Second of a two-part series.
By Emily Paulsen

Last week, we brought you Part I of this two-part series on the recent discussion we had with Lucian Leape, MD, a leader in the national patient safety movement. Currently, he is a health policy professor at Harvard School of Public Health, and chair of the Lucian Leape Institute, part of the National Patient Safety Foundation.

Hospital Impact: Why haven't we made more progress on the patient safety front? Is it just because culture change is so hard or is there another impediment?

Lucian Leape: There's no question that we're moving up hill in terms of the culture, but, in addition to that, the whole financing of healthcare works against us.

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The current fee-for-service system provides not only strong incentives for doing things that are beyond what is necessary, but it has a perverse effect of reducing compensation for good care. The classic example is the care of a patient with asthma. The great breakthrough in asthma care was to teach patients to take care of themselves and provide them with equipment, instruction and support. So now, patients with asthma check their breathing frequently and adjust their own medication accordingly. This prevents complications, and patients stay out of the hospital and the doctor's office. And the doctor and the hospital both lose money.

The same consideration applies to safety: Reducing unnecessary care reduces exposure to hazardous care and reduces the number of things that can go wrong. But the hospital and the physician lose money. There's something wrong about a system like that.

In addition, we've learned, from the very important work in preventing infections, that the whole concept of teamwork is absolutely crucial to safety. But the current financing doesn't pay for team care, it pays for individual care. The best way to take care of diabetes is with a team, but the current financing system doesn't pay teams. It pays for doctor's visits or specific medicines and so forth. Certainly if a healthcare organization got a fixed amount for taking care of a population of people they would get more interested in reducing the waste that goes with complications that we know are preventable.

H.I.: What are some of the other challenges to patient safety in today's healthcare system?

Leape: As someone said, we're trying to fasten a 21st century jetliner on top of a horse and buggy. So much of health practice in America is structured around individual doctor-patient visits. Forty percent of doctors are in practices of one to three people. We have had the same model that we've had for 100 years, and it clearly isn't working.

Most of solo and small-practice physicians are grossly overworked, and it's much more difficult for them to keep up and change their practices and incorporate new methods. They don't have a lot of support. It's harder for them, for example, to put in an electronic medical record system or to field a full team of ancillary personnel and support systems.

Physicians in small practices also have very limited feedback; you only have one to three colleagues looking at what you're doing and reviewing it and thinking about it. Much of what we're talking about is learning from others, and that's hard to do when there aren't many others. And so one of the questions is how do we make small groups part of bigger groups so they have the benefits of learning from one another?

H.I.: What are the alternatives?

Leape: What we're really talking about is re-adjusting our healthcare system to provide different levels of sophistication of care according to the need of the individual patient. Most of the time patients don't need complicated care, but they certainly need effective, efficient, correct care.

For example, most babies can be safely delivered by a nurse-midwife, but you have to have a system [in place] so that whenever a problem does come up there's a doctor right on the site at the time. Working all that out is where the challenge is.

One of the big appeals of accountable care systems or the medical home model is that it's not just the doctor but a healthcare team that looks after the patient. Most of a patient's healthcare needs do not require a physician. They require assistance in terms of monitoring diabetes, anticoagulants, referrals to physical therapy. All of these things don't necessarily require a physician. You can have a team that does it. If doctors have a lot more help, they can see patients less often. When they do see them, [they can] spend more time with them. That's more satisfying to everybody.

So I think it's going to be a very interesting time of transition in the next five to ten years as we move to more modern ways of giving care. The challenge is to not interfere with the critical aspects of the doctor-patient relationship of trust and personal involvement.

Emily Paulsen is a freelance journalist who specializes in writing about the business and operational aspects of healthcare.

Note: You can read the first part of our interview here.