Response: Re: Reporting and Using Near-Miss Events to Improve Patient Safety in Diverse Primary Care Practices: A Collaborative Approach to Learning from Our Mistakes
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* Steven D. Crane
* Philip D. Sloane
* Nancy Elder
* Lauren Cohen
* Natascha Laughtenschlaeger
* Kathleen Walsh
* Sheryl Zimmerman

*To the Editor:* We appreciate the thoughtful letter from Dr. Auciello regarding our article “Reporting and Using Near-Miss Events to Improve Patient Safety in Diverse Primary Care Practice.”1 Dr. Auciello's primary concern is that “large monthly monetary rewards for a set quantity of reports is likely to cloud the intention of near-miss reporting: to reduce errors that could cause patient harm.” Specifically, he suggests that financial compensation to report near-miss events and performance improvement activities to a common database introduces potential bias to the quality of these reports, and may be unnecessary.

While we did compensate practices for costs related to participating in the collaborative, this reimbursement was by no means “large,” and probably under-represented the actual costs practices incurred from their involvement in the project. Each practice received $5000 to implement the project, which included a 90-minute orientation for key practice leaders (a physician champion and the practice manager, at a minimum), a 60-minute training for all staff, and installing the near-miss reporting icon on all desk top computers in the practice. Many practices incurred additional costs from legal counsel, risk management consultants, and information technology department staff who had to review the project and agree that the practice could participate. Once implemented, practices received an additional $1500 per month, for which they were expected to have their practice manager and physician champion participate in a monthly hour-long conference call, review near-miss reports, implement practice improvement projects resulting from the near-miss reports, and hold all-staff safety meetings once a month. Practices were not paid per near-miss report; rather, they received the monthly stipend only if they met the minimum participation criteria, which included at least 10 reports a month.

These payments were not large when considering the median practice volume was >2000 patient visits a month. Although we did not report the average monthly income for the participating practices, the monthly stipend would have represented <0.1% of gross income for the typical practice. This amount would be highly unlikely to provide a strong incentive to over-report.

Moreover, only 2 practices made any attempt to share even a portion of the monthly stipend with practice staff. In one case a practice provided lunch for the staff during their monthly safety/quality improvement meeting, and in the other a practice provided a drawing for a $25 gift card if the practice met its reporting goal. Given that the reports themselves were anonymous and staff did not receive any individual inducement to report near-miss events, there seems to be little incentive to over-report or otherwise bias the reporting process. Furthermore, we did not observe any difference between either the number or type of near-miss reports from those 2 practices and those from the other practices that did not provide any monetary or in-kind reward to staff.

Dr. Auciello suggests that for near-miss reporting, the “primary incentive should be to improve care,” and reports that his own practice has a “good catch” program as part of the internal performance improvement curriculum of his residency program. We commend him and his program for this but suggest that this is rare, even for residency programs, and is almost unheard of in primary care practices.

With respect to the larger issue of “pay for performance,” there is a growing movement among payers to provide substantial incentives for quality reporting and performance improvement, including the Centers for Medicare and Medicaid Services Physician Quality Reporting System2 and meaningful use incentives,3 as well as private payer incentive programs for quality.4 Physicians do indeed have a responsibility to care about the quality and safety of the care they provide to patients; despite this, however, medical errors continue to plague the medical care system.5

There are real costs associated with identifying and correcting near-miss events. Given that primary care is already undercapitalized and understaffed relative to hospitals, and that primary care physicians are undercompensated relative to specialty colleagues, who should bear these costs of practice improvement? Absent a market for consumers (patients) to have information regarding safer practices to reward those practices with greater volume and an enhanced payer mix, we believe that payers themselves would be well served by creating safety incentive payments for practices that engage in safety improvement programs, since safer care is undoubtedly less expensive over the long term. From this perspective, there should be considerably more incentive payments for safety improvement efforts rather than relying solely on the professionalism of overworked primary care physicians.

An advantage of a near-miss reporting and improvement collaborative such as our project is the opportunity to learn from each other and reduce the cost of innovation and improvement. If I can learn from your mistake I do not have to make that mistake myself; more important, working together we can build a safer primary care system for all our patients.

## References

1.  1.Crane S, Sloane PD, Cohen L, et al. Reporting and using near-miss events to improve patient safety in diverse primary care practice. J Am Board Fam Med 2015;23:452–60.
    
    

2.  2.Centers for Medicare & Medicaid Services. Medicare EHR incentive program physician quality reporting system and electronic prescribing incentive program comparison. May 2013. Available from: [https://www.cms.gov/regulations-and-guidance/legislation/ehrincentiveprograms/downloads/mln\_medicareehrprogram\_pqrs\_erxcomparison.pdf](https://www.cms.gov/regulations-and-guidance/legislation/ehrincentiveprograms/downloads/mln_medicareehrprogram_pqrs_erxcomparison.pdf). Accessed September 26, 2015.
    
    

3.  3.Centers for Medicare & Medicaid Services. Electronic health records (EHR) incentive programs. October 29, 2015. Available from: [https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms](https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms). Accessed September 26, 2015.
    
    

4.  4.Blue perspective. Value-based programs. Washington, DC: BlueCross BlueShield Association; 2014. Available from: [http://www.bcbs.com/healthcare-news/press-center/BP-and-Quality-and-Plan-Innovations.pdf](http://www.bcbs.com/healthcare-news/press-center/BP-and-Quality-and-Plan-Innovations.pdf). Accessed September 26, 2015.
    
    

5.  5.Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. March 2001. Available from: [https://iom.nationalacademies.org/∼/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf](https://iom.nationalacademies.org/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf). Accessed November 18, 2015.