2016 Federal Employee of the Year

Paul McGann, Jean D. Moody-Williams and Dennis Wagner

Reduced preventable patient harm in U.S. hospitals, which resulted in an estimated 2.1 million fewer medical errors and saved nearly 87,000 lives and $20 billion.

Each year, it’s estimated that tens of thousands of people die in hospitals as a result of medical errors and avoidable infections. These preventable events not only result in the tragic loss of life, but cost the nation’s hospitals billions of dollars annually and lead to patients losing trust in the health care system.

Seeing this huge number of patients harmed year after year, Dr. Paul McGann, Jean Moody-Williams and Dennis Wagner created a unique public-private sector initiative at the Centers for Medicare and Medicaid Services to increase patient safety and reduce readmissions to U.S. hospitals.

The results have been extraordinary.

“There has been an unprecedented 39 percent reduction in preventable patient harm in U.S. hospitals compared to the 2010 baseline. Their performance has resulted in 2.1 million fewer patients harmed, 87,000 lives saved and nearly $20 billion in cost-savings,” said Patrick Conway, CMS acting principal deputy administrator and chief medical officer.

“I have been working in the field of quality improvement in and out of government for 20 years, and I have never seen this level of results,” Conway added.

To make hospital care safer, more reliable and less costly, McGann and Wagner recognized they would need to create a national collaborative of diverse public-private sector partners, including physicians, nurses, hospitals, employers, patients and their advocates. 

Launched in 2011, the Partnership for Patients initiative had two goals: decrease preventable hospital-acquired conditions by 40 percent and decrease hospital readmissions by 20 percent. To track the success of this effort, McGann and Wagner used as a starting point the estimate of deaths and excess health care costs established by the Agency for Healthcare Research and Quality in 2010.

The Partnership for Patients identified nine hospital-acquired conditions that were responsible for more than 50 percent of all needless injuries and deaths. These conditions included adverse drug events, catheter-associated urinary-tract infections, pressure ulcers and surgical-site infections, among others.

Prior to the initiative, hospital-acquired conditions were hard to measure and interventions typically focused on only one preventable harm at a time, such as reducing falls. The initiative “brought disparate pieces into one measurement for the first time,” McGann said. “We had to think of patient safety as a single hospital system issue.”

“These front-line caregivers got into the health care business because they want to give good care,” Wagner said. “A big part of our work is unleashing their talent, helping them to transform their own work and helping institutions provide the care that they want to deliver.”

The four-year effort involved 3,700 hospitals, representing 80 percent of the U.S. population. To help them make progress, McGann and Wagner identified high-performing hospitals and shared with other participants how they were able to achieve a dramatic reduction in a specific harm, such as medication errors.

“This was our special sauce,” McGann said.

For the first time, the views of the patients and families also were integrated into all aspects of the initiative.

“Dennis and Paul put a structure in place that engaged people to make them feel like they were part of a movement. You would go the Partnership for Patient meetings, and it felt like a revival,” said Kate Goodrich, director of the Center for Clinical Standards and Quality at CMS.

“Hospitals were not hearing from the government, but from each other on how to improve, and for the first time ever, this actually happened at national scale across multiple issues affecting patient safety,” Goodrich said.”

To achieve the goal of reducing hospital readmissions by 20 percent, McGann and Wagner turned to Moody-Williams, who led the Quality Improvement Organization program, one of the largest federal initiatives dedicated to improving health quality for Medicare beneficiaries.

Moody-Williams implemented solutions to improve care for patients as they transition from one health care provider or setting to another. This required collaboration and communication among patients, health-care providers, hospitals, nursing homes, patient caregivers and social service providers to share both good and poor results.

“You are asking health care systems and hospitals, which are normally competitors, to share vulnerabilities,” Moody-Williams said. “It took a lot of work for them to share where they were struggling.”

Goodrich credits McGann, Moody-Williams and Wagner for changing the culture at the majority of the nation’s hospitals.

“We have proven that these patient harms don’t have to occur,” she said. “It’s truly transformative work for the country.”