Pay for Performance in Nursing is Topic of New Brief from RWJF's Charting Nursing's Future

Two key objectives of the push for sweeping health care reform are holding down costs and driving up quality. “Pay for performance,” a demonstrated approach to accomplishing both of those goals, has gained significant traction among policy-makers and some payers. But according to the latest publication in the Robert Wood Johnson Foundation’s Charting Nursing’s Future series, “pay-for-performance initiatives related to nursing care are just emerging, largely because—while nurses are central to patient safety and quality of care—their work remains invisible to payment systems.”

The brief, Perspectives on Pay for Performance in Nursing: Key Considerations in Shaping Payment Systems to Drive Better Patient Care Outcomes, cites a 2007 literature review in which Ellen T. Kurtzman, M.P.H., R.N., assistant research professor, Department of Nursing Education, The George Washington University, found not a single example of nursing-focused incentive programs in the United States. By contrast, Kurtzman’s research identified more than 100 such programs focused on hospitals and physician practices.

“Payers recognize nurses’ importance to quality and safety,” Kurtzman explains. “The problem is that nurses are invisible in the payment system. In hospitals, for example, their work is bundled into room-and-board charges. And any change in how nurses’ time is billed would require a major overhaul of the hospital payment system.”

Click here to read more.

Initiative on the Future of Nursing's Forum on Community Health, Public Health, Primary Care and Long-Term Care

On December 2, Mary Naylor, INQRI's director, and Heather Kelley, INQRI's program associate, attended the second forum convened by RWJF's Initiative on the Future of Nursing, at the Institute of Medicine.  Speakers included Pennsylvania Governor Ed Rendell, Tine Hansen-Turton, M.G.A., J.D., executive director of the National Nursing Centers Consortium, Sandra Haldane, B.S.N., M.S., R.N., director of the Indian Health Service’s Division of Nursing and the Indian Health Service Chief Nurse and many others.

To read a recap about this exciting forum, please click here.

INQRI Director Received Nursing's "Nobel"

INQRI National Program Director and 2007 Edge Runner Mary D. Naylor, R.N., Ph.D., F.A.A.N., is this year's recipient of the Episteme Award—nursing's "Nobel Prize."

Click here to read more.

Study Finds Hospitalized Patients Often Ignorant of Their Drug Regimen

Each year, about 7,000 people die because of medication errors in hospitals. Although errors can happen throughout every step of the medication process, experts say they occur most frequently during the prescribing and administering stages. According to the Institute of Medicine, on average, a hospital patient can expect to be subjected to at least one medication error each day.

A new study in the Journal of Hospital Medicine suggests that hospitalized patients tend to have significant gaps in knowledge of their medication regimen, with 96 percent of patients surveyed omitting at least one drug they had been prescribed during their hospitalization, MedPage Today reports.

To read more about this study, please click here.

To read about what INQRI teams are doing to address medication management issues, please click here.

Reducing Pressure Ulcers

Smart Card Revolutionizes Wound Care at NYU Langone

By Marcia Frellick

Medical teams using a cutting-edge communication and tracking tool in treating wound patients at NYU Langone Medical Center in New York City, now can put clinical data behind their success.

With the help of the National Institutes of Health, Harold Brem, MD, chief of the Division of Wound Healing & Regenerative Medicine in the Helen & Martin Kimmel Wound Center, found that what he developed as a “smart card” was able to prevent 93% of Stage II pressure ulcers, or bed sores, from progressing to Stages III and IV, even in the most critically ill, bed-bound hospitalized patients, and decreased limb amputation rates by 75%.

Click here to read the rest of the article.

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An INQRI team at the University of Cincinnati is also working to prevent pressure ulcers. Tracey Yap, Ph.D., a nurse researcher and Jay Kim, Ph.D., an engineer, are leading an interdisciplinary research team which will develop a sustainable, system-wide program for pressure ulcer prevention that enhances mobility of long-term care residents. The primary goal, under nursing's leadership, is to reduce LTC facility-acquired pressure ulcer incidence by 50% using a cost-effective innovative program to increase resident active or passive movement. This team was funded by the INQRI progam this October and has just begun their work.

Linda Aiken: Health Reform Could Be Turning Point For Nurses

The role of the nurse in primary care and in coordinating patient care is evolving. This, coupled with the movement toward health reform, presents an opportunity to modernize the scope of what nurses do to let them “work to the full extent of their education and expertise,” says INQRI National Advisory Committee member Linda Aiken, Ph.D.  Aiken, who is the Director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania, spoke about how her research has helped inform health reform debates and what INQRI researchers can do to make their research relevant to policy.

Q: How has your research and work helped to inform the current health reform debates?

Aiken: My research on nursing education policy has been influential in the increases in funding for Title VIII support for baccalaureate nurse education and nurse practitioner education. I have a longstanding program of research beginning with my 1994 paper in JAMA showing that Medicare funding for pre-licensure nursing education has not contributed to improving access to and quality of care for Medicare beneficiaries. That research has been influential in the design of a new funding vehicle for graduate nursing education included in the health reform bills.

My 2003 JAMA paper showing that each 10% increase in the proportion of hospital bedside care nurses with at least a baccalaureate degree was associated with a 5% decline in mortality has been cited in legislative debates in support of more federal funding for baccalaureate education.

