way, has been the product of dedicated medical 
institution functioning in a rather unique community where sharing 
knowledge and initiatives that improve quality is common, even amongst 
competitors. This cross-cultivation has all but assured the spread of 
best practices.
    Specifically, with respect to treatment, the principle in play is 
``get it right the first time'' and ensure that the treatment process 
is managed before, during and after acute admissions. For example, 100 
percent of Mercy's 85 primary care providers are utilizing an 
electronic heath record. Health coaches are now embedded within these 
practices to augment and enhance the physicians' capacity to 
effectively interact with their respective patients to better manage 
chronic diseases such as diabetes, congestive heart failure, and to 
drive wellness and prevention initiatives.
    Additionally, chronic disease management self-help courses are held 
throughout our community, led by Mercy trainers, supported by a 
curriculum developed at Stanford.
    Every Mercy-employed primary care physician is now on an incentive 
program designed to improve compliance with evidence-based practices.
    In the event that acute care is required, a myriad of initiatives 
have been undertaken to ensure top quality. Adopting the technology of 
LEAN, the facility is constantly challenging its performance and 
instituting initiatives that are evidence-based, standardized, and 
hard-wired. A few examples are, in 2003 rapids response teams were 
deployed, inpatient glycemic control protocols were instituted, 
clinical pharmacists were deployed to the floors to work side-by-side 
with bed-side nursing and physicians. In 2004, the palliative care 
consultative service was instituted and a 12-bed community-based 
hospice house was constructed. 2005 saw recognition of Mercy's cardiac 
care with the American Heart Associations ``Get with the Guidelines'' 
project. It has been nearly 18 months of consistent door to balloon 
times of less than 90 minutes, the national benchmark: in fact our 
times are consistently less than 50 minutes. In 2006, a Venous 
Thromboembolism prophylaxis initiative was instituted across all 
surgical and stroke patients. In 2007, an organization-wide initiative 
tackled hand-hygiene, the simplest and most impactful means of reducing 
the spread of infections. Linn County became a pilot for the State of 
Iowa undertaking IPOST--the creation of an advanced directives document 
that would be universally honored by all providers and institutions. 
You may have noticed that several of these, if not all are consistent 
with the nine areas of focus embedded within the ``Partnership with 
Patients'' Center for Innovation.
    With each successive year, blending technology and LEAN process 
improvement the hospital environment has become safer and more 
reliable. Process improvement coupled with advanced technology--from 
robotics in the pharmacy, computerized SMART IV pumps, bed-side 
medication verification and bar coding, vocera communications systems--
the organization has grown in its sophistication.
    The Commonwealth Fund's interest in re-admissions and its 
subsequent identification of leading institutions is an important 
leading indicator of overall success in managing the clinical process. 
This success, from our perspective is the cumulative consequence of 
striving for and achieving many varied certifications and designation 
of expertise in specialty programs. A few examples are, the American 
College of Surgeons Commission on Cancer, American College of 
Radiologists Breast Imaging Center of Excellence, The Joint Commissions 
disease specific certifications such as the Advanced Primary Stroke 
Center and the Heart Attack in Women Program, as well as recognized as 
a most-wired hospital. These designations are important for the 
recognition that specific requirements have been met, a high standard 
of care has been measured and verified, and the commitment to 
excellence has been sustained.
    The data that drives these initiatives is a critical dimension to 
our success story. Mercy reports core measures as all others do today. 
We also participate in several other comparative data bases: the 
American College of Cardiology-National Cardiology Data Registry (ACC-
NCDR), the National Database for Nursing Quality Indicators (NDNQI) 
Registry, and the National Healthcare Safety Network for Infections. We 
are also a participant in the Cedar Rapids Oncology Project supporting 
25 years of cancer research in affiliation with Mayo Clinic, and 
finally the Delta Groups, whose trending of Mercy's risk-adjusted 
mortality demonstrated a drop from 1.27 in 2003, where 1.0 is the 
expected, to a current rate of .44 in the most recent report.
    Once a patient departs the hospital, the work doesn't stop. Most 
recently, Mercy's process improvement teams have been working on two 
initiatives: post discharge followup by homecare nurses for all high-
risk patients, and the use of home-based monitoring systems that 
provides data to providers alerting them to patient progress or 
deterioration thus enabling early effective counter measures that avoid 
re-hospitalization. These monitoring systems are not compensated under 
the current reimbursement system but by providing the right resources 
to provider and patient alike, results such as reduced re-admission 
rates can be accomplished.
    Cedar Rapids may be a somewhat unique context for care that 
contributes to the overall performance. Today we have one dominant 
surgical specialty group serving both competing hospitals. We have one 
group of anesthesiologists and one group of radiologists. Cedar Rapids 
has a significant primary care community, supports a free clinic and 
federally qualified community health center. Access to care and 
services is relatively good. More importantly, access to clinical data 
is also remarkably good. Four years ago, Mercy brought to our community 
an innovative information technology product called Patientkeeper. It 
is an overlay that enables a doctor and or provider to acquire health 
information about a patient irrespective of the Cedar Rapids hospital 
in which they are being treated. This is important because physicians 
can now access information, through one device, even though that 
information may reside in a repository of different legacy systems of 
the two hospitals. Additionally, there is universal access to radiology 
images. Mercy has just entered into a partnership with a young IT 
development company, called GEONETRIC--located in Cedar Rapids, to 
develop a robust patient portal that will significantly increase the 
engagement of patients in their own health, wellness and care.
    So what will the future bring? The first is significant investment 
in information technology as the most powerful tool in improving 
communication, data gathering, sharing, verifying outcomes and 
empowering the individual patient to take responsibility for their 
health.
    In step with this will be increased engagement with providers 
across the spectrum of the health care continuum jointly developing and 
overseeing community standards of practice that improve outcomes, 
eliminate waste and harm.
    Finally, the Medical Home Model will become embedded within every 
primary care practice. Reducing the terrific burden of our health care 
system requires us to address the drivers--the epidemic of chronic 
diseases for example. Effectively managing the burgeoning prevalence of 
chronic disease, coupled with, as Senator Harkin has long understood 
and appreciated, a commitment to wellness is the partnership between 
provider and persons in their care, and is the very essence of the 
medical home model.
    There is much yet to do. I sense that there is authentic will and 
leadership to get the job done. While we sort out the national agenda, 
I am encouraged and I respectfully suggest you can be as well by the 
work long underway in States like Iowa, and communities like Cedar 
Rapids.
    Thank you again for the opportunity to be with you today.

    The Chairman. Thank you very much, Mr. Charles.
    Dr. Mehler, welcome and please proceed.

  STATEMENT OF PHILIP S. MEHLER, M.D., CHIEF MEDICAL OFFICER, 
                   DENVER HEALTH, DENVER, CO

    Dr. Mehler. Good morning. Thank you, Dr. Bennet, for your 
kind introduction.
    Senator Harkin and members of this committee, I am honored 
to be here to testify and affirm Denver Health's commitment to 
patient safety and quality. Denver Health is an academic, 
integrated health care system and Colorado's principle safety 
net institution providing close to $400 million of care to 
people without insurance in 2010. We care for one in three 
people of Denver and 40 percent of Denver's children.
    Denver Health's vertically integrated system, employed 
physician model, and our robust information technology provided 
a foundation upon which to build. The employed physician model 
promotes the alignment of goals across the enterprise and helps 
with the effectuation of patient quality and safety 
initiatives.
    Seven years ago we began on a structured journey toward 
safety and quality, which included a comprehensive approach to 
patient care, establishing a department with primary 
responsibility for quality and safety, creating new programs to 
manage high risk clinical situations, and implementing systems 
to reduce variability in care.
    The adoption of Toyota Production Systems, know as Lean, is 
an important piece of the comprehensive approach to care. 
Heretofore, the Lean concept of standard work had not 
traditionally been applied to the patient care arena. Denver 
Health recently opted to utilize Lean to address a common and 
potentially fatal hospital acquired condition, that of deep 
venous thrombosis, namely clots in the leg, which break loose 
and end up in the lungs. Because practice varied widely among 
different Denver Health provider specialty groups, and because 
one of the medicines used for preventing blot clots had become 
the most costly line item in our hospital's pharmacy budget, 
and most importantly, because our rate of blood clots was 
higher than other academic hospitals, we needed a new approach 
to beget sustainable quality improvement.
    Our experience in this regard was recently published in the 
Joint Commission's Journal on Quality and Patient Safety. Using 
Lean, we achieve now one of the lower rates of this 
complication and reduced potential costs by millions of 
dollars, thus demonstrating the link between safer care and 
lower cost.
    We also developed new approaches to other high risk, high 
opportunity clinical situations. Failure to risk rescue refers 
to a common and costly failure to identify hospitalized 
patients who are deteriorating and to intervene in a timely 
manner to prevent further deterioration. Differences in 
national mortality rates across hospitals have been shown 
largely to be due to failure to rescue issues.
