Lehigh Valley Hospital: engaging patients and families

BACKGROUND: Lehigh Valley Hospital (LVH), a 623-bed tertiary care referral center, is one of two hospitals of the Lehigh Valley Hospital and Health Network. PATIENT AND FAMILY INVOLVEMENT: Improving patient safety requires active engagement. Many units have collaborative rounds, which family members may join. Family meetings often include multimedia sources to review patient conditions, results, and plans of care. LVH's advanced intensive care unit program allows virtual meetings with an off-site intensivist. USE OF INFORMATION TO SET AND EVALUATE QUALITY GOALS AND PRIORITIZE INITIATIVES: The Institute of Medicine (IOM) aims of care are addressed in terms of Donabedian's clinical outcomes (safety, effectiveness, and timeliness), financial outcomes (efficiency), and service outcomes (patient-centeredness and equity). APPROACH TO ADDRESSING THE SIX IOM AIMS: Two strategies to address the IOM's six aims have been employed--patient engagement and an emphasis on technology. More than $30 million has been invested, thereby creating a digital hospital, which, in combination with evidence-based practice, uses advanced computerized and wireless systems to improve patient care and safety. CHALLENGES AND LESSONS LEARNED: New problems evident once process improvements are made are quickly addressed. Technology cannot fix bad processes; rather, process improvements should come first, with technology then added to enhance those improvements.     

Assessing recommendations from the IOM's quality chasm report

The most recent Institute of Medicine report recommends immense changes for healthcare institutions and places information technology as a central component of proposed changes. This paper gives an overview of the IOM report, analyzes several key IT topics, and suggests required actions to effect the IOM's recommendations.     

Calling in the feds. IOM's new report says government must take lead in quality,but can Congress,hospitals find the money and support?

A new report by the Institute of Medicine calls for the federal government to "take the lead" in healthcare quality. Janet Corrigan, director of the IOM's Board of Health Care Services, and other members of the IOM say only the nation's largest provider and payer has what it takes to build a safer environment for patients. Can Congress come up with the money and support necessary to sustain such an undertaking?     

The Cease Smoking Today (CS2day) initiative: a guide to pursue the 2010 IOM report vision for CPD

This article reviews the articles in this supplement that describe a smoking cessation project, Cease Smoking Today (CS2day) that demonstrated successful outcomes: physician adoption of a smoking cessation guideline and an increase in smoking quit rates. The authors examine how the activities of the CS2day project compared to the principles and characteristics of the vision for a future system of continuing professional development that was described in the 2010 Institute of Medicine (IOM) report, Redesigning Continuing Education in the Health Professions. While it did not meet all the characteristics of the IOM's vision, the CS2day Initiative met enough of them for the authors to suggest that the momentum that the IOM report generated has been sustained. The authors point out two strengths and two weaknesses that further strategic and organizational efforts should consider. The two strengths were the collaborative nature of the project and an approach to continuous outcomes assessment that was based on competencies derived from a practice guideline. The authors also suggested that future similar efforts should place more emphasis on instructional design and developing a program theory to guide program operations and educational development. The authors encouraged members of the CME profession to consider the accomplishments of the CS2day project as they are planning to move their CME programs toward the vision described in the IOM Report.     

The identification of best practices in teaching quality competencies for preparing future health care leaders

The mandate for quality in all aspects of clinical practice, service delivery, and management practice has never been greater. The Institute of Medicine's (IOM) landmark work To Err is Human heightened the urgency of this serious issue. In a follow-up report, the IOM's Crossing the Quality Chasm called for radical change to achieve numerous quality objectives throughout the continuum of the healthcare system including the preparation of future healthcare leaders. This study was conducted to assess how effectively healthcare management education faculty are meeting the challenge of integrating quality improvement into their curricula and how faculty perceived their quality expertise. Another goal was to identify the student learning assessment strategies, teaching methods, content, and resources utilized by faculty to achieve this integration and to suggest a framework for "best practices" in teaching quality competencies citing the literature. The study's findings raise a number of important issues with respect to the ways in which QI is conceptualized and integrated into curricula and concludes that there is substantial need for 'quality improvement' in healthcare management education faculty's approaches to the teaching of QI.     

The identification of best practices in teaching quality competencies for preparing future healthcare leaders

The mandate for quality in all aspects of clinical practice, service delivery, and management practice has never been greater. The Institute of Medicine's (IOM) landmarkwork To Erris Human heightened the urgency of this serious issue. In a follow-up report, the IOM's Crossing the Quality Chasm called for radical change to achieve numerous quality objectives throughout the continuum of the healthcare system including the preparation of future healthcare leaders. This study was conducted to assess how effectively healthcare management education faculty are meeting the challenge of integrating quality improvement into their curricula and how faculty perceived their quality expertise. Another goal was to identify the student learning assessment strategies, teaching methods, content, and resources utilized by faculty to achieve this integration and to suggest a framework for "best practices" in teaching qualitycompetencies citing the literature.The study's findings raise a number of important issues with respect to the ways in which QI is conceptualized and integrated into curricula and concludes that there is substantial need for 'quality improvement' in healthcare management education faculty's approaches to the teaching of QI.     