I have contributed to the growing literature demonstrating that nurse practitioners contribute to improving access and quality at affordable costs that has been useful in inserting language in primary care pilots and demonstrations that enable qualified advanced practice nurses to lead and participate in interdisciplinary primary care models.

Q: How can INQRI researchers link their research to current debates? How can they ensure their work does not just sit on a shelf, but has impact in the real world?

Aiken: Policymakers, managers, and the public often do not understand the relevance of nursing research to real life decisions. The key to linking research to current debates is to frame research findings in the context of current debate and policy decisions.

For example when we studied the impact of hospital nurse staffing on mortality, our study took place in Pennsylvania, a state without pending nurse staffing legislation. However to illustrate how our findings could be applied more broadly, we used our findings in Pennsylvania to estimate how hospital mortality might vary under the ratios being debated in California that varied from four to eight patients per nurse.

Our finding that every patient added to a nurses’ workload was associated on average with a 7% increase in hospital mortality following common surgical procedures was influential to decisions about the final regulations implemented in California. It helped make our paper relevant to audiences that might not have thought that they would be interested in nursing prior to reading the paper.

Q: How might health reform change the role of nurses?

Aiken: The weight of the evidence in support of nurses’ expanded roles in primary care and care coordination for the chronically ill is finally being recognized as in the public’s interest. I suspect that health reform will be a turning point in the public legitimization of nurses in expanded roles and result in modernization of scope of practice and reimbursement policies to enable nurses to work to the full extent of their education and expertise.

Nursing, Technologies and Medication Management: New Multidimensional Measures of Cost and Quality

INQRI gives special thanks to Pascale Carayon, Bentzi Karsh and Joy Rivera from the University of Wisconsin-Madison for their fascinating presentation during last Friday's webinar.  This grantee presentation concludes our Fall webinar series and we thank all of the presenters we have heard from this year!

Please click here to download the slides from last week's session on medication management.

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We have an exciting calendar of events planned for 2010.  We will continue our partnership with the Gordon and Betty Moore Foundation to present a series of webinars focused on medication management.  We will also debut our series on translating research into practice.  This series is co-sponsored by the Donaghue Foundation. 

To register for the Spring webinars, please click here.

RWJF's Voices of Quality

This month's edition of the Robert Wood Johnson Foundation's e-newsletter "Quality Matters" featured an audio clip by Marshall Chin, M.D., M.P.H., F.A.C.P.  Dr. Chin is an associate professor of medicine at the University of Chicago and director of the RWJF-funded Finding Answers: Disparities Research for Change program. 

In this clip, he talks about the three key elements needed for the transformational change needed to improve quality.

Click here to listen to other stories from the field.

To receive the "Quality Matters" newsletter, please click here and sign up.

Let’s not wait another 10 years

This post is part of our two-week series commemorating the 10-year anniversary of the seminal IOM Report "To Err Is Human." To see all posts in the series, please click here.

I would like to extend a very warm thank you to everyone who participated in our two week series to commemorate the 10^th anniversary of the “To Err is Human” report.  Thank you to those who were interviewed, wrote blog entries, promoted us on your sites, followed along on Twitter, wrote comments, voted in our poll and read with us for the past two weeks. I hope you will continue to do so.

We have heard from hospital administrators, clinicians, researchers, journalists, and fellow bloggers.  We have heard what we already suspected to be true – patient safety is a team sport.  Doctors, nurses, patients and families are all part of this effort… and, though progress has been made, we still have a long way to go.

As the report said ten years ago:

“To err is human, but errors can be prevented. Safety is a crucial first step in improving quality of care…Must we wait another decade to be safe in our health system?”

Let’s not wait another 10 years.

Continue following us on our journey. Be a part of the conversation. We want to hear from you.

Patients Play Key Role In Quality Movement

This post is part of our two-week series commemorating the 10-year anniversary of the seminal IOM Report "To Err Is Human." To see all posts in the series, please click here.

Teamwork has become a standard of care in many U.S. hospitals since the IOM released its landmark report on medical errors, says nurse researcher Kathleen Stevens at The University of Texas Health Science Center at San Antonio.

That team often includes nurses, doctors and other health professionals who work together to both check for errors and provide the highest standard of care, Stevens says. But she says that more and more hospitals are starting to involve patients and family members in the final effort to raise the bar on quality.

For example, nurses on a neonatal intensive care unit often provide one-on-one care for tiny babies. But the mother is often at the bedside for hours and in some cases is the first line of defense against an error or complication, Stevens says. If the mother notices the baby seems to be showing signs of distress, she can press a button on the side of the bed and call for a rapid response team.

Medical Errors in Popular Culture: Nurse Jackie

This post is part of our two-week series commemorating the 10-year anniversary of the seminal IOM Report "To Err Is Human." To see all posts in the series, please click here.

In this clip from the very first episode of Showtime's Nurse Jackie, Jackie's attempt to voice her opinion to a doctor is rebuffed, with catastrophic consequences...

Ten Years Later: Look To Nurses As Champions of Patient Safety

This post is part of our two-week series commemorating the 10-year anniversary of the seminal IOM Report "To Err Is Human." To see all posts in the series, please click here.

Today, Kaiser Health News featured this column by Mary Naylor and Mark Pauly, INQRI's co-directors.