    Denver Health opted to institute a very unique rapid 
response system to identify such patients and proactively 
intervene. As a result, our mortality rates have been reduced, 
as have our cardiopulmonary arrest rates within the hospital.
    Another Denver Health patient safety initiative was related 
to infectious disease care. Overuse and underuse of antibiotics 
are important barriers to quality improvement. Therefore, a 
formal antibiotic stewardship program was established to 
provide careful oversight and guidance to our clinical 
services.
    This approach spawned new programs, including mandatory 
infectious disease consolations for certain serious infections, 
concurrent and timely feedback to a prescribing team when 
multiple antibiotics were being used for the same patient, and 
new rules-driven guidelines embedded within our computerized 
physician order entry, CPOE, system for common inpatient 
infections, such as pneumonia and cellulitis.
    As a result, Denver Health's antibacterial drug use was the 
lowest amongst academic health centers reporting through the 
university health system consortia.
    The aforementioned interventions have focused on 
hospitalized patients. Improving ambulatory care poses unique 
challenges. Despite the fact that there are currently 900 
million outpatient visits annually in the United States, 
compared to only 35 million hospital discharges, there has been 
much less effort directed toward improving the care of 
outpatient.
    However with the growing focus on medical home and health 
reform's emphasizes on accountable care organizations, it is 
crucial that high quality care also be delivered to our 
outpatients. Denver Health, with its multiple community clinic 
sites, has embarked on outpatient quality initiatives using its 
integrated health information technology system, robust data 
warehouse, and dynamic patient registries.
    These registries trigger improved quality by providing 
aggregate, point of care performance data by specific clinic 
site and specific clinicians to make the data available for 
audit and feedback. The cancer registry's patient specific data 
serve as a visual prompt to the physician during the patient 
encounter reminding the physician to encourage the patient to 
comply with recommended breast, cervical, and rectal cancer 
screening.
    Moreover, as a result of these registries, hypertension 
control is at 70 percent at Denver Health for our patients, and 
more than 50 percent of our diabetic patients have their 
cholesterol values at the target level. Both of these rates far 
exceed national averages.
    Based on these structured approaches to quality and safety, 
Denver Health was ranked first of 112 academic medical centers 
with the lowest observed-to-expected mortality ratio in the 
2010 University Health Systems Consortium's quality aggregate 
score. These structured approaches have made Denver Health's 
care safer. The aforementioned low observed-to-expected 
mortality rate translates into more than 200 people walking out 
of Denver Health alive, who would have been expected to die.
    While Denver Health is safer, we are not perfect. That is 
why Denver Health is committed to sustaining this effort and 
why I am honored to be standing here today. Thank you.
    [The prepared statement of Dr. Mehler follows:]
              Prepared Statement of Philip S. Mehler, M.D.
                                Summary
    America's health care systems have not achieved the desired level 
of quality and safety. This may be due, in part, to the lack of clear 
and robust approaches for institutions to follow. Denver Health, an 
integrated, public safety-net institution, developed a multifaceted, 
structured approach to quality and safety improvement that has produced 
positive outcomes. For example, in 2010 Denver Health ranked first of 
112 U.S. academic medical centers in terms of actual mortality observed 
versus expected mortality rates. Given these results, we argue that 
regulatory bodies should refocus their oversight to consider an 
institution's overall structured approach to quality improvement and 
safety. The Denver Health experience demonstrates that care quality and 
patient safety can be advanced within America's health care 
institutions, even in organizations challenged by lack of resources and 
by socially disadvantaged patients. Denver Health demonstrates one 
pathway. Its integrated system of care, employed medical staff, and 
strong health information technology infrastructure has allowed the 
creation of a structured approach to patient safety and quality of 
care. Our approach includes the designation of a responsible person and 
department for quality and safety that focuses on high-risk clinical 
areas, uses standardized care based on rigorous scientific evidence, 
and is supported by transparent and robust real-time performance data 
that can be used for peer comparisons.
                                 ______
                                 
    I am honored to be here to testify and affirm Denver Health's 
commitment to patient safety and quality. Denver Health is an academic, 
integrated health care system and Colorado's principle safety net 
institution providing $382 million of care to people without insurance 
in 2010. We care for one in three people in Denver and 40 percent of 
Denver's children. Like most American health care systems, we strongly 
espouse quality and safety, but clearly understand that aspiration 
alone will not produce excellent patient safety or quality.
    Denver Health's vertically integrated system, employed physician 
model and our robust information technology provided a foundation upon 
which to build. The employed-physician model promotes the alignment of 
goals across the enterprise and helps with the effectuation of patient 
quality and safety initiatives. Seven years ago we began a structured 
approach to safety and quality which included creating a comprehensive 
approach to patient care, appointing a person and a department with 
primary responsibility for quality and safety, creating new programs to 
manage high risk clinical situations and implementing systems to reduce 
variability in care. The adoption of Toyota Production Systems, or 
Lean, is an important piece of the comprehensive approach to care. 
Heretofore, Lean tools and the Lean concept of standard work had not 
been traditionally applied to the patient care arena. Denver Health 
recently opted to utilize Lean to address a common and potentially 
fatal hospital acquired condition, that of deep venous thrombosis and 
pulmonary embolism--clots in the leg which break loose and end up in 
the lungs. Because practice varied widely among different Denver Health 
provider specialty groups, and because one of the medicines used for 
preventing blood clots had become the most costly line item in the 
hospital pharmacy budget, and most importantly, because our rate of 
blood clots was higher than other academic hospitals, we needed a new 
approach to beget sustainable quality improvement. Our experience in 
this regard was published in March 2011, as the lead article in The 
Joint Commission Journal on Quality and Patient Safety. Using Lean we 
achieved one of the lower rates of this complication and reduced 
potential costs by millions of dollars, thus demonstrating the link 
between safer care and lower cost. Each blood clot prevented avoids 
$25,000-$40,000 in medical costs. We expect to apply Lean methodology 
to other clinical situations wherein there is costly and dangerous 
inconsistent implementation of validated clinical guidelines.
    Safety includes freedom from harm and from the risk of harm. 
Therefore we developed approaches to other high-risk--high opportunity 
clinical situations. ``Failure to rescue'' refers to a common and 
costly failure to identify hospitalized patients who are deteriorating 
and to intervene in a timely manner to prevent further deterioration. 
Differences in national mortality rates across hospitals have been 
shown to largely be due to ``failure to rescue'' issues. Denver Health 
opted to institute a unique rapid response system to identify such 
patients and intervene, which differed from the common rapid response 
team approaches being promoted by others. As a result, our mortality 
rates have been reduced as have our cardiopulmonary arrest rates.
    Another Denver Health patient safety and quality initiative was 
related to infectious disease care. Overuse and underuse of antibiotics 
are important barriers to quality improvement. Almost 60 percent of 
Denver Health's inpatients were being treated with an antibiotic during 
their hospital stay. Therefore, a formal and robust antibiotic 
stewardship program was established to provide careful oversight and 
guidance to our clinical services. This approach spawned new programs, 
including mandatory infectious disease consultations for certain common 
and serious infections; concurrent and timely feedback to a prescribing 
team when multiple antibiotics were used for the same patient; new 
rules-driven guidelines embedded within our computerized physician 
order entry (CPOE) system for common inpatient infections such as 
pneumonia and cellulitis; and formal weekly infectious disease 
consultant rounds with intensive care unit teams. As a result, Denver 
Health's antibacterial drug use, in days of therapy per 1,000 patient 
days, was the lowest of 35 U.S. academic health centers reporting 
through the University HealthSystem Consortium. Moreover, proper 
treatment has increased, and adverse consequences from illness have 
decreased, for the highly prevalent Staphylococcus aureus bacteremia.
    The aforementioned interventions have all focused on hospitalized 
patients. Improving ambulatory care poses unique challenges. Despite 
the fact that there are currently 900 million outpatient visits 
annually in the United States, compared to 35 million hospital 
discharges, there has been less effort directed toward improving the 
quality of outpatient care. However, with the growing focus on medical 
homes and health reform's emphasis on accountable care organizations, 
it is crucial that high-quality care is also delivered to outpatients. 
Denver Health, with its multiple community clinic sites, has embarked 
on outpatient quality initiatives using its integrated health 
information technology system, along with a robust data warehouse and 
dynamic patient registries. These registries trigger improved quality 
by providing aggregated point-of care (care delivered during an office 
visit) performance data by specific clinic site and specific clinician 
to make the data available for audit and feedback. The cancer 
registries' patient-specific data serve as a visual prompt to the 
physician during a patient encounter, reminding the physician to 
encourage the patient to comply with recommended breast, cervical, and 
rectal cancer screening. These registries are also tools for proactive 
management and outreach to patients between visits. As a result of our 
hypertension and diabetes registries, 70 percent of patients with 
hypertension have their blood pressure controlled, and more than 50 
percent of diabetic patients have their low-density lipoprotein 
cholesterol, or ``bad'' cholesterol, values at the target level. Both 
of these rates far exceed national averages.
