Wednesday, December 2, 2009

Searching for Reliable Health Care Ten Years After IOM

To Err Is Human Blog Series Logo

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.

While presenting at her 25th medical school reunion, Dr. Anne-Marie Audet was struck by the sophistication of questions from second year medical students and how prepared they seemed to practice in a health care system built around teamwork and quality improvement. Audet learned that McGill University was exposing students to the real-life world of health care today using a simulation exercise in which actors pose as doctors and nurses operating under stressful conditions and working as teammates to provide the best care and avoid medical errors. Audet, Vice President of Quality Improvement and Efficiency for the Commonwealth Fund, says that experience is very different from the kind of training she got when she attended medical school at McGill. Then, physicians were trained to be autonomous and there was very little discussion about “team work.” Today’s training reflects how much health care and the practice of medicine has changed, in part due to a focus on fixing some of the problems reported by the Institute of Medicine in its 1999 report To Err is Human. The Commonwealth Fund was one of several foundations that supported that landmark study, which by highlighting the breadth of medical errors in U.S. hospitals energized a whole movement to enhance patient safety. Dr. Audet reflects on the effect that report has had on health care 10 years later and what challenges lie ahead.

Do you think hospitals are safer places today than in 1999?

The jury is still out on whether health care is safer today than 10 years ago. We are safer in some places, some times, for some patients. But this is not what I would describe as reliable health care. One of the biggest areas where we have seen progress is with hospital acquired infections. We have seen how possible it is for some hospitals to achieve zero rates of infections. In large metropolitan areas for example, some hospitals achieve zero infections while others may have five times the national average rate of infections. If we are aiming for high-reliability and safety in U.S. health care, we are clearly not there yet.

Where do we need to improve?
One area is leadership. If we are going to reduce unnecessary hospital readmissions, we need interventions at every level of the health care system, from the front line clinicians to the hospital board. Today, a third of hospital boards are still not looking at issues of quality, or at safety (Full study available by subscription only through Health Affairs). If we are going to make any inroads, the hospital board and the CEO need to make quality and safety a priority. That is the only way to start changing the culture. It is the leadership that signals to staff and patients that this is important. If there is no such signal delivered to staff in the chaos of everyday care of patients, the status quo will remain.

How would this play out in day-to-day practice?

If safety is a priority, leadership will give staff time to focus on it. This means health care teams are excused from daily work to put together their patient safety checklists, go over safety protocols, implement those protocols and teach others how to do the same. It also means that there is time for problem solving, for teams to share near misses and errors they have encountered during the day, and to intervene to prevent similar problems in the future.

Iowa Health System is a great example of what I’m talking about. Gail A. Nielsen, Clinical Performance Improvement Education Administrator has made safety and process improvement a priority and they are implementing a new model where staff get time off to be trained and are given time to train others. They also teach nurses how to learn from shadowing other nurses on their units, and allow members of the health care team to observe transitions of care and debrief on what they saw and how to improve what and how they do things. This makes a difference. In one case, a nurse shadowing a colleague was able to see how many times the nurse was interrupted during an 8-hour shift. In just one, typical hour she documented that while the nurse cared for 5 patients, she was in 8 locations, changed locations 18 times, and interacted with 14 people on 30 topics. Multiply that by 8 or 12 hours to discover an astounding number of interruptions in one day. This provides insight into how to redesign systems so that nurses can do their jobs without risking error

If you had to pick one area we should be focusing on for errors, what would that be?

In addition to hospital acquired conditions, patient hand-offs, or transitions between care are two big challenges we need to work on. Health systems need to be looking at care across the continuum, not just in a unit. Errors of transition and handoff are pretty significant. When you talk to the public about the need to reduce avoidable hospitalizations, they think you want to prevent them from getting care. We need to educate the public that some hospitalizations are avoidable, and can be viewed as errors – events that should not happen if the management plan is well executed.

Where do you think the IOM report fell short?

The report helped raise awareness, and get our attention about safety and system problems but it fell short in providing a blueprint on how to get from where you are to where you need to be. We still don’t know how to truly design a safe health care system or a safe health care environment. The past 10 years gave us a lot of new knowledge about safety interventions but we now have to implement these and scale up to affect the whole system not just one unit or one hospital.

Will a reformed health system help?

I think health reform may remove a lot of barriers. Hopefully payment reform can send important signals that redesign is important and should be paid attention to. We also need to do better in the next five years in setting targets and working to meet them. If we want 80 percent of hospitals to have zero infection rates in three years, after one year, we need to measure where we are and intervene to make sure we meet our target.

But you still have to engage providers in the effort?

The challenge for health care organizations in the next five years is to provide consistent signals. Right now health providers – hospitals, doctors and nurses – are getting too many signals. We need to find a way of aligning all of these. What I fear is that people who are taking care of patients every day don’t necessarily make the connections between the importance of a medical home, an accountable care organization, inappropriate readmissions, and safety. These are really high-level organizational concepts and we really have to help providers and health professionals see how to make these concepts real. For example, if you talk to a physician about how to avoid unnecessary hospitalizations, it is unlikely that you will get much attention. The physician is focused on the immediate clinical condition of the patient, not necessarily on reducing a potential future hospitalization. Yet, if patients are managed well for their diabetes or asthma, if they are seen in the office soon after they leave from a hospital stay where things like medication reconciliation may happen, those actions will impact on patient outcomes and rehospitalizations. So there is a link between redesigning a practice to be more integrated or to have the elements of a medical home and the fact that by doing this, it will impact safety. The concepts have to be discussed to make sense to those redesigning the care. We have to make the connection to all providers and show them that by pulling a few key levers you can improve care as well as impact safety.

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