Ten years ago this month, the Institute of Medicine shattered a widely held perception that American health care was safe. IOM’s finding that as many as 98,000 patients die each year in hospitals from medical errors launched an aggressive patient safety movement that continues today.

But the report also cast a spotlight on the role of the nurse in keeping patients safe, a role that will become even more important under the ongoing effort to reform the health care system.

Prior to the IOM report To Err is Human, there was little recognition among health care leaders of the contributions nurses make to improve quality and prevent medical errors. Although they are the caregivers who have the most contact with patients, nurses have typically been undervalued and have had to practice in an environment that often set them up for failure.

For example, a nurse working on an understaffed unit with lots of very sick patients might, in some cases, make a mistake. But the IOM report is credited with taking the blame off individual health care workers and shifting the focus to system-wide flaws that lead to errors.

Today, nurses are playing a central role in offering solutions that correct such flaws and advance patient safety and quality—throughout the system.

System-Wide Safety Changes Spurred by IOM

This post is part of our two-week series commemorating the 10-year anniversary of the seminal IOM Report "To Err Is Human." To see all posts in the series, please click here.

By Tracey Yap and Susan Kennerly

Ten years ago the IOM report issued this challenge to health care leaders:

“The status quo is not acceptable and cannot be tolerated any longer. Despite the cost pressures, liability constraints, resistance to change and other seemingly insurmountable barriers it is simply not acceptable for patients to be harmed by the same health care system that is supposed to offer healing and comfort.”

Today, we believe the health care system is safer, although we still have a long way to go. Part of the revolution in the way that care is delivered has to do with a change driven by the IOM, which noted that faulty systems or procedures are often responsible for common medical errors. Rather than put blame on the individual, the IOM report shifted the focus so that hospitals now try to create a culture of safety.

What we’ve noticed in the decade after IOM is that hospitals and other health facilities take a broader view of quality and instead of homing in on one mistake and one individual, they look at systems to try to figure out how they can make the whole process of providing care more safely. Here are some ways:

Diffusing technology. Increasingly, hospitals now rely on technology, such as computerized prescribing systems to prevent drug errors. In the past, a doctor ordering a drug might write out the prescription by hand and the nurse trying to read the script might get the drug name wrong. Now, hospitals that use computerized systems have the doctor type the drug prescription right into the computer. Such systems eliminate errors that resulted from hard-to-read handwritten prescriptions.

That’s an example of a technology fix that’s made a big difference in errors.

Improving Systems. Another big picture change we’ve noticed is this: In the past, people who made mistakes might have focused on the error and pledged to change their ways. But in many cases, the IOM report pointed out that the error was not caused by a “bad apple” but by a faulty system.

Now, we believe that the entire health care industry has started to look for ways to improve quality on that system-wide level. One key change is that hospitals and other facilities have put teams in charge of patient care, a move that spreads responsibility for safety throughout the entire team. For example, doctors, nurses, therapists, and others might all work together to provide the highest standard of care.

INQRI in the Health Wonk Review

This post is part of our two-week series commemorating the 10-year anniversary of the seminal IOM Report "To Err Is Human." To see all posts in the series, please click here.

INQRI was pleased to be included in this week's edition of the Health Wonk Review, which highlighted Terri Schmitt's post and provided a link to our entire "To Err is Human" series (Scroll down to the "Quality and Safety" section.).

The Health Wonk Review is a biweekly compendium of the best health policy blogs. It is a roving digest, with each issue hosted at a different participant's blog. This week's edition is being hosted at Workers Comp Insider. For more information about the Review, check out its website at http://www.healthwonkreview.com/.

Changing Hospital Cultures to Reduce Hospital-Acquired Infections

This post is part of our two-week series commemorating the 10-year anniversary of the seminal IOM Report "To Err Is Human." To see all posts in the series, please click here.

This video comes from an interview with Ramanan Laxminarayan, Senior Fellow at Resources for the Future and Director of Extending the Cure, a project engaged in policy research to extend antibiotic effectiveness.

Here, Dr. Laxminarayan discusses strategies to address hospital-acquired Infections (HAIs). Certain efforts to date have been successful. For example, checklists have been associated with a significant drop in central-line bloodstream infections. The challenge is figuring out how to permanently change hospital cultures and structure incentives to reduce HAIs—because despite certain successes, there’s no conclusive evidence that overall rates of HAIs have decreased substantially in recent years. 

Patients still struggle to find their role in reducing medical errors

This post is part of our two-week series commemorating the 10-year anniversary of the seminal IOM Report "To Err Is Human." To see all posts in the series, please click here.

This post is written by Nancy Shute, a contributing editor for US News & World Report, and vice president of the National Association of Science Writers. Contact her at nancy@nancyshute.com.

Last July 26 started out like a typical summer Sunday; pancakes with the family, talk about an afternoon at the neighborhood pool. Instead, I spent the day at the ER, suddenly and horribly ill with pyelonephritis and bacteremia. I was lucky; four days of IV antibiotics knocked back the bad bugs (thank you, Cipro!). But I spent those days in the hospital worrying about more than when I’d be back home cooking dinner for the family. As I watched the IV drip, hour after hour, I fretted. Was I being given the right medication? The right dose? How could I tell if there was a medication error? As a journalist who has covered health care quality for years, I knew what I should do: Check medications and doses; ask questions; recruit a family member to be my advocate. Did I do those things? Nope. Afraid that I’d be labeled a nutcase or a troublemaker by the busy nursing staff if I voiced my fears, I clammed up.