    Based on these structured approaches to quality and safety, Denver 
Health was ranked first of 112 academic medical centers, with the 
lowest (0.55) observed-to-expected mortality ratio--the ratio of actual 
deaths at Denver Health compared to national death trends--in the 2010 
University HealthSystem Consortiums Quality and Accountability 
Aggregate Score.
    These structured approaches have made Denver Health's care safer. 
The aforementioned low observed to expected mortality among 112 
academic health centers translates into more than 200 people walking 
out of our hospital alive who would have been expected to die. While we 
are safer, we are not perfect. That is why Denver Health is committed 
to sustaining this effort and why I am standing here today.

    The Chairman. Thank you very much, both you, Dr. Mehler, 
and Mr. Charles, for your testimony, but more importantly, for 
the work that you are doing.
    Mr. Charles, I'll start with you. As I said to you before 
we formally sat here for the hearing, I said the thing that was 
interesting I thought was how Mercy Hospital, the way you got 
different competitors to work together to advance patients' 
interests, and I asked you how you achieved that and I think we 
were interrupted at that time, so I would like to ask you 
formally for the record. How did you get all the different 
competitors to work together?
    Mr. Charles.  That was the very question that Don Berwick 
was asking when he brought us together with that unique group 
of eight other communities. There are a couple of facets or 
dimensions to Cedar Rapids that may be unique. First of all, we 
have one common medical staff. In other words, the same medical 
staff practices in both hospitals.
    What is interesting is that there is a tradition that has 
developed over the years which is when a best practice is 
developed in one institution, such as Mercy's Door-to-Balloon 
Time initiative, that best practice finds its way, migrates to 
the other institution. And there has been, I think, a silent 
recognition that while we may be competitors with respect to 
market share and wanting obviously the attention of the 
community and loyalty of our patients, the reality is when it 
comes to quality we are absolutely fighting the same fight.
    We have a number of specific initiatives that we have 
actually worked cooperatively on, one of which was the 
development of a family practice residence program that was 
critical and that has been critical to the fact that we have a 
very, very well-staffed primary care community. We worked 
cooperatively on the development and evolution of the free 
clinic, which took care of the indigent. We worked 
cooperatively on the development and the execution of the 
community health center, a federally funded community health 
center. We have worked cooperatively on the training of 
professionals, radiologists, nurses. We found touch points that 
have enabled us, even in the face of being competitors, and we 
are competitors, to take on those projects together.
    Another interesting project was a joint venture around MRIs 
as a way of containing the number of MRI units in our community 
and ensuring that we didn't have one on every corner. That has 
been very effective, it has been a very effective way to manage 
the evolution of technology in our community.
    The Chairman. You mentioned something about how you monitor 
patients after they leave the hospital. You said, in your 
written testimony, I think you mentioned it also in your verbal 
testimony, about how you had some home-based systems to check 
up on patients and how they were doing, so you would have early 
interventions?
    Mr. Charles.  A critical initiative that we undertook just 
a couple of years ago was to send home, with high risk 
patients, a home monitoring system which enables the clinical 
team to check in with the patients and actually get a read on 
various clinical indicators. And the intention was to be able 
to identify patients as they are deteriorating, not only when 
they have gotten to the point where they are requiring a return 
visit to the emergency room. Highly effective way of managing 
the post-acute care process.
    The Chairman. Dr. Mehler, what I am really impressed with 
your operation is that you are serving a very diverse group in 
Denver, very diverse group. And I would assume that the 
characteristics of that diverse population has certain 
challenges for delivering quality care.
    Could you speak a little bit more, just openly, again about 
how does dealing with a broad spectrum of people you see--you 
cover about a third, I think, of the people in Denver and what, 
over half the children or more of the children, so you have 
various income groups, various language problems. Give us a 
little bit of a sense of how you deal with all that and still 
come out with the kind of quality end results that you have.
    Dr. Mehler. Denver Health is what is referred to as a 
safety net hospital and we are considered, I think, one of the 
premier ones in the country. We deal with a very ethnically 
diverse population; close to 50 percent of our patients do not 
have payer sources and that is how we were forced to give out 
close to $400 million of un-reimbursed care last year. That 
does create challenges, as you have astutely pointed out.
    There are simple challenges such as language. We have to 
spend a lot of money on interpreters. We have our own staff. We 
have a language line, which we use after hours. We have very 
unique dialects that are spoken by populations that have 
migrated to Denver and use our healthcare system which creates 
challenges.
    But it also creates opportunities. I think part of the 
reason that we have been successful is that we have a very 
energized medical staff and we have a very energized employed 
staff of healthcare professionals. Our mission is sacred. These 
people don't have other options for care and so we are sort of 
the last provider that is going to take care of them. That 
energizes you every day.
    I have worked at Denver Health for almost 30 years now, it 
has really been my only job, and when you come to work you 
really feel like you have a mission to be able to provide for 
exactly what you are talking about, this very diverse 
population of patients.
    In addition to that, you have to be culturally sensitive 
because there are unique things that are challenges in that 
regard that emanate from different cultures that you are taking 
care. That is a challenge as well. So we have training in 
cultural sensitivity, which is very important, how to deliver 
that care to patients.
    But in addition to that, we have a population of patients 
that come to Denver Health, because that is where they want to 
go because of the quality that we have there. And it is that 
ability to provide quality of care that attracts insured 
patients and VIPs to come to Denver Health and to get that 
reputation out there which then allows us to support the sacred 
mission of taking care of people without insurance.
    It is a daily challenge. But, we made the commitment a 
number of years ago that we wanted to be the best healthcare 
system in the country, we wanted to certainly be the best 
safety net system in the country, because again, many of these 
patients don't have another option for their care. But it does 
require the confluence of many different efforts, from an 
employed medical staff, a devoted medical staff, devoted 
caregivers across very unique things to care for the 
populations that are embedded within safety net institutions.
    The Chairman. Thank you both very much.
    Senator Mikulski.
    Senator Mikulski. First of all, I want to say to both of 
you, thank you. You are doing, in your local community, exactly 
what we would like to do for the Nation. Your practices came 
out of our quality initiatives and our national health effort 
through the Patient Protection and Affordable Patient Care Act 
and then in very practical, I might add grassroots ways, you 
are doing it. So I just want to thank you for what you are 
doing for the people and patients in your community and the 
lessons learned.
    Dr. Mehler, I would just make one comment to you, since I 
have a lot of questions about Mercy, because of a Mercy 
parallel in Baltimore. The fact that you have such high quality 
when you are known as, as you say, the safety net hospital. 
Often in communities they are called the charity hospitals and 
they often get a bad rap. They often get a stigma, ``oh that is 
the charity hospital, that is where the poor go.'' Code name, 
poor people, poor care. But wow, this is stunning in what you 
are doing. And you and the people who work there for the people 
of Denver and Colorado should be really acknowledged for that.
    Now, Mr. Charles, I know Cedar Rapids Mercy. I have been by 
it; I have never been in it. I didn't want to be in it when I 
went by it. I was there for a presidential campaign, not my 
own, another lady. Then I saw you under flood conditions on TV. 
Senator Harkin spoke eloquently about what you all were going 
through. This is a great set of accomplishments as well.
    You obviously come with the spirit of Mercy, the charisma 
of Mercy. My question goes to the fact that you are not in the 
major medical center community, that is Iowa City. You are 45 
minutes away, you are a community-based hospital, which means 
you are always foraging for revenue. My question is, when you 
wanted to embark upon this, how did you find Dr. Berwick?
    In other words, it goes to my question with Dr. Clancy for 
the community-based, perhaps university affiliated, perhaps not 
university affiliated, rural or suburban hospitals. How did you 
get connected to what you wanted to learn to do this 
transformational effort?
    Mr. Charles.  A couple of things. One is that like Denver 
Health, we have an aspiration and our aspiration is, even 
though we are sitting in the Midwest, we are in a community 
that often I have to tell people how to get to, we want to be 
nationally recognized, which is to say that we are able to 
stand the test of our quality up against the very best 
anywhere. That has been our aspiration.
    In 2003 we were introduced to Dr. Berwick. And at that time 
we became----
    Senator Mikulski. How were you introduced to Dr. Berwick?
    Mr. Charles.  Just through literature. It was essentially 
looking at some of the publications.
    Senator Mikulski. OK, now can I jump in?
    Mr. Charles.  Yes.
    Senator Mikulski. In your quest to be the very best and to 
improve the methodologies of quality, was the government of any 
help to you? Was there government information or was it 
primarily through Berwick?
    Mr. Charles.  Actually, I would have to say that quite 
frankly it was not through governmental assistance that we 
worked at this. It was driven internally. We used our own 
internal resources. But one of the very important things that 
we also did, and you heard the term Lean being used by Denver 
Health, we had a conversation with the chairman and CEO of 
Rockwell Collins and this was in 2004. And Clay Jones, whom you 
may know, actually sat me down and basically said, the one 
thing that absolutely keeps me up at night are my healthcare 
costs. It is the most unpredictable cost of my company and I am 
looking at the trajectory of that and my ability to have 
capital to fund the kind of work that we are here to do as a 
company will be jeopardized if we don't get this under control. 
