The Financial and Human Cost of Medical Error … and how Massachusetts can lead the way on patient safety
If we set bold aims, leverage the extraordinary expertise we have within this state, and work on spreading and scaling the knowledge and tools that patient safety leaders have developed over the past 20 years, we will accelerate improvement.
Message from Barbara Fain, Executive Director, Betsy Lehman Center
Using health insurance claims data, we identified almost 62,000 preventable harm events at a cost of more than $617 million in a single year. A statewide survey of Massachusetts residents who reported recent experience with medical error found that not only do many patients and family members suffer persistent physical, emotional and financial impacts, but they also lose trust and avoid health care.
These findings make clear that Massachusetts faces the same patient safety challenges that persist across the country. They also point to a complex set of problems for which there are no easy fixes. But there is also reason for optimism that if we set bold aims, leverage the extraordinary expertise we have within this state, and work on spreading and scaling the knowledge and tools that patient safety leaders have developed over the past 20 years, we will accelerate improvement.
Nearly 100 people attended a lively panel discussion following release of the research findings. Panelists included Dr. Tejal Gandhi of the Institute for Healthcare Improvement, Kim Hollon of Signature Healthcare, Linda Kenney of the Betsy Lehman Center, Dr. Audra Meadows of Brigham and Women’s Hospital, and Mark Reynolds of CRICO. The panel discussed both the challenges and opportunities the state faces in trying to accelerate the pace of improvement in health care safety. Dr. Evan Benjamin of Ariadne Labs moderated the discussion.
To support the sustained, coordinated, multi-stakeholder response needed to accomplish these goals, we also announced the formation of a Massachusetts Health Care Safety and Quality Consortium. The Consortium’s nearly 20 members represent health care delivery, policy, patient, and other organizations. The group will produce a Roadmap to Patient Safety—a strategic framework and goals to guide statewide investment in improvement around four “pillars” of safety: transparency, leadership and culture, learning health systems, and support for patients and the health care workforce. The Consortium will kick off its work this summer.
There is no state better equipped than ours to improve patient safety. We look forward to collaborating with you to do just that.
Tejal K. Gandhi, MD, MPH
Co-Chair, National Steering Committee for Patient Safety and Chief Clinical & Safety Officer, Institute for Healthcare Improvement
Kim Hollon, FACHE President & CEO, Signature Health Care
Linda K. Kenney Director of Peer Support Programs, Betsy Lehman Center for Patient Safety
Audra R. Meadows, MD, MPH Co-Chair, Perinatal-Neonatal Quality Improvement Network and Director of Practice Quality and Innovation, Ambulatory Obstetrics Practice, Brigham & Women’s Hospital
Mark E. Reynolds President & CEO, CRICO
Moderator: Evan Benjamin, MD, MS, Chief Medical Officer, Ariadne Labs
Tejal K. Gandhi, MD, MPH
Dr. Tejal K. Gandhi is chief clinical and safety officer at the Institute for Healthcare Improvement and president of the IHI/NPSF Lucian Leape Institute.
She is a prominent advocate for patient safety at the regional, national and international levels, driving educational and professional certification efforts, and helping to create and spread innovative new safety ideas. Gandhi was formerly the executive director of quality and safety at Brigham and Women’s Hospital, and chief quality and safety officer at Partners Healthcare. In these roles, she led the efforts to standardize and implement patient safety best practices across hospital and health systems.
Throughout her career, Gandhi has been committed to educating other clinicians on the topic of patient safety. She is regularly invited to speak on this issue, has mentored physicians in post-doctoral study, and frequently served on regional and national committees and boards. She was included in Modern Healthcare’s 100 Most Influential People in Healthcare 2014-2015; Top 25 Women in Healthcare 2015; and 50 Most Influential Physician Executives and Leaders 2016.
Gandhi’s research interests focus on patient safety and reducing error using information systems. In 2009, she received the John M. Eisenberg Patient Safety and Quality Award for her contributions to understanding the epidemiology and possible prevention strategies for medical errors in the outpatient setting.
Gandhi is an internist and associate professor of medicine at Harvard Medical School, and she is a certified professional in patient safety. She received her Doctor of Medicine from Harvard Medical School and Master of Public Health from the Harvard School of Public Health, and trained at Duke University Medical Center. Her undergraduate training at Cornell University was in biochemistry.
Kim N. Hollon, FACHE
Kim Norton Hollon has been chief executive officer and president at Signature Healthcare Brockton Hospital since July 1, 2010. Signature is an integrated health system managing full population risk. The system has achieved stable profitability while reducing total medical expense while improving quality and safety through numerous innovative initiatives.
Prior to joining Signature Healthcare, Hollon served as the chief operating officer for the Excela Health System in Pennsylvania where he oversaw four hospital campuses and a workforce of 4,500.
Prior to Excela, he worked for 21 years with the Methodist Health System, in Dallas, serving as the president of Methodist Dallas Medical Center, and president of Methodist Charlton. He has over 30 years of experience in hospital administration.