My tiny medical drama ended happily. But each year, tens of thousands of patients aren’t so lucky. Ten years after the publication of the landmark Institute of Medicine Report “To Err Is Human,” patients remain subject to errors in medical treatment that threaten their health and their lives. The federal government, hospitals, foundations, and health care providers have made concerted efforts to educate patients on their role in protecting themselves from medical errors. I’ve done my part, too, writing about successful experiments to reduce medical errors, as well as “News You Can Use” articles intended to help patients and their families advocate for safer, better care. Yet too often, patients like me still feel powerless, rather than empowered.

Initiative on the Future of Nursing - Archived Webcast Now Available

The RWJF Initiative on the Future of Nursing, at the IOM held the second of three regional forums on December 3, 2009, at the Community College of Philadelphia. The forum focused on improving care delivered at the community level, with an emphasis on primary and long-term care.

Over 300 health care leaders attended the forum, and many provided testimony to the IOM committee about the important role that nurses play in delivering care in the community. Forum participants also heard remarks from Pennsylvania Gov. Ed Rendell and Washington State Secretary of Health Mary Selecky. If you missed the forum or the live webcast, the archived version is now available. Registration is required before viewing the archived webcast. For more details on the forum, we invite you to visit the Future of Nursing blog, where you can read commentary on the forum from our guest blogger, RWJF Executive Nurse Fellow Margaret Flinter.

For more information on the Initiative of the Future of Nursing:

• Follow us on Twitter
• Join us on Facebook
• Read our blog
• Visit our Web sites www.iom.edu/nursing and www.thefutureofnursing.org
  

Modern Healthcare article: A long way to go

This post is part of our two-week series commemorating the 10-year anniversary of the seminal IOM Report "To Err Is Human." To see all posts in the series, please click here.

The below comes from an article by Jean DerGurahian in Modern Healthcare this week.  The full article is available here.

In the decade since the IOM's groundbreaking study on medical errors, there's progress to report, but many of the objectives remain elusive

In the winter of 1999, one ticking time bomb appeared to be the “Y2K bug,” when it was feared that computer glitches on Jan. 1, 2000, could cause any number of annoyances and even calamities. While that fizzled, another bomb—the Institute of Medicine report To Err is Human—soon exploded in the healthcare industry.

The IOM report is still causing repercussions 10 years later.

It was not the kind of event that later leads people to ask each other: “Where were you when you heard the news?” But Helen Haskell remembers when she first heard about the IOM report. She was in her car, listening to a news report on National Public Radio, and thinking it had little to do with her life. She recalls that moment now, a decade later, after losing her son to medical errors and helping to lead patient-safety advocates in their crusade for better care in hospitals. She founded the advocacy organization Mothers Against Medical Error.

Researcher Looks At Education, Experience of Staff and Safety

This post is part of our two-week series commemorating the 10-year anniversary of the seminal IOM Report "To Err Is Human." To see all posts in the series, please click here.

Nancy Donaldson is Director of the Center for Nursing Research & Innovation, a collaboration between the University of California San Francisco School of Nursing, its UCSF Medical Center, Stanford Hospital and Clinics and Lucile Salter Packard Children’s Hospital at Stanford.


I have observed a transformational revolution in health care during the 10 years that have passed since the IOM released its landmark report, To Err Is Human. That report estimated that as many as 98,000 Americans die in hospitals each year as a result of preventable medical errors. It also casts a harsh light on delays or lapses in care that can threaten patient safety and challenges all health care providers to examine the quality, safety and outcomes of their care.

IHI Seminar: From the Top - The Role of the Board in Quality and Safety

January 11-12, 2010

Los Angeles, California

The Institute for Healthcare Improvement (IHI) has witnessed first-hand the powerful impact that a skilled and committed board can have in driving quality improvement, and as we learn more about communities and organizations that are achieving the highest level of quality at the lowest levels of cost, the engagement of governance and executive leadership is front and center in every story.

Join IHI for the upcoming program "From the Top: The Role of the Board in Quality and Safety" and we’ll equip you, your senior leaders, and your board members with the tools and strategies necessary to lead your organization’s quality agenda and achieve system-level performance improvement.

At the end of this two-day program, you will:

• Understand what the best boards do and how they do it
• Be prepared to deal with a quality crisis
• Be able to have meaningful conversations with board members and with physicians
• Know how to best involve patients and families in creating the will for change

To learn more about IHI, please click here.

Checking the Right Boxes, but Failing the Patient

This post is part of our two-week series commemorating the 10-year anniversary of the seminal IOM Report "To Err Is Human." To see all posts in the series, please click here.


Dena Rifkin, M.D., recently published a piece in the New York Times Health section with her reflections on the care delivered to patients in the ten years following the release of "To Err is Human." While she acknowledges the need for adherence to best practices and understands the importance of newer interventions (i.e. pay-for-performance and electronic prescription systems), she also believes that there is a large problem in our current health care system: "a change in focus from treating the patient toward satisfying the system."

"The effects of focusing physicians’ attention on benchmarks and check boxes are not, I think, to the patient’s advantage. "

Click here to read more.

Nursing Research Helps Drive Safety

This post is part of our two-week series commemorating the 10-year anniversary of the seminal IOM Report "To Err Is Human." To see all posts in the series, please click here.

