Healthcare continues to face significant challenges as our population continues to age, diversify, and costs continue to soar. The following publications are landmark studies that have served to improve the field and guide healthcare professionals in their quest to improve healthcare for all Americans.
“To Err Is Human: Building a Safer Health System” by The Institute of Medicine
This report from the Institute of Medicine released on November 29, 1999 came at a time when hospital deaths from medical errors were happening at an increasing number and media attention on the subject was heightening. The Institute of Medicine made it their mission to address these errors by focusing on the larger issue of patient safety.
As a starting point to this issue, the Institute of Medicine called for a rethinking of medical errors and how they happen. They claimed that viewing an error as being the result of incompetence, recklessness or poor attention to detail was incorrect and detrimental to ensuring safety. This type of thinking does not promote an open discussion about righting medical errors, but instead results in healthcare professionals and administrators fearing censure, blame, lawsuits and feelings of shame.
The road to preventing patient injury and death through medical errors lies in changing the system of care. The responsibility belongs to healthcare organizations to establish processes to prevent, recognize and mitigate harm from errors as quickly and efficiently as possible so that patients remain safe. [1]
The Institute of Medicine’s Four-Tiered Plan for Improvement
1. Establishing a national focus on safety. Since healthcare is a high-risk industry, they called for Congress to create a National Center for Patient Safety within the Agency for Healthcare Research and Quality (AHRQ) to set national safety goals and track progress, develop methods of research, evaluate tools for identifying errors and educate people about patient safety.
2. Developing mandatory and voluntary reporting systems. This step requires state governments to collect and healthcare organizations to report information about medical errors that result in death or serious injury in order to hold organizations accountable and provide incentives for implementing safety procedures. Voluntary reporting is a means to other errors that may not cause harm, but will help guide future improvements.
3. Raising standards and expectations for safety improvements. The Institute of Medicine calls for setting and enforcing performance standards through regulatory, licensing and accreditation mechanisms, healthcare professionals and providers and group and individual purchasers of healthcare.
4. Creating a culture of safety. Finally, healthcare organizations must establish an environment where safety is of the utmost importance. This requires a top down approach in which leaders promote and educate about safety practices by ensuring safe working conditions establishing systems where safety is the objective. [2]
“The Strategy That Will Fix Health Care” by Michael E. Porter & Thomas H. Lee, MD.
In their Harvard Business Review paper, Michael E. Porter and Thomas H. Lee, MD promote a new approach to fixing the many struggles facing healthcare that focuses primarily on maximizing value for patients. The authors state that health care delivery systems need to be transformed from a supply-driven system to a patient-oriented system where outcomes matter most.
Improving value for patients as defined by the authors required improving health outcomes without raising costs or lowering costs without compromising outcomes, or both. The strategic agenda they propose involves six components.
1. Organizing into Integrated Practice Units (IPUs). This involves a change of structure to organize around the patient’s medical condition by not only treating the disease, but by treating the related conditions and circumstances that come with it and by engaging patients and their families in care.
2. Measuring outcomes and costs for every patient. Continuous measurement of value allows for tracking progress and comparing performance.
3. Bundled payments for care cycles. Moving away from global capitation and fee-for-service payment models, bundled payments encourage teamwork and high-value care.
4. Integrating Care Delivery Systems. This step eliminates fragmentation and duplication of care and optimizes care delivered in each location.
5. Expanding Geographic Reach. Providers need to help more patients and extend their reach through expansion of IPUs.
6. Building an Information Technology Platform. Health IT platforms should be centered on patients, use common data definitions, encompass all types of patient data, be accessible to all parties involved in care, include expert systems for each medical condition and have a simple architecture for extracting information. [3]
“Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction” by Dr. Linda Aiken
Dr. Aiken’s study of the nursing shortage and its relation to the increased risks for patients brought to light a very real and negative consequence of the lack of nurses that the U.S. is facing.
In 2002, Dr. Aiken found that 40% of 10,000 nurses surveyed reported high job dissatisfaction, emotional exhaustion and burnout. When comparing hospital discharge abstracts of surgical patients, she discovered that ¼ of post-operative patients experienced a major complication and 2% died within 30 days of admission. These numbers increased for each additional patient assigned per nurse
This study illuminated the relationship between nurse staffing and the outcomes of patients, proving that good work environments lower job dissatisfaction for nurses and improves patient safety. [4] [5]
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Sources
1. Donaldson MS. An Overview of To Err is Human: Re-emphasizing the Message of Patient Safety. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 3. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2673/
2. To Err is Human 1999 report brief. National Academies of Sciences. 2000. https://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf
3. Porter, Michael E. and Thomas H. Lee, MD. The Strategy That Will Fix Health Care. Harvard Business Review. October 2013. https://hbr.org/2013/10/the-strategy-that-will-fix-health-care
4. Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Journal of the American Medical Association. 2002; 288: 1987-1993.
5. Changing Practice, Changing Lives: 10 Landmark Nursing Research Studies. The National Institute of Nursing Research. https://www.ninr.nih.gov/sites/www.ninr.nih.gov/files/10-landmark-nursing-research-studies.pdf