Hollon has a bachelor's degree in Business Administration from University of Montevallo in Montevallo, Alabama, and a master's Degree in Hospital and Health Administration from the University of Alabama in Birmingham.
Linda K. Kenney
Linda K. Kenney is the director of peer support programs at the Betsy Lehman Center for Patient Safety.
As a result of a personal experience with a near fatal medical event 17 years ago, Kenney identified the need for support services in cases of adverse medical events and outlined an agenda for change. Since that time, she has been encouraging organizations to tackle the challenges that impair effective communication, apology, and support programs for patients, families, and clinicians following medical errors and unanticipated outcomes.
Kenney serves on the board of the Massachusetts Coalition for the Prevention of Medical Errors and Collaborative for Accountability and Improvement. She is also a member of Board of Advisors of Mass. Alliance for Communication and Resolution following Medical Errors and Accreditation Council for the Society for Simulation in Healthcare.
Audra R. Meadows, MD, MPH
Dr. Audra Meadows cares for women before, during and after pregnancy. She is a clinical faculty member of The Brigham and Women’s Hospital Department of Obstetrics and Gynecology and an instructor at Harvard Medical School. She received her Doctor of Medicine from the University of Texas Health Science Center at San Antonio and completed a chief residency in obstetrics and gynecology at The Brigham and Women’s Hospital. Prior to joining the faculty in 2008, Meadows received the Commonwealth Fund Harvard University Fellowship in Minority Health Policy at Harvard Medical School and obtained a Master of Public Health from the Harvard School of Public Health.
Meadows actively engages in clinical, public health and policy initiatives to prevent preterm birth and infant mortality. In addition to full-time clinical practice, she works to establish clinical and community-based, quality improvement intervention programs to improve birth outcomes and eliminate health disparities; and to sustain a high-performing system of perinatal care delivery across clinical practices in Boston. She has demonstrated this work in her roles as Massachusetts Perinatal Quality Collaborative (MPQC) Preterm Birth Prevention Committee chair, medical director of the BWH Birth Equity Initiative at the Center for Community Health and Health Equity, medical director for the Boston Public Health Commission’s Healthy Start Initiative and director of the BWH Group Prenatal Care Practice.
Meadows has received the BWH Obstetrics/Gynecology Foundation Fellowship, the BWH Minority Faculty Development Award and the BWH Nesson Fellowship for her work.
Mark E. Reynolds
Mark E. Reynolds is President and CEO of the Risk Management Foundation of the Harvard Medical Institutions Incorporated (CRICO). He has held this position since 2012. The CRICO insurance program serves all of the Harvard medical institutions and its affiliates, providing coverage to 26 hospitals, 13,500 physicians, more than 300 other health care organizations, and 100,000+ other clinicians and employees. Founded more than 40 years ago, CRICO has become is an international leader in patient safety, simulation and team training, and risk management through its dual mission to protect providers and promote safety.
Reynolds has more than 20 years of experience in the health care and insurance industries. Prior to CRICO, he was CEO of Neighborhood Health Plan of RI, where his outcome-driven approach resulted in it being rated among the nation’s top 10 Medicaid health plans. Throughout a career path involving complex governance, health care, and financial environments, he has exhibited a consistent commitment to excellence and service to the community. Reynolds was educated at Swarthmore College and MIT.
Evan Benjamin, MD, MS Moderator
Dr. Evan Benjamin is the chief medical officer at Ariadne Labs, a joint center of health care innovation at Harvard School of Public Health and Brigham & Women’s Hospital. As CMO he provides oversight, guidance, and support to Ariadne Labs research faculty, ensuring that Ariadne’s findings are supported by rigorous evidence and result in clinically meaningful change. Benjamin mentors faculty and research scientists and works with individuals to enhance the design and implementation of healthcare solutions. In addition, he works in close collaboration with Ariadne’s founder, Dr. Atul Gawande, to develop and expand Ariadne’s strategic partnerships, and to raise the Ariadne Labs profile as a global leader in health systems innovation.
Prior to becoming CMO at Ariadne Labs, Benjamin was senior vice president for population health and quality at Baystate Health, a $2 billion revenue integrated delivery system in Massachusetts, where he oversaw clinical quality, patient safety, population health, infection control, a 100-physician primary care practice, and information technology for the five-hospital system. He was responsible for bringing reliability and efficiency to the health system using modern tools of improvement science.
He is associate professor of medicine at Harvard Medical School with a secondary appointment at the Harvard T.H. Chan School of Public Health and is an adjunct professor of medicine at Tufts University. He is active in scholarly research in healthcare delivery and speaks and consults nationally on issues related to improving healthcare delivery. Benjamin is faculty for the Institute for Healthcare Improvement, where he teaches leadership and improvement. He sits on numerous national boards and healthcare panels including the National Academy of Medicine, the American Hospital Association, CMS and others. He currently serves as a board member for the UMass Memorial Health Care System.
Benjamin received a bachelor's degree in Chemistry from Williams College, a Doctor of Medicine from Case Western Reserve University, and a Master of Science in Healthcare Delivery Science from Dartmouth College. He completed an internal medicine residency at Yale-New Haven Hospital.