Ten years after the IOM reported on medical errors, research funded by INQRI has been adding crucial information to the ongoing debate on quality of care. So says Laura Caramanica, Senior Vice President and Chief Nursing Officer for Westchester Medical Center in Valhalla, New York.

She should know. Caramanica is also a member of INQRI’s National Advisory Committee. She says INQRI grantees have been hard at work generating data that’s already being used by policymakers and health care leaders to enact changes aimed at making the U.S. health care system safer for patients.

For example, INQRI funded studies have been investigating the role that nurse staffing levels have on the quality of care that patients receive in hospitals and other health care settings.

“Nurses make a tremendous difference in the provision of high-quality care and often step in and prevent medical errors,” Caramanica says.

Advocates of a safe staffing level suggest that when the number of registered nurses dips too low, the quality of the care can suffer. But INQRI research suggests that the safe staffing question is more complicated than just counting the number of registered nurses. They’re finding that the skill mix and staffing levels for non-nursing positions can also make a difference: For example, nurses on units that don’t have enough staff, including secretarial staff, can end up being pulled away from direct bedside care, Caramanica says.

What Do YOU Think?

This post is part of our two-week series commemorating the 10-year anniversary of the seminal IOM Report "To Err Is Human." To see all posts in the series, please click here.

During this series, we are hearing from researchers, clinicians and journalists about their views on patient safety in the ten years following the release of To Err is Human. Now, we want to hear from you. On the top right corner of this page, we have posted a one question poll about patient safety. Please take a moment to cast your vote and then comment on this post to explain your thoughts.

Hospital Error Rates - Still a Long Way to Go

This post is part of our two-week series commemorating the 10-year anniversary of the seminal IOM Report "To Err Is Human." To see all posts in the series, please click here.

"In hospitals, high error rates with serious consequences are most likely in intensive care units, operating rooms and emergency departments…" — To Err is Human, p.36

We'd all like to think that, 10 years after the publication of To Err is Human, the problems and conflicts it described have been examined and improved. But a new study published Dec. 2 in the Journal of the American Medical Association underlines how very far we have to go.

The study, informally named EPIC, was a prospective point-prevalence survey — essentially, an intense single-day snapshot — of infections in 1,265 ICUs in 75 countries on May 8, 2007. It found that 51% of the critically ill patients in those ICUs (7,087 of 13,796 adults) were experiencing infections on that day, and 71% (9,084 of 13,796) were receiving antibiotics.

Those percentages are dismaying enough. But here's the really bad news: This iteration was EPIC II; its predecessor study, EPIC I, was conducted 15 years earlier, on April 29, 1992. And over those 15 years, the ratios of infected patients and antibiotic therapy worsened: In 1992, they were respectively 45% and 62%.

IHI Seminar: Building a Quality Measurement System that Works

March 18-19, 2010

Chicago, IL

Building a Quality Measurement System that Works, a new hands-on seminar from the Institute for Healthcare Improvement (IHI), will provide participants with a practical framework for constructing and evaluating a dashboard of key measures. Robert Lloyd, PhD, IHI’s Director of Performance Improvement, will offer valuable guidance and recommendations for selecting a balanced set of measures, specifying operational definitions, and building data collection plans. In addition, both conceptual and statistical approaches to understanding data variation will be reviewed and participants will be challenged to link their measurement efforts to improvement strategies within their organizations.

For more information about this program, or to enroll, please visit: http://www.ihi.org/IHI/Programs/ConferencesAndSeminars/BuildingaQualityMeasurementSystemThatWorksMarch2010.htm

Medical Mistakes, 10 Years Post-Op

This post is part of our two-week series commemorating the 10-year anniversary of the seminal IOM Report "To Err Is Human." To see all posts in the series, please click here.

To commemorate the 10th year anniversary of "To Err is Human," The Hospitalist caught up with two of the committee's original members: Donald Berwick, MD, MPP, FRCP, president and CEO of the Institute for Healthcare Improvement (IHI) and Christine Cassel, MD, president and CEO of the American Board of Internal Medicine (ABIM) to discuss the advances made in medicine since November, 1999 and what still needs to be accomplished. They discuss the report's legacy and the impact it has had on medicine and the patient safety agenda.

Click here to read the interview.

How Safety Protocols Prevent Drug Mistakes

This post is part of our two-week series commemorating the 10-year anniversary of the seminal IOM Report "To Err Is Human." To see all posts in the series, please click here.

The IOM report, To Err is Human, highlights the chilling story of Ben Kolb, an 8-year-old Florida boy who died in 1995 after he was injected with the wrong drug during a routine surgical procedure.

That case, and other medication mishaps or errors are less likely to happen in today’s hospital, says INQRI grantee Linda Costa, a nurse researcher at the Johns Hopkins Hospital in Baltimore. She says that in the wake of the IOM report, hospitals have gotten much better at protecting patients from medical mistakes, like the one that killed Ben Kolb.

Perspectives: The Answer Is With Nurses, Leapfrog CEO Says

This post is part of our two-week series commemorating the 10-year anniversary of the seminal IOM Report "To Err Is Human." To see all posts in the series, please click here.

If you want to know if a hospital is safe, look at how much nurses lead efforts to reduce errors and have the ability to take charge of the decisions the keep patients safer. That, according to Leapfrog Group CEO Leah Binder, is the key to keeping patients safe and preventing medical errors.

