How Zero-Harm Policies Hurt Patients and Clinicians

CMS’s single-metric goals have unintended consequences.

The Centers for Medicare and Medicaid Services (CMS) announced earlier this year that they were pursuing a “zero-harm goal” to keep patients safe when receiving care. The agency is working to reach this goal by “using the many tools and authorities at its disposal.” The problem with zero-harm goals is that they tend to come at the expense of other goals, unintentionally causing harm in other ways.

Back in 2006, the National Quality Forum released a list of 29 serious reportable events or, as they’re often referred to, “never events.” Never events are rare medical errors that patients ought to never experience, including injuries in the process of receiving care, inpatient suicide, or the administration of unsafe products. The publication of the list was followed by an announcement that CMS would take action to minimize the number of never events and make data about their occurrence public. Zero-harm policies grew in prominence with the Affordable Care Act’s requirement that the Secretary of the US Department of Health and Human Services create a plan to improve healthcare quality. In 2011 the first National Quality Strategy was published, and it established a zero-harm goal.

Health care providers should be relentless in their efforts to reduce the risk for injury from care, aiming for zero harm whenever possible and striving to create a system that reliably provides high-quality health care for everyone.

Zero harm to patients is a laudable goal, but we must not forget that the objective of healthcare is health. An easy way to achieve a zero-harm goal is not to provide any care. A patient with a cancer diagnosis will be severely harmed by chemotherapy, but the treatment is intended to save her life.

Zero-harm policies have a well-documented history of unintended consequences. For instance, CMS’s obsession with zero falls has led many hospital administrations to scare nurses into restricting patients to bed rest. As a result, patients suffer from a greater number of preventable ailments, including pressure ulcers, blood clots, muscle loss, and a general decrease in physical fitness.

Similarly, the Affordable Care Act mandates that CMS impose penalties on hospitals whose readmission rates exceed a certain threshold. The policy was significantly associated with an increase in patient mortality.

These metrics don’t just harm patients: They also contribute to clinician burnout. The top-down governance that CMS is imposing nationwide puts doctors and nurses in the uncomfortable position of having to make clinical decisions based not on what they know to be best for the patient but rather to comply with CMS’ metric du jour.

The bureaucrats who establish zero-harm goals often can't (or, to be less charitable, don't try to) foresee how they'll play out in real life. They signal to the public how much they care about American patients and then get to do a victory lap about their success in meeting a single metric.

But in light of the impact on patient health, CMS should tread carefully when setting one-size-fits-all objectives for the entire country’s health systems. In the face of physician, nurse, and other healthcare worker shortages, CMS leaders would be wise to consider how their policies may discourage willing healthcare professionals from continuing to work in the field.

Note: Many thanks to Dr. Anthony DiGiorgio for his insights on this topic. Read his thoughts on “good intentions” leading to misplaced incentives in his recent commentary at Health Affairs.