Medical technology in the United States. The last decade.

This paper reviews the evolution of U.S. policy toward medical technology in areas such as cost containment, regulation of devices and drugs, and third party reimbursement. In addition the authors chronicle the diffusion of major medical technologies, procedures, and organizational innovations in the United States. Finally, the article provides tentative observations on the effect of recent policy changes and concludes with some recommendations for the future.     

Dietary reference intakes: implications for fiber labeling and consumption: a summary of the International Life Sciences Institute North America Fiber Workshop, June 1-2, 2004, Washington, DC

Multiple definitions of dietary fiber have been developed and are in use around the world. The definitions vary as to which substances are considered to be fibers, the analytical methods utilized to identify and measure these fibers, and whether physiological criteria are part of the definition. A workshop entitled "Dietary Reference Intakes: Implications for Fiber Labeling and Consumption" was held by the International Life Sciences Institute North America Technical Committee on Carbohydrates to review the fiber definitions recently published by the Institute of Medicine (IOM) of the National Academies. Presentations and facilitated discussions reviewed the rationale for the IOM definitions of dietary fiber, functional fiber, and total fiber in light of evolving nutritional science. Also discussed were potential analytical, regulatory, and consumer issues involved if the US Food and Drug Administration and/or Health Canada were to implement the IOM's recommendations. Issues, concerns, and questions to be addressed are summarized here.     

Service-learning: an integral part of undergraduate public health

In 2003, the Institute of Medicine (IOM) described public health as "an essential part of the training of citizens," a body of knowledge needed to achieve a public health literate citizenry. To achieve that end, the IOM recommended that "all undergraduates should have access to education in public health." Service-learning, a type of experiential learning, is an effective and appropriate vehicle for teaching public health and developing public health literacy. While relatively new to public health, service-learning has its historical roots in undergraduate education and has been shown to enhance students' understanding of course relevance, change student and faculty attitudes, encourage support for community initiatives, and increase student and faculty volunteerism. Grounded in collaborative relationships, service-learning grows from authentic partnerships between communities and educational institutions. Through emphasizing reciprocal learning and reflective practice, service-learning helps students develop skills needed to be effective in working with communities and ultimately achieve social change. With public health's enduring focus on social justice, introducing undergraduate students to public health through the vehicle of service-learning as part of introductory public health core courses or public health electives will help ensure that our young people are able to contribute to developing healthy communities, thus achieving the IOM's vision.     

A new health system and its quality agenda

This article reviews recent work on healthcare quality, highlights findings and recommendations of the Institute of Medicine (IOM) reports on medical errors and quality, and describes response to the reports to date. In it, Detmer, chair of the IOM's Board of Health Care Services and a member of its Committee on Quality of Health Care in America, identifies implications of the reports for healthcare delivery organizations and professionals and outlines ways organizations and professionals can improve the six dimensions of patient quality defined by the IOM. Sustained efforts at the point of care and in policy development are needed to overcome cultural inertia, realign incentives, support innovation, and address technical and human resource issues. Success requires that healthcare executives embrace the goal of transforming the healthcare sector into a true system and provide leadership for their organizations and communities in this most fundamental of challenges for twenty-first century healthcare.     

Using electronic health records to help coordinate care

The use of electronic health records that can securely transmit patient data among physicians will help coordinate the care of 60 million Americans with multiple chronic conditions. This article summarizes the different organizations in the United States that are developing this technology. It discusses some of the problems encountered and the current initiatives to resolve them. The article concludes with three recommendations for enhancing care coordination: (1) a common health record, such as the Continuity of Care Record, to facilitate the exchange of clinical information among health providers; (2) regional governance structures to encourage the exchange of clinical data; and (3) payment by purchasers of care, both public and private, to physicians for using electronic health records.     

Health departments' implementation of public health's core functions: an assessment of health impacts

OBJECTIVES: The purpose of this article was to investigate the relationship between state health agencies' adherence to the recommendations of the United State's Institute of Medicine's (IOM) report, "The Future of Public Health", and changes in their populations' health. STUDY DESIGN: Data were abstracted from agencies' plans, budgets, annual reports, etc. spanning a 5-year period. A comprehensive change in population health measure over the same period was drawn from the UnitedHealth Group's annual survey. METHODS: Configurations, based on public health core functions, were established using linear regression and qualitative comparative analysis. The dependent variable was a holistic measure of change in a state population's health status. RESULTS: State agencies that most completely adopted a public health model emphasizing assessment, assurance and policy development also experienced significant improvements in their population health measures. CONCLUSIONS: State agencies that more completely adopted the IOM's public health core functions had a concomitant improvement in their populations' health statuses. Further research to explore if there is a causal link between adoption of the core functions and positive health impacts is warranted.     

