Patient Safety in the World of Value Based Healthcare (Part One)

In 1999, the Institute of Medicine released its eye opening and controversial report which surmised that anywhere between 44,000 and 98,000 patients die each year in hospitals as a result of medical errors. More recently, Johns Hopkins analyzed medical death rate data over an eight-year period and assessed that more than 250,000 deaths per year are due to medical errors in the U.S. alone, exceeding the estimated 150,000 deaths yearly reported by the U. S. Centers for Disease Control and Prevention. Published May 3, 2016 in the British Medical Journal, this significant figure exceeds the CDC third leading cause of death—respiratory disease, surpassed only by cardiovascular and cancer which are first and second respectively.

A closer examination of the factors in both the iconic IOM and Johns Hopkins analyzes show the most common root cause of medical errors stem from:

  1. Communication problems
  2. Inadequate information flow
  3. Human problems
  4. Patient-related issues
  5. Organizational transfer of knowledge
  6. Staffing patterns/work flow
  7. Technical failures
  8. Inadequate policies and procedures

Poor or lack of communication represents the most common cause of medical errors and can lead to varying type of errors involving all members of a health care team. Verbal and written communication failures vary but generally include miscommunication within a provider’s office, providers changing shifts, and outside the provider’s clinic within the different components of the health care system. The lack of available pertinent healthcare information for decision making, coupled with inadequate coordination during the transfer of care will lead to medical errors. Insufficient and ineffective work flow processes can cause errors especially when the patient process of care is disrupted due to poor documentation and clinical procedures.

Arguably, the errors stemming from communications, information, and workflow faults can potentially be addressed through the Centers for Medicare and Medicaid Services (CMS) in its final October 2016 ruling through the Quality Payment Program (QPP). Providers can choose one of two tracks; Merit Based Incentive Payment System (MIPS) or Alternative Payment Model (APM).  Since a vast majority of physicians (surveyed 90%) will select the MIPs track, I will focus on the MIPs categories and activities which can help prevent the errors cited by the aforementioned studies. For 2017, CMS will assess three categories: Quality, which replaces the Physician Quality Reporting System; Advancing Care Information, which replaces EHR incentive program aka Meaningful Use; and a new category, Improvement Activities. Providers can earn a performance-based incentive payment adjustment to their annual Medicare payment or a non-participation penalty as high as 9% by year 2022.

For the Quality category, there exist 271 measures across 30 specialties. Sixty percent of the performance bonuses are tied to this category for reporting year 2017. These measures are divided into six domains produced by The National Quality Strategy led by the Agency for Healthcare Research and Quality on behalf of the U.S. Department of Health and Human Services which was established as part of the Affordable Care Act to focus on quality improvement and measurement. The six NQS domains are:

1.     Patient and Family Engagement

2.     Patient Safety

3.     Care Coordination

4.     Population/Public Health

5.     Efficient Use of Healthcare Resources

6.     Clinical Process/Effectiveness

Conducting a search of Quality measures at the URL, you will find 137 measures with the NQS Domain Effective Clinical Care, another 45 on Patient Safety and another 44 measures on Care Coordination. Adherence to these three domains will significantly aid in preventing clinical errors caused by ineffective communications, patient non-adherence to medications/therapies, lack of patient risk assessments, reducing patients exposure to ionized radiation either diagnostically or therapeutically, etc.

The Advancing Care Information category is designed to ensure meaningful use of EHRs and is 25% of the bonus potential for reporting year 2017. There are two measure set options for reporting in 2017 based on a provider’s electronic health record edition:

1.     Advancing Care Information Objectives and Measures

2.     2017 Advancing Care Information Transition Objectives and Measures

The option measures can be found in the following URL Similar to the Quality category, there are measures that are designed to enhance communications among attending physicians, referring physicians, and patients. This would theoretically enhance patient experiences and outcomes while reducing medical errors gaging e-Prescribing, Patient Access, Send Summary of Care, Health Information Exchange, Medication Reconciliation, and Immunization Public Health and Clinical Registry Reporting. Although there are studies that suggest EHRs do reduce medical errors, there are some concerns raised by the Centers for Disease Control and Prevention for outdated software and inoperability of systems that will need to be addressed. Nonetheless, EHRs are building more confidence as communications and error reduction tools are used by providers more each day.

The third MIPS performance category is Improvement Activities where physicians choose up to four improvement activities from a list of 92 options representing eight subcategories which can be found at  This category will represent 15% of the reward potential for physicians whose care focuses on the following subcategories:

1.     Achieving Health Equity

2.     Behavioral and Mental Health

3.     Beneficiary Engagement

4.     Care Coordination

5.     Emergency Response & Preparedness

6.     Expanded Practice Access

7.     Patient Safety & Practice Assessment

8.     Population Management

Of the eight subcategories, three (Beneficiary Engagement, Care Coordination and Patient Safety) provide for 58 activities that are designed to enhance the patient experience and safeguard their wellbeing. Providers can select activities such as Care Coordination Agreements, Administration of the Agency for Healthcare Research and Quality (AHRQ) Survey of Patient Safety Culture, Care Transitions, Prescription Drug Monitoring, Documentation for Process Improvements, etc. Clearly in designing the MIPs categories, CMS was determined to enhance the patient experience and outcome while reducing medical errors.

How Can Crux Quality Solutions Help Reduce Medical Errors Caused by the Lack of Communications and Care Coordination?

The Crux patient flow management system software FlowBoard™, can significantly assist providers improve care coordination, engagement, and safety, while enhancing patient experience. FlowBoard™, narrows the patient consult to treatment time, thus providing an anxious patient a quick, efficacious, and safe start. This results in a significantly enhanced patient experience because of its transparency and close coordination while creating robust, relevant reports that can be shared with referring physicians. One of the Improvement Activity subcategories, Care Coordination, CMS gives an example: “Care coordination encounter that tracks all clinical staff involved and communications from date patient is scheduled for outpatient procedure through day of procedure”. This is unquestionably FlowBoard™.

According to Crux Founder and Chief Development Officer, Dharanipathy Rangaraj, Ph.D. “making treatment process safe by mitigating potential errors arising from lack of communication, transparency, and accountability; improves communications between the care team coupled with making intelligent predictive decisions in real-time to improve quality, eliminate treatment delays and rework while efficiently utilizing resources. We were inspired to correcting manual and electronic systems which forced providers to scramble to get though the day and end up with less than desirable results. We decided to design a technology that focuses primarily on the above that is designed fundamentally different than the traditional systems that are currently in place with visual controls, predictive tools, flow analytics and human factor engineering coupled with technological innovation and artificial intelligence.”

For more information on Crux Quality Solutions products and services please click on the link below.

Link: Crux Quality Solutions


The Institute of Medicine, “To Err is Human Building a Safer Health System”, November 1999

British Medical Journal, “Medical error—the third leading cause of death in the US” BMJ 2016; 353 doi: (Published 03 May 2016)

Centers for Medicare and Medicaid Quality Payment Program:


Ed Mercado


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