So I am going to give you the one thing I know I can give you 
that would make a difference and that is Lean, which they have 
been devoted for years. Which is to get after your processes in 
such a way that you eliminate waste.
    Senator Mikulski. Is it the Toyota model?
    Mr. Charles.  It is the Toyota model.
    Senator Mikulski. OK, now let me come to Berwick. Then 
because you heard from Lean, Colorado learned from Lean, there 
was no 411 government number that you called. The government 
wasn't telling you to change, do better or whatever out of 
Medicare. So now we have Berwick, Guru Berwick. The Institute 
for Healthcare, really brings in private sector people with 
healthcare people. The Berwick initiative in addition to Lean, 
were your primary motivators? I have very limited time.
    Mr. Charles.  There were two very important dimensions that 
the Institute for Healthcare Improvement brought. One was the 
inspiration of Dr. Berwick. And quite frankly, in an industry 
that lacked that kind of direction and leadership, that was 
critically important. But the second was that he created 
communities where individuals could begin to share their best 
practices.
    Senator Mikulski. OK. Now Mr. Chairman, I don't think we 
have confirmed Dr. Berwick.
    The Chairman. I don't think so.
    Senator Mikulski. I don't think we have confirmed Dr. 
Berwick, so I would like to just say this to the committee and 
I am sorry there are no Republicans here, I am sorry Senator 
Enzi, for I am sure very good reasons, isn't here. We just said 
to Dr. Clancy and then we just said, ``Oh CMS never delivers,'' 
gee whiz, but we haven't confirmed Dr. Berwick. It is a little 
hard to have acting people running CMS, no matter how due 
diligent and so on. And, CMS is headquartered in my State.
    I think we need to confirm Dr. Berwick and stop fooling 
around here because under his leadership, the most important 
healthcare finance officers in America work. If you are going 
to do this with Medicare or poke Medicaid in the eye and so on, 
a lot of the action is at CMS. We have someone nationally 
recognized in Dr. Berwick, agreed upon in the healthcare/
hospital community, brings private sector practices to the 
healthcare delivery system and understands the medical 
healthcare delivery community. I think it is a national waste 
that we don't have this man confirmed.
    I would like to urge, as one of our quality initiatives 
from the community, that we pound the table and even throw over 
a table or two--to get Berwick confirmed.
    I could go on with my questions, but I think that this is 
absolutely essential. I could elaborate on it. I think it is a 
national disgrace that when we are talking about how to have a 
more frugal government, how to get our budget costs under 
control, healthcare costs being No. 1, how we are about to 
devolve Medicare, we don't have the head of CMS.
    So can we link arms on this and----
    Senator Harkin. I am with you.
    Senator Mikulski [continuing]. Wear your bowtie.
    [Laughter.]
    I just think you have held a terrific hearing. We could 
talk all day about this.
    I would like to work with the Harkin staff. What you have 
done is exactly what we hope to do through our quality 
initiatives. You both have done exactly what we want to do for 
the Nation. So again, may the force be with you and may it get 
behind us. Thank you very much.
    Mr. Charles.  Thank you, Senator.
    The Chairman. Thank you, Senator Mikulski.
    Senator Bennet.
    Senator Bennet. Thank you, Mr. Chairman.
    I just want to join Senator Mikulski in congratulating both 
of you for the work you have done and saying to people that in 
this political conversation about government take over of 
healthcare and death panels and all this other stuff, all 
people need to do is go to your two institutions to see where 
we need to head and what it looks like.
    Mr. Chairman, I was--my introduction to this healthcare 
problem occurred about 10 years ago in Denver when I was 
sitting in the mayor's office. The mayor had just been elected, 
I was his chief of staff. I come from this hotshot business 
career to the city and I thought I was a genius.
    And a woman shows up in the office bearing a bunch of 
slides. She turns out to be Dr. Patty Gabow who runs Denver 
Health. She showed me her revenue slide which was flat because 
of Medicare and Medicaid reimbursement. She showed me the slide 
of her costs which were going like this and she showed me the 
slide of the uncompensated care that Denver Health was 
delivering and how it was growing over time because people were 
losing health insurance. This was 10 years ago.
    She said they were going to fix this problem. She knew that 
her revenue wasn't going to increase but she had all these 
costs that were rising. I have seen those slides year after 
year after year since then. I didn't believe a word she was 
saying to me. I thought it was impossible for Denver Health to 
be able to achieve what she was saying in terms of quality of 
care with the population they were serving and the complete 
lack of attention from the Federal Government about the 
problems we were facing and she was facing.
    And they have done it. They have done far--not only have 
they made me a believer, but they have exceeded anybody's 
expectations about what could be done. What I would say to 
people that doubt they can condition higher quality and higher 
care is go to Denver Health and take a look at what they are 
doing.
    What I would ask you, Dr. Mehler, because you have been 
there, you were there before, you have been there since, it is 
one thing to say, you know, we put in place this pay system, we 
put in place the registry, we put in place the Lean system from 
Toyota. I wonder if you could share with the committee a little 
bit of how you built a culture that was able to do this and 
what the steps were like. I mean does somebody come in and say, 
``We are going to do this Toyota project'' and you say, ``We 
don't even know what that means.'' You are talking about an 
auto manufacturer.
    How did it start and give us a sense of the iterative 
nature of the work and where you think it stands today. What is 
next? I won't talk anymore so you can have the rest of my time.
    Dr. Mehler. That is a great question. The answer is that it 
is really the confluence of many iterative steps to get you 
there. I think the first thing is the model at Denver Health. I 
think the model of this vertically integrated system is 
something we need to see more of in U.S. healthcare systems. 
Where you deliver the right evidence-based care to the right 
patient at the right place at the right time.
    And we have all talked this morning about transitions of 
care which beget problems, whenever you hand off care, whether 
it is from a hospital to a clinic or from a clinic to a nursing 
home, wherever it is, you set yourself up for problems. When 
you have a vertically integrated system and when you have all 
components of that care model, those transitions are much more 
seamless. And so we invested a lot of money to make sure that 
we had a very tight vertically integrated system.
    A second thing that we did is that we had to have the will 
and the desire and the sustainable will to put in place the 
proper structure processes and perhaps most importantly, 
behavioral cultural change. In the past, value, as being 
valuable to healthcare as a provider, I never thought about. I 
thought it was the next guy's problem and perhaps more 
embarrassingly, I thought it was professionally ignoble for me 
to worry about dollars. But we need to realize, as healthcare 
providers, I continue to see patients and I am an active 
clinician, that value in healthcare is our responsibility as 
providers.
    And inculcating that cultural change within the medical 
staff and as they said at Cedar Rapids, having the employed 
medical staff, where you are able then to inculcate the changes 
that you have and insinuate them into practice helps you 
achieve success.
    In addition to that, we decided that we needed to be 
transparent. That infection rates needed to be posted in units. 
That we needed to be able to go into a particular physician's 
profile and know what his hypertension control was. We needed 
to feedback, in a timely manner, data to physicians. And so 
transparency and concurrent with that a significant investment 
in health information technology.
    Denver Health has invested close to $400 million over the 
last decade in HIT. Having a system which helps the physician, 
which helps the nurses, which helps the CNA take care of the 
patient is going to beget better care.
    It is really the confluence of many things. But at the end 
of the day it is the will to change and then the sustainability 
and accountability that demands that that change is being 
effectuated. And then the respect for the patient population 
that we take care of, the vulnerable patients of Denver who 
don't have another choice, that is what energizes our staff to 
say, despite the challenges that we face every day we have to 
achieve this care, we will achieve this care and we will 
continue to audit data and provide feedback to make sure that 
we are doing that.
    The last thing would be is that when you get quality your 
reputation improves. We used to be the Denver Gun and Knife 
Club. I was born in Denver, you went there when you got shot, 
you didn't go there for anything else. Now we have the VIPs of 
Denver coming to Denver Health because our quality informs the 
public, through transparency, that when you come there you are 
going to get a good product.
    Senator Bennet. Thank you Dr. Mehler. I hope you will say 
hello to Dr. Gabow for me.
    Dr. Mehler. I will.
    Senator Bennet. Mr. Chairman, I can't thank you enough for 
including us.
    The Chairman. Senator Bennet thank you for suggesting that 
we have Dr. Mehler here as a witness. I think this has added 
greatly to our deliberations and to our information that we are 
gathering here for the committee. I thank you for that, Senator 
Bennet.
    Senator Whitehouse.
    Senator Whitehouse. Thank you, Chairman and thank you 
gentlemen for being here.
