The IOM Report(s) Albert W. Wu, MD, MPH Johns Hopkins University

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2 The IOM Report(s) Albert W. Wu, MD, MPH Johns Hopkins University

3 Section A To Err Is Human

4 Prior to The IOM Report National Halothane Study Anesthesia Patient Safety Foundation Celebrated cases Libby Zion Betsy Lehman Harvard Medical Practice Study 4

5 Institute of Medicine Report (1999) The problem is large Health care workers are not to blame Errors and safety are caused by systems 5

6 A Systems Approach Is Necessary Errors are a leading cause of death and injury Blaming an individual does not change the factors and conditions that contribute to errors, and the same error is likely to recur Preventing errors and improving patient safety requires a systems approach Leadership, knowledge, and tools are needed 6

7 Lesson 1: The Problem Is Large 44,000 98,000 deaths annually 7,000 death from medication errors Total cost of preventable adverse events is between $17 and $29 billion Relative silence surrounds the issue 7

8 Lesson 1: The Problem Is Large 44,000 98,000 deaths annually 7,000 death from medication errors Total cost of preventable adverse events is between $17 and $29 billion More than from motor vehicle accidents, breast cancer, or AIDS 8

9 Institute of Medicine Report, November 29, 1999 Errors kill 44,000 98,000 in U.S. hospitals each year 120, ,000 80,000 60,000 40,000 20,000 Accidental Deaths in the U.S. An estimated one million people are injured by errors during hospital treatment each year and 120,000 people die as a result of those injuries, according to a study led by Lucian Leape of the Harvard School of Public Health. Here s how that number compares with other causes of accidental death in the United States ,000 medical error deaths 43,649 motor vehicle deaths 14,986 deaths from falls 3,959 drowning deaths 329 commercial aviation deaths Source: The Philadelphia Inquirer and the National Safety Council. 9

10 Lesson 2: The Workers Are Not to Blame Blame Pursuit of excellence Denial The Vulnerable System Syndrome Source: Reason. (1990). 10

11 Lesson 3: Errors and Safety Result from System Factors Patient Characteristics Institutional Hospital Departmental Factors Work Environment Team Factors Individual Provider Task Factors 11

12 A Comprehensive Approach Needed to achieve a 50% reduction in errors over 5 years Leadership at level of government and health care organizations Enhance knowledge and tools Break down legal and cultural barriers that impede safety improvement 12

13 Errors Can Be Prevented To err is human, but errors can be prevented Safety is a critical first step in improving quality of care 13

14 December 7, 1999 December 7, 1999: President Clinton directed the Quality Interagency Coordination Task Force to respond with a strategy to identify prevalent threats to patient safety and reduce medical errors Goal: Reduction in medical errors by 50% in next 5 years 14

15 QuIC Report to the President Report of the Quality Interagency Coordination Task Force (QuIC) to the President, February 2000 Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact 15

16 Steps Toward Increasing Safety Center for Patient Safety formed within the Agency of Healthcare Research and Quality Funding provided for reporting systems Greater attention on patient safety paid by regulators and accreditors Greater emphasis paid to patient safety within health care organizations 16

17 BMJ Devotes Issue to Medical Error British Medical Journal, March 18,

18 Ladies Home Journal Publishes Article on Medical Error 18

19 Section B Crossing the Quality Chasm

20 A New Health System for the 21st Century Americans should be able to count on receiving care that uses the best scientific knowledge to meet their needs, but there is strong evidence that this frequently is not the case. The system is failing because it is poorly designed.... For too many patients, the health care system is a maze, and many do not receive the services from which they would likely benefit. 20

21 Optimal Patient Outcome System Care System Supportive payment and regulatory environment Organizations that facilitate the work of patient-centered teams High performing patientcentered teams Outcomes: Safe Effective Efficient Personalized Timely Equitable Source: The Institute of Medicine. (2001). Crossing the quality chasm. Redesign Imperatives: Some Challenges Reengineered care processes Effective use of information technologies Knowledge and skills management Development of effective teams Coordination of care across patient conditions, services, sites of care over time 21

22 High Quality of Care Safe Effective Patient-centered Timely Efficient Equitable 22

23 Simple Rules for the 21st-Century Health Care System Current approach Care is based primarily on visits Professional autonomy drives variability Professionals control care Information is a record Decision making is based on training and experience Do no harm is an individual responsibility Secrecy is necessary The system reacts to needs Cost reduction is sought Preference is given to professional roles over the system New rule Care is based on continuous healing relationships Care is customized according to patient needs and values The patient is the source of control Knowledge is shared and information flows freely Decision making is evidence-based Safety is a system property Transparency is necessary Needs are anticipated Waste is continually decreased Cooperation among clinicians is a priority 23

24 Crossing the Quality Chasm Redesigning the health care delivery system will require changing the structures and processes of the environment in which health professionals and organizations function in four main areas 24

25 Four Changes in Structure and Process Applying evidence to health care delivery Using information technology Aligning payment policies with quality improvement Preparing the workforce 25

26 Evidence-Based Practice Move from practice based on tradition to practice based on evidence 26

27 Information Technology Electronic health records Reporting systems Automated treatment delivery systems 27

28 Payment Policy Public and private purchasers should develop payment policies that reward quality Current methods provide little financial reward for improvements Compensation methods should be more closely aligned with quality-improvement goals 28

29 Preparing the Workforce Change the way health professionals are trained Modify regulation and accreditation Use the liability system to support changes in care delivery 29

30 Essential Reading To Err Is Human: Building A Safer Health System. National Academies Press, 2000 Crossing the Quality Chasm: A New Health System for the 21 st Century. National Academies Press,