Leapfrog Group, an employer consortium that seeks to use its purchasing power to improve the quality of care in hospitals and the health care system, has been pushing for better information that will help patients make informed decisions about hospitals and providers. It was the 1999 Institute of Medicine report on medical errors that gave the Leapfrog group its initial focus of reducing preventable medical mistakes. The report recommended that large employers take a more direct role in pushing for safer care.

“Nurses know what needs to happen. They know the safety answers,” says Binder, who once served as public policy director at the National League for Nursing.

But too often, they don’t have the influence in a hospital to change a system and make things safer for the patients. “That’s the role nurses need to take on. Nurses should be very critical of the real lack of progress on patient safety,” Binder maintains.

One way to make that happen is for nurses to take a strong stand on the issue of transparency, which Binder believes is sorely lacking in today’s health care system. Binder calls for independent, unbiased, transparent reports about medical errors, providers and hospital quality as a solution. “We have smoke and mirrors today. What we have today is some information that isn’t all that interesting or relevant to consumers. We need information that allows consumers to choose between hospitals and providers.”

Another step in the right direction will be reforming payment incentives to reward both doctors and nurses for improving patient safety, she says.

Click here to hear more from Leah Binder on quality and transparency from an interview with Modern Healthcare.

Fulfilling the Promise: Advancing Patient Safety and Medical Liability Reform Innovations

This post is part of our two-week series commemorating the 10-year anniversary of the seminal IOM Report "To Err Is Human." To see all posts in the series, please click here.

This Thursday, December 10, 2009 in Washington, D.C., Common Good is hosting a public forum in connection with the U.S. Department of Health and Human Services’ $25 million initiative to test patient safety and medical liability innovations. The event will present information on promising avenues of reform, and will engage national legal, medical, and policy experts, potential applicants, and other interested parties on how to develop viable proposals for submission to the Department in January.

Fulfilling the Promise: Advancing Patient Safety and Medical Liability Reform Innovations will be held between 8:30 a.m. and 2 p.m. at the National Press Club at 529 14th Street, NW.

Speakers include:

• Lucian Leape, M.D., chair of the Lucian Leape Institute at the National Patient Safety Foundation and an internationally recognized leader on patient safety
• Michelle Mello, J.D., Ph.D., professor of law and public health, Harvard School of Public Health
• Nancy Foster, vice president for quality and patient safety policy, American Hospital Association
• Philip K. Howard, J.D., chair, Common Good

To register for the event, please e-mail your name and contact information to RSVP@commongood.org.

A Webcast of the event will be broadcast at http://www.visualwebcaster.com/event.asp?id=64481.

Week 1 Wrap Up: Nursing is Poised to Answer the Call

This post is part of our two-week series commemorating the 10-year anniversary of the seminal IOM Report "To Err Is Human." To see all posts in the series, please click here.

“Nursing, nursing, nursing is poised and ready to answer the call. We have been translating research, including important parties, and increasing access for years. Good partnerships with nursing will increase patient safety, access, and quality as we move forward.”

– Terri Schmitt, NurseStory.com

As we conclude the first week of our blog series, the above comment from Terri Schmitt is exactly what we had in mind when deciding to commemorate the ten-year anniversary of the groundbreaking IOM report.

This week, we have offered posts by our program leaders, Mary Naylor, Mark Pauly and Lori Melichar. We have shared perspectives from grantees Linda Flynn, Tracey Yap and Mary Beth Happ. And we have heard from wonderful leaders from the field like Janet Corrigan, Paul Levy and Anne Marie Audet. We were also thrilled to present posts from Terri and from Barbara Olson, two nurses who are continually working to advance the field of patient safety not only in their work, but also in the growing on-line community. We welcome the contributions from other bloggers and tweeters, whether for this series or in the future.

After all, Terri is right – it is forging good partnerships which will allow us to advance the quality agenda.

Stay tuned for next week – there is more to come!

The Foundation of Quality Is Safety

This post is part of our two-week series commemorating the 10-year anniversary of the seminal IOM Report "To Err Is Human." To see all posts in the series, please click here.

Recently, Janice Simmons blogged for HealthLeaders Media regarding a presentation by Richard Shannon, MD (chair of the department of medicine at the Hospital of the University of Pennsvlvania in Philadelphia) at a Consumer Union's Safe Patient Project forum. Shannon asserted that healthcare could become a "high-performing organization" and provided tips to health leaders on ways to improve their organizations. Shannon believes that a new mindset can lead to greater patient safety... Patient safety, he says, should be considered "a precondition of work."

"The foundation of quality is safety—and safety must be a precondition."

Click here to read the piece.

How Teamwork Can Reduce the Risk of Infection

This post is part of our two-week series commemorating the 10-year anniversary of the seminal IOM Report "To Err Is Human." To see all posts in the series, please click here.

Tracey Yap, Susan Kennerly, and Elaine Miller

More Americans die each year from medical mistakes than from car crashes, breast cancer or AIDS—so said the IOM report a decade ago. But the real impact of the report, according to two INQRI researchers, was to shift the focus from individual blame to an atmosphere of collective responsibility for patient safety.

