Key Topics in Healthcare Quality and Safety

The IOM Reports

1.The IOM Reports

In 2000 the Institute of Medicine (IOM) published To Err Is Human: Building a Safer Health System, and in 2001 a follow-up report, Crossing the Quality Chasm. The resulting efforts to reduce medical mistakes have dramatically changed the face of healthcare in the United States. Understanding the content of these reports is foundational to effective leadership in healthcare. With that in mind, respond to the following:

1.Briefly explain the key focus of To Err Is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century. What were the objectives of each? How did the reports differ? 

2.Explain the impact of each of these reports. What changes have occurred that can directly be tied to their dissemination? Access some of the recent State of Health Care Quality Reports to explore improvements in quality. 

3.Identify IOM’s six aims for improving healthcare quality, and describe subsequent advances made in delivering quality healthcare related to IOM’s six aims. 

2.System-Wide Safety Failures

Every system is perfectly designed to achieve the results it gets. 

Dr. Paul Batalden

In the years following the publications of To Err Is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century, increased attention was given to mitigating the circumstances in which patient safety is compromised. Increasingly, adverse events that occur within healthcare organizations are recognized, not as the failure of any individual (health provider or patient) but as system-wide failures. High-profile sentinel events, such as Libby Zion, Josey King, and the Quaid twins, to name a few, have attracted public attention and spotlighted the tangled or missing systemic threads that can lead to serious outcomes. Likewise, in this environment, adverse events that might cause little or no harm are gaining increased attention. This shift in perspective is having a profound and ongoing impact on how healthcare is delivered, regulated, and reimbursed.

Bring to mind an adverse event that has been publicized or one with which you are familiar, one for which there was a resulting systems change. With this event in mind, respond the following:

a..Analyze the adverse safety event that became an impetus for systems changes related to patient safety as follows: 

b.Describe the event and its effects on key persons involved. 

c.Explain the systemic failure that allowed the event to occur. 

d.Explain system changes that were made as a result of this event as well as the outcomes of those changes. 

3.Roles and Activities of Organizations in Ensuring Patient Safety and Quality

Many different organizations deal specifically with quality and safety in healthcare situations. These organizations include, among others, the Institute for Healthcare Improvement (IHI), the Agency for Healthcare Research and Quality (AHRQ), The Leapfrog Group, and the Institute for Safe Medication Practices (ISMP). It is important for healthcare administrators to be familiar with these organizations and understand their missions, what they can offer, and their approaches to ensuring patient safety and quality. Demonstrate your knowledge of these organizations as follows:

a.Briefly describe two different organizations associated with the area of patient safety, including their mission, purpose, and values.

b.Describe the history of each organization. How and why was it begun? Who were its principal organizers? 

c.Explain how the key activities of the organization align to its mission.

d.Describe two key achievements of each organization in the area of patient safety and the impact of those achievements on patient safety.

4.Victims of Errors: A Broader Perspective

No one goes into healthcare to hurt people, and yet healthcare is a high-stakes arena in which adverse events occur. Based on your understanding of the concept of “victim” in terms of medical errors (as presented in the Learning Resources), complete the following: 

a.Articulate the pros and cons of this statement: Those who make errors that harm patients themselves are victims and need support and perhaps counseling. Then, state your position on the statement.

b.Provide a rationale for your point of view that references the larger context of patient safety, including transparencies, reporting of errors, and accountability. 

c.Write a brief analysis of the impact of “no-blame” systems in encouraging providers to report their own mistakes.