Providing
quality patient care continues to be the underpinning of all patient
experiences from hospital and long term care, to physician offices and
community clinics. Quality, safe patient care impacts patient satisfaction,
employee retention, and reimbursement. Have we made any progress since the 2002
publication Across the Quality Chasm? This Institute of Medicine’s (IOM)
publication, written in response to the seminal treaty on patient harm titled
To Err Is Human: Building a Better Healthcare System, still informs and guides
quality initiatives today. The Institute of Medicine continued to bring focus
to the patient safety movement with seven more publications highlighting rural
health care, healthcare provider competency, communication and
interdisciplinary teamwork.
Since
1970, the IOM’s goal, under the US National Academy of Sciences, has been to
focus on utilizing evidence based research to make recommendations and provide
guidance for the health of the general public as well as advising science
policy. Beginning in 1996, the IOM began a healthcare quality initiative that
involved three phases. To Err Is Human was published within the end of phase
one (1999), bringing to light the challenges for providing quality care, and
the devastating impact medical error has on individuals, communities and health
care organizations. Across the Quality Chasm, published in 2002, laid the
foundation and vision to promote safe quality care through the work of health
care policy, and health system involvement. The IOM’s Six Aims of Quality
continues to be the template in the ongoing phase three. Quality care should be
Safe, Effective, Patient-Centered, Timely, Efficient and Equitable.
So
how do we measure up, 17 years after the publication of To Err Is Human? Do we
see less medical error and stronger, safer health care models for patient care?
A recent report by researchers at Johns Hopkins University states that after an
eight year review of data, more than 250,000 deaths in the US per year are due
to medical error, and is the third leading cause of death. This increase in
deaths is possibly due to the underreporting of medical error.
Great
strides continue to be made in areas such as standardization of care and
procedures, advancements in technology, and stronger leadership commitment to high
reliability organizations.
Hospitals
maintain focus on several crucial areas
to reduce error. First, involve the patient in their care by empowering and
encouraging them to question, engage and partner with all health care providers
in health care decisions. Next, monitor vulnerable populations and strive to
eliminate disparities in healthcare. Third, make communication between all
members of the health care team essential in all patient interactions. Finally,
health care leaders must encourage a culture of safety, allowing all members of
the health care team to not only safely report error, but be involved in
ongoing safety plans and initiatives. All of these areas assist in becoming
high reliability organizations. A highly reliable organization views safety as
an ongoing, ever changing strategy to monitoring, reviewing and adjusting
safety plans at every level of the organization.
Resources:
Agency for Healthcare Research and
Quality. High Reliability. (2017). Retrieved from: https://psnet.ahrq.gov/primers/primer/31/high-reliability
Harvard Business Review. (2016). The Next Wave of Hospital
Innovation to Make Patients Safer. Retrieved from:
https://hbr.org/2016/08/the-next-wave-of-hospital-innovation-to-make-patients-safer
Institute of Medicine. (2001). Crossing
the Quality Chasm: A new Health System for the 21st Century.
Retrieved from: http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf
Johns Hopkins Medicine. (2016). Study Suggests Medical Errors Now
Third Leading Cause of Death in the U.S. Retrieved
from: https://www.hopkinsmedicine.org/news/media/releases/study_suggests_medical_errors_now_third_leading_cause_of_death_in_the_us
Managed Healthcare Executive. (2017). Four ways to reduce dangerous medical
errors at your hospital. Retrieved from: http://managedhealthcareexecutive.modernmedicine.com/managed-healthcare-executive/news/four-ways-reduce-dangerous-medical-errors-your-hospital?page=0,1
Written by Katie Cross,
MSN, RNC-OB, Part-Time Faculty, Saint Joseph's College
