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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 

( 

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

(1) 

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 
2 

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 num-
3 

ber 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. 
4 

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:] 
5 

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 readmissions 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 
6 

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 team-
7 

work 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 
8 

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 
9 

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 lMinutesl04l12l10lFinal.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 
10 

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 patientcentered, 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. 
11 

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. 
12 

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 readmissions 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. 
13 

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 
14 

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 
15 

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 Im- provement 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 
16 

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. 
17 

[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. 
18 

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. 
19 

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. 
20 

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. 
21 

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. 
22 

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 
23 

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? 
24 

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 worldrenowned 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 
25 

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 rath-
26 

er 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. 
27 

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. 
28 

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 readmission 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 evidencebased, 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 
29 

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. 
30 

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. 
31 

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 
32 

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. 
33 

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 
34 

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. 
35 

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 unreimbursed 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 
36 

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 
37 

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 
38 

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 
39 

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 
40 

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 nec-
41 

essarily 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. 
42 

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 tremen-
43 

dously. 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. 
44 

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.] 
45 

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 
46 

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. 2 Sachdeva AK, Blair PG. Educating surgery resident in patient safety. Surgical Clinics of 

North America 84 (2004) 1669–98. 

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. 

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. 

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. 
47 

1 ‘‘Hospitalization in the United States, 2002,’’ Agency for Healthcare Research and Quality, 

2002. <http://www.ahrq.gov/data/hcup/factbk6/factbk6a.htm#howdischarged>. 2Medicare Payment Advisory Commission, ‘‘Report to the Congress: Increasing the Value of 

Medicare,’’ June 2006. 3 Bodenheimer, T, ‘‘Coordinating Care—a perilous journey through the health system,’’ New 

England Journal of Medicine, 2008; 358(10):1064–71. 4Fisher, E, ‘‘Performance, Measurement: Achieving Accountability for Quality and Costs,’’ 

Quality Forum Annual Conference on Health Policy, October 2006. 

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

• Approximately 25 percent of Medicare skilled nursing facility (SNF) residents 

are readmitted to the hospital.2

• 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

• 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

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 an-
48 

5 ‘‘Hospital Survey on Patient Safety Culture: 2007 Comparative Database Report,’’ Agency for 

Healthcare Research and Quality, 2007,<http://www.ahrq.gov/qual/hospsurveydb/>. 6 Harris, G, ‘‘Report Finds a Heavy Toll from Medication Errors,’’ New York Times, 21 July 

2006 . 7Santell, J., ‘‘Catching Medication Errors at Admission, Transfer and Discharge,’’ United 

States Pharmacopia. 8Kwan, Y, Fernandes, OA, Nagge, JJ, et al., ‘‘Pharmacist medication assessments in a surgical preadmission clinic,’’ Arch Intern Med, 2007;167:1034–40. 9Forester, 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. 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. 11Medicare Payment Advisory Commission, ‘‘Report to Congress: Promoting Greater Efficiency 

in Medicare,’’ June 2007, Chapter 5. 

other’’ 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. 

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

• One study found that, on discharge from the hospital, 30 percent of patients 

have at least one medication discrepancy.8

• 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

• 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

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 
49 

1Society 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). 

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

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 pro-
50 

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. 5Moore, Juliane, ‘‘Dispatches From the Front Line of the Patient Safety Movement (Book Review).’’ Health Affairs, December 2010 Vol. 29 No. 12. 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. 7The Leapfrog Group. Fact Sheet. http://www.leapfroggroup.org/aboutlus/leapfrog-factsheet. 

gram 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

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. 

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. 

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 
51 

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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