    When we started down this road in Rhode Island many years 
ago, we decided we would do the Pronovost Keystone principles 
in our intensive care units statewide. The discussion, the 
conversation that ensued was very instructive to me. Now the 
hospitals said, ``Yes, we will do this, don't worry, we are 
totally behind this.'' We want to have our patients have this 
value. But, we want you to understand what this means on our 
financial side because when these things happen we get paid for 
treating them and that is in our top line. And when the 
infections, whether line infections or pulmonary conditions or 
whatever, don't take place that will reduce the reimbursement 
that we get.
    Any other business that saved money through quality 
improvement or information technology applications would get 
the benefit of that. But in the case of hospitals the benefit 
goes to the payers more than it does to the hospitals.
    There is a reimbursement paradox in terms of--I see both of 
your heads nodding--there is a reimbursement paradox that you 
experience or your fiscal people experience and there is a 
larger reimbursement paradox that the places that are doing the 
best things, like you, get less of a reward and the places who 
the Dartmouth Studies and others show are making a complete 
hash of this end up sucking up a lot more money. We reward, 
systemically, the worst performers and we punish the best 
performers.
    What is the best way we in Congress could help reverse that 
dynamic? Knowing that you can't undercut the other places right 
away, we have to steer toward a standard where people who 
aren't meeting the standard that you are setting not only know 
it but feel it financially if we are going to drive behavior. 
Don't we?
    Dr. Mehler.
    Dr. Mehler. I think you are exactly right. Currently the 
incentives are misaligned. You get paid for doing more and not 
necessarily for providing better quality. I think the answer to 
your question is that we need to, in short order, effectuate 
these accountable care organizations. Where you get a bulk 
payment to take care of patients and then by definition if you 
do less and have better quality and less costs you are going to 
benefit at the end of the day.
    We didn't used to like the term managed care organizations, 
but in reality, when you have a population of patients that you 
are given to take care of and you are responsible for their 
care and you are given X number of dollars to do it, it is 
going to exhort you to deliver the most efficient, high quality 
care to that physician population.
    On the other hand, when you are paid for quantity, exactly 
as you say, you get that formula where the incentives are 
misaligned and if you do more you make more and if you do less 
and achieve better quality you get less. Not the ideal dream 
model.
    I think the answer is we need to move ahead with these 
collaboratives. Denver Health is actively involved in one with 
Mayo Clinic, other systems across the country--Dartmouth--to 
try to achieve these collaboratives now, specifically in the 
vein of an accountable care organization, in the vein of 
getting a capitated payment to take care of patients and then 
using evidence-based medicine to drive decisionmaking, not to 
base it on gut feelings.
    Voltaire once said that opinion has caused more trouble in 
this little world than earthquakes and plague. And it is true. 
We can't base it on gestalt, it has got to be based on 
evidence-based that if you do it through an ACO model you are 
going to effectuate exactly what you are getting toward and we 
agree fully, and support fully the questions that you just 
raised.
    Senator Whitehouse. Mr. Charles, do you agree with ACOs and 
would you suggest anything else?
    Mr. Charles.  I think that one of the important new 
directions that is being undertaken now is understanding that 
it is quality and it is efficiency. The reality is States like 
Iowa already rank very, very high in terms of being able to 
deliver very high quality care but doing so at very low costs. 
As this evolves----
    Senator Whitehouse. Sounds like, say Florida. Not to throw 
anybody under the bus in particular, but I think they are kind 
of a standout at the other end of the equation.
    Mr. Charles.  And the reference that was made to Atul 
Gawande's article about comparisons with McAllen, TX really 
brought that to light. I think that is vitally important.
    I also see that directionally it is important to create 
incentives. Yes, it could be argued that all of this is work 
that should be done and quite frankly our systems had been 
doing this for many years, absent any indication that there 
would be financial incentives to get this accomplished. But, 
the reality is you are sending a very strong message and the 
message you are sending is, begin to uncouple yourself from 
that fee for service world, begin to recognize that more of 
your income should come from the outcomes you produce versus 
what you actually do.
    I think you are moving in the right direction. We have a 
long way to go. This is going to be a complicated process.
    Senator Whitehouse. Mr. Chairman, I know I am over my time 
but we are down to just the two of us. May I ask one more 
question?
    The Chairman. If you will permit me to just interject here. 
I was listening to your question. I asked my staff to get me 
this information. Section 3001 of the Affordable Care Act goes 
into effect in October 2012 and that is the penalties and 
bonuses for overall quality. That starts next year. Also 
starting in October 2012, there will be penalties for high re-
admissions. And then later on, in October 2014, there will be 
penalties for high infection rates.
    So beginning next year is the high re-admissions penalty. 
Next year is the bonuses, where you start getting bonuses for 
overall quality starts next year. And then 2 years after that 
is the penalty for high infection rates. What you were talking 
about, this adverse thing where the payers save the money but 
the hospitals don't, I think these three sections, I hope, will 
start addressing that point.
    Senator Whitehouse. Yes, I think they will. But they sort 
of carve islands out of the broader tide. And in those areas 
they reverse it but they don't force the system-wide change, at 
least at once. When you are dealing first with just the re-
admissions and then just with the hospital acquired infections, 
then in other areas the same prevailing tide is pushing people 
gently and steadily and consistently in the direction of doing 
more instead of better.
    I was trying to see if they--I think the Accountable Care 
Organization is the way to have it be a system change rather 
than just in specific targeted areas. But what we did in the 
Affordable Care bill to focus in those areas where we know 
there is room for real improvement, I think was really 
important and as Mr. Charles said, it helps to send a signal so 
that people know that a change is coming and they don't 
necessarily have to wait for it.
    The Chairman. I understand. If we could couple both the 
medical home model and the Accountable Care Organization, it 
seems to me then we get at the system problem----
    Senator Whitehouse. Yes, we do.
    The Chairman [continuing]. That you mentioned.
    Senator Whitehouse. I think we do.
    The Chairman. I thank you for letting me interject that.
    Go ahead.
    Senator Whitehouse. Of course. I just wanted to ask one 
other thing, since you guys are both way out in front in this 
area, information technology is obviously a very significant 
issue, we have made a very significant investment. Could you 
tell me to what extent information technology has facilitated 
or made possible the changes that you have made to date? And 
going forward, what is the next big step that we need to drive 
through in our development of a robust national health 
information infrastructure to sort of make the next game-
changer, if you will?
    Mr. Charles.  I can say unequivocally that information 
technology is the enabler. Back in the early 1990s when there 
were discussions of healthcare reform, there were many of us 
that were involved in trying to re-design the system. What 
became readily apparent was the inability to share information 
and data from silo to silo to silo, prevented us from 
accomplishing any of the intentions of that process. Today 
information technology has evolved tremendously. It is at the 
core. Four hundred million dollars, we expect that we will be 
investing $50 million over the next 5 years.
    I would say that an example of the next important 
initiative is to pave the way for electronic communication 
between practitioners and their patients. Patients want this. 
They want to be able to link with their doctors electronically. 
They are using it more frequently. Right now within our system, 
quite frankly, there isn't a way to capture and appreciate the 
value of that interaction in the form of revenue to physicians. 
Somewhere in this process we have got to address that concern.
    Senator Whitehouse. Anything to add, Dr. Mehler?
    Dr. Mehler. I would fully agree with what was said. It is 
clear that HIT has helped effectuate major advancements for 
Denver Health. We really have all of the latest and greatest in 
that regard, with CPOE, MAC, computerized medical record is in 
its last stages right now. And there is no doubt that it has 
made care safer, more efficient.
    I think one thing we haven't talked about this morning that 
is worth really briefly talking about is the fact that all the 
changes in resident work hours is really creating a bit of a 
crisis in healthcare because at the end of the day the 
residents deliver a lot of the care but there are all these 
work hour restrictions. We have to make sure that we are 
training the best generation to provide care for the next 
century and they are very adept with information technology. We 
have to give them the tools that are going to help make their 
jobs more efficient in the more limited time that they have in 
the hospital.
    The last point I would make is that the reality is, there 
is a huge problem with clinical inertia in the United States 
right now. Why is it that only 48 percent of Americans have 
their blood pressure controlled when all that is involved is to 
take a blood pressure pill? Well, there is this entity of 
clinical inertia, we just don't take the next step.
    But the way you achieve better care is by having rules 
embedded within order sets. The reason that we were able to 
achieve such great results with our deep venous thrombosis 
initiative is because when you type into the computer this 
medicine, it forces you to do x, y or z to achieve those cares 
so there is no doubt. Registries having data, it comes back to 
the physician that says only 30 percent of your patients or 
Mrs. Jones hasn't had her pneumovax the last time, when you see 
her, because it is imbedded and it is populated into the 
encounter when you see that patient. No doubt, it is 
unequivocal that that has made care more efficient and higher 
quality.
    Senator Whitehouse. I thank the both of you and I very much 
thank the distinguished chairman for allowing me the extra 
time. Thank you, sir.
