New York City Comptroller William C. Thompson Jr. testified today at a joint hearing by the New York State Assembly and Senate Committees on Health regarding patient safety and the New York Patient Occurrence and Tracking System (NYPORTS).

In March, Thompson released a comprehensive investigation of hospitals’ NYPORTS underreporting, titled The High Costs of Weak Compliance with the New York State Hospital Adverse Event Reporting and Tracking System. To read the full report, visit www.comptroller.nyc.gov.

Comptroller Thompson’s Testimony:

Good morning Senator Duane, Assembly Member Gottfried, and members of the committees.
Thank you for the opportunity to speak today.

A decade ago, a groundbreaking report by the Institute of Medicine of the National Academies concluded that hospital medical errors were responsible for as many as 98,000 deaths in the United States annually.  These errors were associated with $29 billion in extra costs.  

In New York, NYPORTS -- the New York State Patient Occurrence Reporting and Tracking System – is the most important tool government has for reducing the number of hospital medical errors and other adverse occurrences.   Through NYPORTS, hospitals are required by law to report specified categories of medical adverse occurrences to the State Department of Health.   The Department would analyze this data and use it to identify patient safety and quality issues at individual hospitals, which could lead to Department intervention, and to prepare studies with risk reduction strategies for distribution to hospitals.   
The Health Department has emphasized that accurate and complete reporting of adverse occurrences is essential if NYPORTS is to accomplish its goal of improving quality of care and avoiding needless costs.   Without full reporting hospitals lose a very important tool for identifying areas where systemic improvement may be needed and for comparing their performance against their peers. 

However, a study released this March by my office, The High Costs of Weak Compliance with the New York State Hospital Adverse Event Reporting and Tracking System, found that underreporting is widespread. 

We analyzed the numbers of reports hospitals submitted to the Health Department for adverse occurrences that occurred in 2004, 2005, 2006 and 2007.  The reporting data was broken out by hospital and reporting category.

We found enormous reporting disparities that can only be explained by systematic underreporting of adverse occurrences.

First, we found that that New York City hospitals reported adverse occurrences at a rate approximately 40 percent lower than hospitals elsewhere in the state.   This finding echoed the Health Department’s own finding in 2001 that there were large regional disparities in occurrence reporting rates, with New York City hospitals reporting adverse occurrences at a lower rate than elsewhere.  The Department concluded that this was due primarily to underreporting.  

Second, we discovered enormous, inexplicable reporting rate disparities among individual hospitals.  For example, measured in occurrences per 10,000 discharges, one of the smaller New York City hospitals reported occurrences at a rate 18 times higher than another similarly sized hospital in the same borough.  One academic medical center located outside of the city reported occurrences at a rate eight times higher than a similarly sized academic New York City academic medical center.  Some hospitals reported hundreds of adverse occurrences while other similarly sized hospitals only several dozen.  

Third, we observed enormous disparities among hospitals in many of the individual reporting categories.  For example, some hospitals reported “acute pulmonary embolism” at rates 30 times other comparable hospitals.   

When we asked Health Department staff why there were such large disparities among comparable hospitals, we were told, “Some hospitals are better reporters than others.”  We were assured that a hospital with a high reporting rate was not necessarily a bad hospital, “it was just a good reporter.”   Indeed, we identified one particular New York City academic medical center that had high reporting rates in multiple reporting categories.   This hospital has been regularly listed among the nation’s “best” in the annual U.S. News & World Report hospital rankings.

We also discovered that medication errors were virtually never reported.  Hospitals are required to report medication errors that result in death, a “near-death event” or “permanent patient harm.”  A major study by the Institute of Medicine concluded that 7,000 hospital patients die from medication errors in the U.S. every year and many times as many are injured.  Yet from 2004 to 2007 there were only 37 medication errors reports by all New York City hospitals.   Twenty-two New York City hospitals did not report any medication errors during this period.   I find that incredible. 

Our study concluded that underreporting is tacitly sanctioned by weak enforcement of the reporting law.   The Department has exhibited little appetite for enforcing reporting requirements, despite the former Commissioner’s warning in 2001 to underreporting hospitals, “We will identify you, single you out and sanction you in a public forum.”

According to a Health Department response to our query, in 2008 only a “handful” of citations resulted from identification by the Department of unreported occurrences.   And a citation merely leads to a requirement for a hospital to submit a Plan of Correction.  Only if the Plan of Correction is inadequate might a fine be imposed.   And the actual fines are low.

An absence of commitment by the Department to NYPORTS was evidenced in 2005, when the Department discontinued 22 of the then-54 reporting categories.   And it is telling that the Department has not issued a NYPORTS annual report since the report covering 2002 to 2004.   In mid-2008 we were told that the Department was working on an update, but it still has not been issued.

NYPORTS reporting compliance is important not only because adverse occurrences harm patients, they also result in higher costs through longer hospital stays and additional medical treatment.   The excess cost when a patient develops “new deep vein thrombosis,” for example, has been estimated at more than $10,000.   New York City taxpayers pick up some of these excess costs through Medicaid and government employee health plans.   There are also higher medical hospital malpractice insurance premiums and lawsuit payouts.

The high reporting rates by some hospitals -- they range from several small community hospitals to a few of the state’s major academic medical centers -- demonstrate that full reporting is indeed feasible.   In our discussions with executives of several of these hospitals, we learned that they had created a “culture” of full reporting and their staffs were extensively trained in NYPORTS reporting.   These hospitals understand that even a small reduction in adverse occurrences can avoid substantial excess costs.

I urge the Department to take NYPORTS seriously.   The Health Department should have a separate NYPORTS unit, with its own staff.   Medical audits and retrospective chart reviews to check for non-reporting should be implemented, focusing on hospitals that have had abnormally low reporting rates and on the most problematic reporting categories.   There should be timely feedback to hospitals of comparative occurrence data.  Penalties for non-reporting should be increased.   In 2001 the Department said it would ask the State Legislature to increase the fine for an initial violation from $2,000 to $6,000 and for a top fine of $60,000.   Fines were recently increased but still stand at only $2,000 for an initial violation and a maximum of only $10,000 if “serious physical harm” resulted.

Full reporting is essential for NYPORTS to work as intended and to be of practical benefit.  I understand that the State fiscal crisis severely constrains any new spending.  But it has been well documented that reducing adverse occurrences in hospitals saves money. 

In the first few years after NYPORTS was established, the Department did take the system more seriously.   It analyzed reporting data and published the periodic NYPORTS Alert focusing on selected reporting categories and providing useful risk-reduction strategies.   Hospitals reported that through NYPORTS they had discovered and remedied deficiencies.   The initial promise of NYPORTS must be redeemed.

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