Prior to the IOM report, hospitals kept track of medical errors, like giving the wrong drug to the wrong patient, say nurse researchers Tracey Yap PhD and Susan Kennerly PhD, of the University of Cincinnati in Ohio. Typically, mistakes were attributed to one person; therefore, that nurse might have to explain how she planned to change her practice to avoid making the same error again.

Now hospitals seek safety protocols that can prevent individual error and also have the ability to raise the quality of care provided throughout a facility, say Yap and Kennerly, who with their University colleagues Elaine Miller DNS, Jay Kim PhD, and C. Ralph Buncher ScD are working on an INQRI-funded project are examining the merits of a team approach to care. The University of Cincinnati’s College of Nursing in partnership with Signature HealthCare of Florida developed a system-wide approach to prevent bed sores or pressure ulcers, which can lead to infection and significantly higher health costs.

The group of researchers, led by Yap, knew nursing home residents needed to be moved every two hours to reduce the risk of a pressure ulcer. The intervention sounds a musical alert over the facility intercom every two hours to indicate it is time for the residents, if capable, to move or be assisted to move by facility staff. Furthermore, the program is designed to be carried out by an entire team (composed of staff from various areas in the facility—not just nursing) working together to reduce the risk of a facility-acquired pressure ulcer.

The housekeeper or another member of the health care team can assist nursing with those residents who only need verbal prompting, while nurses will continue to perform the crucial safety tasks with those who require assistance with moving. The staff member who does the task makes a note that the patient has been moved at the designated time and indicates it on the medical record.

The primary goal of the project is to reduce by 50 percent the risk that an elderly nursing home resident will suffer from a pressure ulcer. The advantage of such a system is that it spreads the responsibility for a safer environment to the team and takes the onus off a single individual, like the nurse who might be handling many duties all at the same time. In addition to reducing the risk of pressure ulcers, the researchers hope this system-wide approach will also free up the nursing staff to attend to other duties.

Today’s nurse must deal with complex patients with multiple medical problems and with an increased workload, say Yap and Kennerly, adding that often, facilities that take some of the load off a single nurse and encourage teamwork are able to provide a higher standard of care, one that keeps patients safer.

Highlight on INQRI Work: Diabetes Prevention

INQRI researchers at Yale University are conducting a randomized clinical trial to reduce the risk of type 2 diabetes (T2D) in at-risk adults with a diabetes prevention program provided by visiting nurses in subsidized housing units. They will modify a research-based diabetes prevention program; evaluate the preliminary effects of the modified diabetes prevention program provided by visiting nurses; and they will explore the reach, adoption, implementation, and cost of a diabetes prevention program delivered by visiting nurses to residents in subsidized housing units.

This work, led by Robin Whittemore, Ph.D., a nurse scholar, and Alana Rosenberg, M.P.H., a scholar in public health, comes at a crucial time. A study published in this month's issue of Diabetes Care suggests that the number of Americans with diabetes is expected to almost double by 2034.

Click here to read more.


To read more about the other important work conducted by INQRI researchers, please visit our website.

Nurses: The Crucial Link for Patient Safety

This post is part of our two-week series commemorating the 10-year anniversary of the seminal IOM Report "To Err Is Human." To see all posts in the series, please click here.

This post is by Terri Schmitt of Nurse Story, a blog that is full of thoughts on nursing, nurse practitioners, service to others and life in general. Terri Schmitt is a nurse practitioner who is currently finishing up her PhD at the University of Missouri-Kansas City (UMKC).

In the past, nurses such as Florence Nightingale, Dorthea Dix, Lillian Wald, Margaret Sanger, and Mary Breckenridge provide a legacy for improving patient access and quality in health care. Nursing has readily embraced this foundation, developing nurse-run clinics, advanced practice models of care, and preventative education. For the current profession of nursing, the publication of To Err is Human brought to light new needs for standards and methods of patient care.

Improving Communication To Reduce Medical Mistakes

This post is part of our two-week series commemorating the 10-year anniversary of the seminal IOM Report "To Err Is Human." To see all posts in the series, please click here.

A man in the intensive care unit (ICU) kept trying to communicate a message to the nurses but he was on a ventilator and it was difficult to speak. The nurse thought he was saying that he was in pain and got him a painkiller. But that’s not what the man was saying and the painkiller was a mistake.

When patients can’t communicate clearly, nurses and doctors can get the wrong message. That miscommunication can lead to unneeded procedures, medication or a lapse in care—all of which can harm patients, says Mary Beth Happ, a nurse researcher at the University of Pittsburgh.

In this case, the man was lucky. Nothing serious happened. But a miscommunication like this could have led to a longer period on the ventilator, or a serious medical complication – all of which are unnecessary and increase hospital stays and health care spending.

Perspective: 10 years after “To Err is Human”

This post is part of our two-week series commemorating the 10-year anniversary of the seminal IOM Report "To Err Is Human." To see all posts in the series, please click here.

We caught up with Lori Melichar, senior program officer for the Robert Wood Johnson Foundation’s Interdisciplinary Research Initiative, to talk about the influence the IOM report on medical errors had on her work, the Foundation’s direction and the role of nurses in patient safety.

“Though the report has always been in my peripheral vision, it has influenced a lot of my work I have been involved with at the Foundation,” explains Melichar, Ph.D., M.A., a labor economist and senior program officer in the Foundation’s Research and Evaluation Unit. The IOM report, Melichar says, helped show researchers what tools would be needed to fix the problem and helped shape research agendas.