    The Chairman. Thank you, Senator Whitehouse, for your great 
leadership on the development of the Affordable Care Act. I am 
delighted that your absence from this committee was short. I am 
glad you are back. Thank you very much, Senator Whitehouse.
    Mr. Charles and Dr. Mehler, again, thank you very much for 
being here, but again I would join with others in saying thank 
you, moreover for what you have done, the example you have set. 
As Dr. Clancy said, this is what we need to do--go out and find 
people like you, what you are doing, take that in and then 
start getting it out to people around the country so they can 
say, ``Well we can follow their example.'' So thanks for 
setting great examples, both of you, very, very much.
    I request to keep the record open for 10 days for Senators 
to submit statements and questions for the record.
    The Chairman. And with that, the committee will stand 
adjourned.
    [Additional material follows.]

                          ADDITIONAL MATERIAL

         Prepared Statement of the American College of Surgeons
    Improving quality of care leads to fewer complications, and that 
translates into better outcomes and greater access for patients, as 
well as lower costs. More than a decade ago that the Institute of 
Medicine published its report that found 100,000 preventable deaths 
occurred in U.S. hospitals each year. Many programs to measure and 
improve quality have come since that report, but the rate of adverse 
events remains alarmingly high.
    To be successful, hospitals and providers need proven tools and 
methods that measurably improve patient care. The American College of 
Surgeons has such proven tools of care and we believe that we can 
improve quality. In fact, in surgery, we are improving quality today.
    Improving quality isn't just a matter of instituting quality 
programs and requirements. The quality programs that have failed to 
reduce errors in hospitals have almost invariably lacked data strong 
enough to measure and improve quality. They are also too limited to 
effectively improve care, because they focus on requiring hospitals to 
implement a handful of best practices--also called process measures--
when in fact there are many more things hospitals should be doing to 
measurably improve patient outcomes.
    The American College of Surgeons has been able to significantly 
improve surgical quality by using strong data and the right approach. 
For more than 100 years, the American College of Surgeons has led 
national and international initiatives to improve quality in hospitals 
overall, as well as the more specific fields of trauma, bariatric 
surgery, cancer and surgical quality. These initiatives have been shown 
to significantly reduce complications and save lives, and that 
translates into lower costs, better outcomes and greater access.
    Complex, multi-disciplinary care--such as surgical care--requires a 
commitment to continuous quality improvement. Surgeons have a long 
history of developing standards and holding themselves accountable to 
those standards. Four years after ACS was founded in 1913, leaders such 
as pioneering surgeon Earnest Codman of Boston helped to form the 
Hospital Standardization Program 1917, which became The Joint 
Commission in 1951. Dr. Codman believed it was important to track 
patient ``end results'' and use those results to measure care, learn 
how to improve care and set standards based on what was learned.
    Since then, ACS has helped establish a number of key quality 
programs, including the Commission on Cancer in 1922, the Committee on 
Trauma in 1950, the American College of Surgeons Oncology in 1998, the 
National Surgical Quality Improvement Program or ``ACS NSQIP'' in 2004, 
and the National Accreditation Program for Breast Centers and Bariatric 
Surgery Center Network Accreditation Program, both in 2005.
    Based on the results of our own quality programs, we have learned 
that there are four key principles required to measurably improve the 
quality of care and increase value. We believe quality programs must 
have these four elements to make the significant improvements we need 
to make for our patients.
    Our first principle is to set the standards that are individualized 
by the patient's condition and backed by research. The core for any 
quality improvement program is to establish, follow and continuously 
reassess and improve best practices. Standards must be set based on 
scientific evidence so that surgeons and other care providers can 
choose the right care at the right time given the patient's condition. 
It could be as fundamental as ensuring that surgeons and nurses wash 
their hands before an operation; as urgent as assessing and triaging a 
critical injured patient in the field; or as complex as guiding a 
cancer patient through treatment and rehabilitation. In each case, it 
is important to establish and follow best practices as it pertains to 
the individual patient and, through constant reassessment, to keep 
getting better.
    Our second principle is to build the right infrastructure. To 
provide the highest quality of care, surgical facilities must have in 
place appropriate and adequate structures, such as staffing, 
specialists and equipment. For example, in emergency care, we know 
hospitals need to have the proper level of staffing, equipment such as 
CT scanners, and infection prevention measures such as disinfectants 
and soap dispensers in the right quantity and in the right locations in 
their emergency departments. If the appropriate structures are not in 
place, the risk for the patient increases.
    Our Nation's trauma system is an example of the importance of 
having the right infrastructure in place. We established the Committee 
on Trauma (COT) to improve all phases of care for the injured patient, 
thereby providing the optimal care in the most cost-effective manner. 
We have learned that for those who suffer a severe injury, access to 
optimal trauma care during the first ``golden'' hour can save their 
life, restore function and prevent disability. That means we need 
trauma centers with the appropriate resources, such as the appropriate 
staffing and equipment, and a trauma system that can get the patient as 
quickly and safely as possible to the trauma center most appropriate to 
handle their injury.
    ACS has established trauma center standards for staffing levels and 
expertise, processes, and facilities and equipment needed to treat 
seriously injured patients. Trauma centers are independently verified 
by the COT and receive a Level I, II, III or IV designation, based on 
the care they are able to provide. Ideally, the most challenging cases 
are immediately rushed to the nearest Level I or Level II center. There 
is good scientific reason for this: Level I trauma centers have been 
scientifically shown to reduce death by 25 percent.
    Our third principle is to use the right data--data from medical 
charts, backed by research, that tracks outcomes after the patient 
leaves the hospital and are part of a continuously updated database.
    We all want to improve the quality of care we provide to our 
patients, but hospitals cannot improve quality if they cannot measure 
quality, and they cannot measure quality without valid, robust data. We 
have learned that surgeons and hospitals need data strong enough to 
yield a complete and accurate understanding of the quality of surgical 
care compared with that provided by similar hospitals for similar 
patients. We need information about patients before, during and after 
their hospital visit in order to assess the risks of their condition, 
the processes of care and the outcome of that care. We've learned that 
the patients' clinical charts--not insurance claims--are the best 
source for this type of data.
    These are the principles of data collection upon which the ACS 
National Surgical Quality Improvement Program (ACS NSQIP) is built. The 
NSQIP program, which has its history in the Veterans Health 
Administration, is now in more than 400 private sector hospitals around 
the country. We use a trained clinical staff member to collect 
clinical, 30-day outcomes data for randomly selected cases. Data is 
risk adjusted and nationally benchmarked, so that hospitals can compare 
their results to hospitals of all types, in all regions of the country. 
The data is fed back to participating sites through a variety of 
reports, and guidelines, case studies and collaborative meetings help 
hospitals learn from their data and implement steps to improve care.
    ACS NSQIP hospitals have also seen significant improvements in 
care; a 2009 Annals of Surgery study found 82 percent of participating 
hospitals decreased complications and 66 percent decreased mortality 
rates. Each participating hospital prevented, on average, from 250 to 
500 complications a year.\1\ Given that major surgical complications 
have been shown in a University of Michigan study to generate more than 
$11,000 in extra costs on average, such a reduction in complications 
would not only improve outcomes and save lives, but greatly reduce 
costs.
---------------------------------------------------------------------------
    \1\ Hall BL, et al. ``Does Surgical Quality Improve in the American 
College of Surgeons National Surgical Quality Improvement Program.'' 
Ann Surg. 2009; 250:363-76.
---------------------------------------------------------------------------
    The fourth principle is to verify. Hospitals and providers must 
allow an external authority to periodically verify that the right 
processes and facilities are in place, that outcomes are being measured 
and benchmarked, and that hospitals and providers are doing something 
in response to what they find out.
    The best quality programs have long required that the processes, 
structures and outcomes of care are verified by an outside body, and 
ACS programs are no exception. ACS has a number of accreditation 
programs that, among other things, offer a verification of standards 
that help ensure that care is performed at the highest levels. Whether 
it is a trauma center maintaining its verification as Level I status or 
a hospital's cancer center maintaining its accreditation from the 
Commission on Cancer, ACS has long stressed the importance of review by 
outside authorities. Undoubtedly, increased emphasis on such external 
audits will accompany efforts to tie pay to performance and to rank the 
quality of care provided.
    Together, these principles form a continuous loop of practice-based 
learning and improvement in which we identify areas for improvement, 
engage in learning, apply new knowledge and skills to our practice and 
then check for improvement.\2\ In this way, surgeons and hospitals 
become learning organisms that consistently improve their quality--and, 
we hope, inspire other medical disciplines to do so as well.
---------------------------------------------------------------------------
    \2\  Sachdeva AK, Blair PG. Educating surgery resident in patient 
safety. Surgical Clinics of North America 84 (2004) 1669-98.
---------------------------------------------------------------------------
    The passage of the health care reform act is intensifying the focus 
on quality by requiring hospitals and providers to be increasingly 
accountable for improving care through measurement, public reporting 
and pay-for-performance programs.
    ACS welcomes the focus on quality but we must ensure that the right 
steps are taken. By taking an outcomes-based approach that relies on 
setting and following standards, establishing the right infrastructure, 
collecting the right data and outside verification, ACS has shown that 
complications and costs can be reduced and care and outcomes improved 
on a continual basis.
    Take ACS NSQIP. If we expanded this quality improvement program to 
every hospital in the country, we could prevent 2.25 million 
complications, save 100,000 lives and $25 billion. Every year, year 
after year.
    But that's if ACS NSQIP can be expanded to the Nation's more than 
4,000 hospitals that perform surgery. ACS NSQIP, which is in about 400 
hospitals, has a long ways to go to achieve that goal. We need to get 
ACS quality programs into more hospitals, more clinics and more 
communities. While this is a straightforward task, it is not one that 
ACS can accomplish on its own. ACS NSQIP's success will require 
collaboration from the broader surgical community; other providers, 
including hospitals; healthcare policy experts, government officials 
and elected representatives.
    The current focus on quality offers an extraordinary opportunity to 
expand the reach of ACS's quality programs and put the country's 
healthcare system on a path to continuous quality improvement.
    The evidence is strong: We can improve quality, prevent 
complications and reduce costs. That's good for providers and payers, 
government officials and taxpayers. Most of all, that's good for 
patients.
   Prepared Statement of the National Transitions of Care Coalition 
                                (NTOCC)
    Chairman Harkin and Ranking Member Enzi and other members of the 
committee, we thank you for holding this important hearing and 
appreciate the opportunity to submit a statement for the record. The 
National Transitions of Care Coalition (NTOCC) believes strongly that 
as policymakers and health care providers strive to improve health care 
quality and patient safety, it is essential that the improvement of 
care transitions in our health care system is made a top priority.
    The National Transitions of Care Coalition (NTOCC) is a group of 32 
leading health care experts and stakeholders dedicated to providing 
solutions that improve the quality of health care through stronger 
collaboration between providers, patients, and caregivers. The 
organization was formed in 2006 to raise awareness about the importance 
of transitions in improving health care quality, reducing medication 
errors and enhancing clinical outcomes among health care professionals, 
government leaders, patients and family caregivers. NTOCC members have 
created a number of useful tools and resources that all participants in 
health care can use to improve patient safety and decrease errors 
associated with poor transitions.
    In the U.S. health and long-term care system, patients--
particularly the elderly and individuals with chronic illnesses--
experience transitions in their care, meaning that they leave one care 
setting (i.e. hospital, nursing facility, assisted living facility, 
primary care physician care, home health care, or specialist care), and 
move to another. The U.S. health care system often fails to meet the 
needs of patients during transitions because care is rushed and 
responsibility is fragmented, with little communication across care 
settings and multiple providers.
    Some key facts about transitions of care:

     Among hospitalized patients 65 or older, 21 percent are 
discharged to a long term care or other institution.\1\
---------------------------------------------------------------------------
    \1\ ``Hospitalization in the United States, 2002,'' Agency for 
Healthcare Research and Quality, 2002. /www.ahrq.gov/data/hcup/
factbk6/factbk6a.htm#howdischarged>.
---------------------------------------------------------------------------
     Approximately 25 percent of Medicare skilled nursing 
facility (SNF) residents are readmitted to the hospital.\2\
---------------------------------------------------------------------------
    \2\ Medicare Payment Advisory Commission, ``Report to the Congress: 
Increasing the Value of Medicare,'' June 2006.
---------------------------------------------------------------------------
     Individuals with chronic conditions--a number expected to 
reach 125 million in the United States by 2020--may see up to 16 
physicians in 1 year.\3\
---------------------------------------------------------------------------
    \3\ Bodenheimer, T, ``Coordinating Care--a perilous journey through 
the health system,'' New England Journal of Medicine, 2008; 
358(10):1064-71.
---------------------------------------------------------------------------
     Between 41.9 and 70 percent of Medicare patients admitted 
to the hospital for care in 2003 received services from an average of 
10 or more physicians during their stay.\4\
---------------------------------------------------------------------------
    \4\ Fisher, E, ``Performance, Measurement: Achieving Accountability 
for Quality and Costs,'' Quality Forum Annual Conference on Health 
Policy, October 2006.
---------------------------------------------------------------------------
    A recent survey by the Agency for Healthcare Research and Quality 
(AHRQ) on Patient Safety Culture, found that 42 percent of the 
hospitals surveyed reported that ``things fall between the cracks when 
transferring patients from one unit to another'' and ``problems often 
occur in the exchange of information across hospital units.'' \5\ Poor 
communication during transitions from one care setting to another can 
lead to confusion about the patient's condition and appropriate care, 
duplicative tests, inconsistent patient monitoring, medication errors, 
delays in diagnosis and lack of follow through on referrals. These 
failures create serious patient safety, quality of care, and health 
outcome concerns. Furthermore, they place significant financial burdens 
on patients and the U.S. health care system as a whole. All of these 
variables contribute to patient and family caregivers' dissatisfaction 
with the U.S. health care system.
---------------------------------------------------------------------------
    \5\ ``Hospital Survey on Patient Safety Culture: 2007 Comparative 
Database Report,'' Agency for Healthcare Research and Quality, 
2007,/www.ahrq.gov/qual/hospsurveydb/>.
---------------------------------------------------------------------------
    We need only to look at the high prevalence of hospital re-
admissions and medical errors to see the inadequacies of care 
transitions and their adverse economic implications to the U.S. health 
care system:

     Medication errors harm an estimated 1.5 million people 
each year in the United States, costing the Nation at least $3.5 
billion annually.\6\ An estimated 66 percent of medication errors occur 
during transitions: upon admission, transfer or discharge of a 
patient.\7\
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    \6\ Harris, G, ``Report Finds a Heavy Toll from Medication 
Errors,'' New York Times, 21 July 2006 .
    \7\ Santell, J., ``Catching Medication Errors at Admission, 
Transfer and Discharge,'' United States Pharmacopia.
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     One study found that, on discharge from the hospital, 30 
percent of patients have at least one medication discrepancy.\8\
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    \8\ Kwan, Y, Fernandes, OA, Nagge, JJ, et al., ``Pharmacist 
medication assessments in a surgical preadmission clinic,'' Arch Intern 
Med, 2007;167:1034-40.
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     According to another study, one in five U.S. patients 
discharged to their home from the hospital experienced an adverse event 
within 3 weeks of discharge. Sixty percent were medication related and 
could have been avoided.\9\
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    \9\ Forester, AJ, Murff, HJ, Peterson, JF, et al., ``The incidence 
and severity of adverse events affecting patients after discharge from 
the hospital,'' Annals of Internal Medicine, 2003:138(3):161-7.
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     On average, 19.6 percent of Medicare fee-for-service 
beneficiaries who have been discharged from the hospital were re-
admitted within 30 days and 34 percent were re-admitted within 90 
days.\10\ According to MEDPAC, hospital re-admissions within 30 days 
accounted for $15 billion of Medicare spending.\11\
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    \10\ Jencks, Stephen F, Williams, Mark V, Coleman, Eric A, 
``Rehospitilizations among Patients in the Medicare Fee for Service 
Program,'' New England Journal of Medicine, 2 Apr 2009;360:1418-28.
    \11\ Medicare Payment Advisory Commission, ``Report to Congress: 
Promoting Greater Efficiency in Medicare,'' June 2007, Chapter 5.

    NTOCC's health care experts have developed a number of tools and 
resources for professionals and policymakers to ensure safe transitions 
of care. These include resources to: help patients and family 
caregivers navigate transitions; assist health care professionals in 
implementing and evaluating effective transitions of care plans; and 
aid policymakers in assessing and measuring transitions of care 
outcomes.
    There are a number of models of care that have demonstrated that 
effective and coordinated care transitions lead to improvements in 
overall health care quality, and results in savings to patients and the 
health care system. Each model brings a set of interventions, tools, 
and resources that help to address the issues of communication, 
transfer of patient information, accountability for sending and 
receiving information and improving quality of care. To assist medical 
providers, NTOCC recently released a Compendium of Evidence-Based Care 
Transition Interventions which provides a user-friendly centralized 
resource for providers to have access to all currently available 
evidence-based interventions and tools. A companion resource to the 
compendium ``Care Transition Bundle: Seven Essential Intervention 
Categories'' is also available which highlights the essential care 
transition interventions identified from a cross-walk of the various 
models of care. We believe this resource will be useful as this 
committee and the Administration look to improve health care quality 
and safety.
    In recognition of the value of proper transitions in leading to 
improved care and the social and economic costs of poor transitions, 
the Patient Protection and Affordable Care Act included several 
initiatives specifically designed to address gaps in care that occur 
between and among health care settings. NTOCC is particularly 
supportive of the Health and Human Services (HHS) recently announced 
``Partnership for Patients'' which identifies effective care 
transitions as a key component of improving the quality, safety, and 
affordability of health care for all Americans. As part of this 
initiative, CMS announced the Community-based Care Transitions Program 
(CCTP) which was created by the Affordable Care Act and will provide 
$500 million to eligible community-based organizations and acute care 
hospitals for care transition services for high-risk Medicare 
beneficiaries. NTOCC strongly supports the CCTP program and urges 
Congress to continue to support this important program.