“The report scared the public in a way they hadn’t been scared before,” she said, referring to the report’s alarming statistics that as much as 98,000 patients die every year as a result of medical errors. Though the Robert Wood Johnson Foundation had been concerned about quality of care for a long time, this report created the momentum, the partners and the framework to make the investment in research aimed at finding solutions to the problem.

The Foundation knew that the role nurses play in keeping patients safe would be integral to the ambitious goals for improving safety that the IOM report laid out. “It was clear, in 2002 that the contributions nurses were making daily to patient care outcomes were invisible. After consulting with the nursing field, the Foundation decided to support a natioinal quality forum effort to endorse a set of valid, reliable quality measures linked to nursing,” Melichar remembers.

In early 2005, the Foundation began looking at ways to build the evidence base that could address gaps identified by the National Quality Forum steering committee that endorsed a set of “nursing-sensitive” quality measures. And the newly created INQRI program set about supporting the development and testing of measures that could provide a window into nurses’ positive contributions to care and guide improvements in the care delivered by nurses.

Most recently, Melichar has been acting as director of research for The Initiative on the Future of Nursing at the Institute of Medicine, a two-year joint effort of the IOM and RWJF to find solutions to biggest challenges in the nursing profession. A committee will issue recommendations next September that are intended to transform the future of nursing.

This IOM report should not scare the public however. “The nursing field is ready for action now. We have measures. We have models and we have evidence that these models work,” she says of the mission ahead.

Melichar is encouraged that those outside of nursing will embrace the report's recommendations by one recent sign: Quality of nursing care is now being included in rankings by U.S. News & World Report on hospital care. “It’s a big deal,” she said, noting that the real trick will be using the right measures that “really capitalize on nurses’ true value.”

The Building Blocks of Better Care, 10 Years In the Making

This post is part of our two-week series commemorating the 10-year anniversary of the seminal IOM Report "To Err Is Human." To see all posts in the series, please click here.

This post is written by Barbara Olson of Florence dot com, a real-time patient safety primer exploring age-old wisdom and new-found solutions for healing healthcare. Barbara Olson is a seasoned nurse, educator, project manager, safety analyst, and healthcare consumer.

Shortly after the second IOM report Crossing the Quality Chasm was published in 2001, Don Berwick authored a "users manual," a short document that clearly identified four broad stakeholder interests: the experience of patients; the functioning of the units where care is provided; the larger organizations in which direct care units reside; and the forces (policy, payment, regulatory, accreditation) that shape the performance of these organizations. Berwick described the model as necessarily hierarchical with the experience of the patient on top and other interests aligned to improve the health and functioning of the patients.

Berwick was probably wise to suggest that we begin crossing the quality chasm by holding on to the hierarchy. After all, no one understands hierarchies better than those who give and receive healthcare. By turning the hierarchy upside down, Berwick gave it a disruptive twist, one that helped re-establish the primacy of the care experience (and the outcomes attained) to the business of healthcare.

Rendell to Speak at Today's Forum on the Future of Nursing

Philadelphia Forum to Highlight Nurses in Community Health, Public Health, Primary Care, and Long-Term Care

Today, from 12:30-5:35 p.m. ET, the Robert Wood Johnson Foundation’s Initiative on the Future of Nursing at the Institute of Medicine will hold the second national forum to discuss how to improve the delivery of medical treatment for Americans in community health, public health, primary care, and long-term care settings. Gov. Ed Rendell of Pennsylvania will address the forum regarding his work on the Prescription for Pennsylvania. The forum will look at opportunities in which nurses—as frontline providers of care—can play a role in ensuring patients in all settings receive the best possible care.

Registration for the live webcast is still open. Other options for participating in the meeting include:

• Tweet your comments and observations of the meeting using #IFNphilly. Make sure you’re following the Initiative Twitter feed @FutureofNursing so you don’t miss any behind-the-scenes news from the forum.
• Leave a comment on the Future of Nursing blog.
• Fan the Initiative on Facebook at http://bit.ly/7tPNPD.

Quality of Care Still a Mixed Bag

This post is part of our two-week series commemorating the 10-year anniversary of the seminal IOM Report "To Err Is Human." To see all posts in the series, please click here.

Paul Levy is President and CEO of Beth Israel Deaconess Medical Center in Boston, Massachusetts. He also writes the blog Running A Hospital in which he shares his thoughts about hospitals, medicine, and health care issues.

So I know as someone who is the CEO of a hospital, quality issues are probably always at the forefront of your mind. I wanted to start by getting your impressions of what quality of care looks like today.

I think it’s still a mixed bag. I think there have been some good improvements, but I think there is a lot that remains to be done. For the most part there is still great a variation in the care that is delivered and, unless more is standardized, we’ll never make progress on using a scientific approach to adopting the types of patient care that are of the highest quality.

So when you say things need to be standardized – are there specific standards you have seen to be more successful than others?

Well we have put some into effect here. For example, installing and maintaining central lines, adopting a bundle to avoid ventilator associated pneumonia, adopting a pre-surgical protocol to help avoid wrong site surgeries or other errors of that sort in surgery. Those are examples of when the procedure is standardized for that portion of the medical care that is appropriately standardized, variation is diminished and the likelihood of preventable harm goes down.