    Finally, as new policies and programs emerge that seek to improve 
care transitions, NTOCC believes the following considerations should be 
taken into account to achieve successful transitions of care:

     Improve communication during transitions between 
providers, patients and family caregivers;
     Implement electronic health records that include 
standardized medication reconciliation elements;
     Expand the role of pharmacists in transitions of care in 
respect to medication reconciliation;
     Establish points of accountability for sending and 
receiving care, particularly for hospitalists, SNFists, primary care 
physicians and specialists;
     Increase the use of case management and professional care 
coordination;
     Implement payment systems that align incentives; and
     Develop performance measures to encourage better 
transitions of care.

    The National Transitions of Care Coalition appreciates the 
opportunity to submit a statement for the record and looks forward to 
working with the committee to health care quality and patient safety.
     Prepared Statement of The Roundtable on Critical Care Policy, 
          Submitted by Stephanie Silverman, Executive Director
    Chairman Harkin and Ranking Member Enzi and other members of the 
committee, we thank you for holding this important hearing and 
appreciate the opportunity to submit a statement for the record.
    Established in 2009, the Roundtable on Critical Care Policy is a 
nonprofit organization that provides a forum for leaders in critical 
care and public health to advance a common Federal policy agenda 
designed to improve the quality, delivery and efficiency of critical 
care in the United States. The Roundtable brings together a broad 
cross-section of stakeholders, including the Nation's leading medical 
professionals with specialized training in critical care, patient 
groups, academia, public health advocacy and industry.
    The Roundtable is supportive of the Department of Health and Human 
Services' (HHS) Partnership for Patients, the public-private 
partnership that aims to make hospital care safer, more reliable, and 
less costly. As the committee moves forward with overseeing the 
implementation of programs authorized by the Patient Protection and 
Affordable Care Act (PPACA) and develops additional policies to improve 
health quality and safety, the Roundtable encourages the committee to 
ensure that policies to improve the care for the critically ill and 
injured are made a priority.
    Each year, over 5 million Americans are admitted into traditional, 
surgical, pediatric, or neo-natal intensive care units (ICUs).\1\ The 
ICU is one of the most costly areas in the hospital, representing 13 
percent of all hospital costs, with the total costs of critical care 
services in the United States exceeding $80 billion annually.\2\ 
Additionally, almost one-fourth of total Medicare spending occurs in 
the last year of life, when critical care is most often utilized. 
Providers of critical care require specialized training, the care 
delivered in the ICU is technology-intensive, treatment is unusually 
complex due to what may be a patient's system--or multiple system--
challenges or failures, and outcomes have life or death consequences. 
Approximately 540,000 individuals die each year after admission to the 
ICU, and almost 20 percent of all deaths in the United States occur 
during a hospitalization that involves care in the ICU.\3\
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    \1\ Society of Critical Care Medicine. Critical care statistics in 
the United States. http://www.sccm.org/AboutSCCM/Public%20Relations/
Pages/Statistics.aspx.
    \2\ Halpern NA, Pastores SM. ``Critical Care Medicine in the United 
States 2000-05: An analysis of bed number, occupancy rates, payer mix 
and costs,'' Critical Care Medicine 37 no. 1 (2010).
    \3\ Angus DC, Barnato AE, Linde-Zwirble WT, et al. ``Use of 
Intensive care at the end of life in the United States: an 
epidemiologic study,'' Critical Care Medicine 32 (2004).
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    The Roundtable appreciates Agency for Health Research and Quality 
(AHRQ) Director, Dr. Carolyn Clancy highlighting the Keystone Project, 
an ICU quality improvement initiative funded by AHRQ to reduce central 
line-associated bloodstream infections in hospital ICUs. As Dr. Clancy 
testified, this quality improvement program resulted in at least a 45 
percent reduction in these infections in less than 18 months, 
decreasing an elderly person's likelihood of dying while hospitalized 
by 24 percent.\4\
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    \4\ Agency for Health Care Research and Quality, ``Landmark 
Initiative to Reduce Healthcare--Associated Infections Cuts Death Among 
Medicare Patients in Michigan Intensive Care Units,'' January 31, 2011 
www.ahrq.gov/news/press/pr2011.
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    Recently, Health Affairs highlighted findings by Drs. Peter 
Pronovost and Eric Vohr showing that an estimated 85,000 errors occur 
each day in ICUs, and, ``of these, 24,650--which include bloodstream 
infections associated with central line catheters, pneumonia associated 
with ventilators, and infections at surgical sites--are potentially 
life-threatening and costly complications of care. They are also 
preventable.'' \5\ The critical care community is committed to 
improving the quality of care delivered in the ICU, and the Roundtable 
urges the Administration and Congress to continue to support 
initiatives like the Keystone Project that test and disseminate quality 
improvement programs for care of the critically ill and injured, 
particularly as they target funding and program support for reducing 
preventable medical errors and hospital-acquired infections.
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    \5\ Moore, Juliane, ``Dispatches From the Front Line of the Patient 
Safety Movement (Book Review).'' Health Affairs, December 2010 Vol. 29 
No. 12.
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    Another challenge facing critical care medicine is the notable 
absence of research on the availability, appropriateness and 
effectiveness of a wide array of medical treatments and modalities for 
the critically ill or injured. At present, many of the current, high-
cost treatments delivered in the ICU lack comparative effectiveness 
data. And in 2009 when the Institute of Medicine released its mandated 
report recommending 100 topics to be given priority for comparative 
effectiveness research funding, few of these topics related to critical 
care. Moreover, current Federal research efforts are partitioned and 
scattered across the government and throughout that National Institutes 
of Health's (NIH) 27 institutes, making it difficult to coordinate 
existing research and identify gaps.
    Lastly, multiple studies have documented that the demands on the 
critical care workforce--including doctors, nurses and respiratory 
therapists, among others--are outpacing the supply of qualified 
critical care practitioners. A 2006 study by the Health Resources & 
Services Administration found that the current demand for 
intensivists--physicians with special training in critical care--will 
continue to exceed the available supply due largely to the growing 
elderly population, as individuals over the age of 65 consume a large 
percentage of critical care services.\6\ Studies by patient safety 
organizations such as the Leapfrog Group have found that intensivist-
led ICU teams have been ``shown to reduce the risk of patients dying in 
the ICU by 40 percent.'' \7\ The current and projected critical care 
workforce shortages pose significant patient safety concerns.
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    \6\ Health Resources and Services Administration Report to 
Congress: The Critical Care Workforce: A Study of the Supply and Demand 
for Critical Care Physicians. Requested by: Senate Report 108-81. 
Available at: http://bhpr.hrsa.gov/healthworkforce/reports/
criticalcare/default.htm. Accessed November 2010.
    \7\ The Leapfrog Group. Fact Sheet. http://www.leapfroggroup.org/
about_us/leapfrog-factsheet.
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    While PPACA included several initiatives to expand the health care 
workforce, they were largely focused on expanding primary care. 
However, a solution cannot be reached solely by adding to the 
workforce--we must also find ways to improve the efficiency of the 
existing workforce. That is why the Roundtable enthusiastically 
supports a provision included in PPACA that prioritizes within the 
newly-established Centers for Medicare and Medicaid Innovation the 
testing of models that make use of electronic monitoring--specifically 
by intensivists and critical care specialists--to improve inpatient 
care.
    A failure to address the challenges facing the critical care 
delivery system could jeopardize patient safety and do little to bend 
the cost curve on rising health care costs. The Roundtable strongly 
believes that as the Administration moves forward with the Partnership 
for Patients and other delivery reforms authorized by PPACA, 
initiatives aimed to improve the care for the critically ill and 
injured should be made a priority.
    Additionally, as the committee seeks to address these issues in the 
future, we hope that you will consider some of the provisions included 
in the ``Critical Care Assessment and Improvement Act of 2011'' (H.R. 
971) that was introduced by Representatives Tammy Baldwin (D-WI) and 
Erik Paulsen (R-MN). The legislation would authorize a much-needed 
assessment of the current state of the critical care delivery system, 
including its capacity, capabilities, and economic impact. The bill 
would also establish a Critical Care Coordinating Council within NIH to 
coordinate the collection and analysis of information on current 
critical care research, identify gaps in such research, and strengthen 
partnerships. And lastly, the bill would authorize a number of 
initiatives to bolster Federal disaster preparedness efforts to care 
for the critically ill or injured.
    The Roundtable on Critical Care Policy appreciates the opportunity 
to submit a statement for the record, and looks forward to working with 
the committee to improve health care quality and patient safety.

    [Whereupon, at 11:55 a.m., the hearing was adjourned.]

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