New and dis-improved: on the evaluation and use of less effective, less expensive medical interventions.

The innovation and diffusion of new technologies is in large measure responsible for the persistent rise in the cost of health care. The increasing cost of health care, in turn, will make cost-saving technologies more attractive. When cost-saving technologies lead to better or equivalent outcomes, their acceptance will not be controversial. However, the necessary conditions for the development and clinical acceptance of cost-saving technologies that might diminish the quality of health care have not been systematically considered. Indeed, as the clinical research enterprise has been focused almost entirely on quality-improving (or quality-neutral) innovations, new concepts may need to be introduced for quality-reducing innovations. Although the development of such therapies would, at least in some circumstances, increase overall societal benefits, replacing a standard therapy with a less effective one may conflict with deeply held values, such that conventional cost-effectiveness benchmarks might not apply. In addition, from a clinical research perspective, there are considerable ethical and methodologic hurdles that might impede the development of less expensive, less intensive therapies. In this article, using a hypothetical scenario, the authors consider economic, ethical, and research design issues concerning the innovation and diffusion of less effective, less expensive therapies and introduce 2 concepts--"decremental cost-effectiveness" and "acceptability trials"--that may in part provide a research framework for the study of "new and dis-improved" therapies.     

The double burden on safety net providers: placing health disparities in the context of the privatization of health care in the US

The US Institute of Medicine's (IOM) influential 2003 report has focused attention on disparities in treatment outcomes and health status for American minorities, zeroing in on the role of unconscious bias in the unequal clinical disposition of minority patients. In keeping with the IOM's focus, current examinations of health disparities in the US tend to explore bias in clinical decision-making to the neglect of the political economic trends that buffet health care safety net sites and create the need for financial shortcuts. This paper recontextualizes the study of health disparities in the US by placing it against the backdrop of private sector trends emphasizing fiscal austerity and increased workforce productivity in health care. The social science literature on workers in human service bureaucracies, only recently applied to health care workers, suggests that higher demands for system "accountability" and worker "efficiency" may encourage providers to take shortcuts by treating individuals as mass categories. This ethnography of a Latino mental health clinic in the Northwestern USA shows that new private-sector measures of "productivity" take a toll on both the Latina clinicians whose invisible work subsidizes the system as well as on particular categories of patients--the uninsured and immigrants with serious psychosocial issues. While clinicians attempt to buffer the impacts of such reforms on patients, they also resort to means to increase their productivity such as firing repeated no-show patients and denial of care to the uninsured. This study is relevant for the health care of the poor in all health care systems considering restructuring along managerial principles to increase system 'efficiencies.'     

Considerations for increasing the competences and capacities of the public health workforce: assessing the training needs of public health workers in Texas

Background  

Over the last two decades, concern has been expressed about the readiness of the public health workforce to adequately address the scientific, technological, social, political and economic challenges facing the field. A 1988 report from the Institute of Medicine (IOM) served as a catalyst for the re-examination of the public health workforce. The IOM's call to increase the relevance of public health education and training prompted a renewed effort to identify competences needed by public health personnel and the organizations that employ them.     

Minimally invasive therapy: the French case study

The diffusion in France of the 10 selected technologies is quite different, depending on the technology. Some are 'ancient', widely diffused and stabilized techniques, such as arthroscopy for knee surgery and lithotripsy for bladder stones. Others are very new but quickly disseminating technologies, such as laparoscopic cholecystectomy, and others, especially those based on lasers, have only a restricted diffusion related in some cases to a lasting skepticism of most physicians. It is therefore not possible to draw a common sketch that would apply to 'minimally invasive surgery in France' as a whole. Nevertheless, it is possible to stress some common points which characterize the dissemination of innovation in the French health care system since the 1980s. These include the lack of methods available to health authorities to control medical innovation; the organizational and financial constraints on health care institutions, restricting their ability to adapt to changing circumstances; a limited judicial response in the face of potentially dangerous technologies; the high degree of freedom that medical practitioners have in adopting innovations; the weakness of French industry; and the important and sometimes destructive role the media play in diffusion of health care innovations.     

Discordance in the assessment of prepregnancy weight status of adolescents: a comparison between the Centers for Disease Control and Prevention sex- and age-specific body mass index classification and the Institute of Medicine-based classification used for maternal weight gain guidelines

In 1990, the Institute of Medicine (IOM) issued maternal weight gain guidelines to prevent intrauterine growth retardation based on adult prepregnancy body mass index (BMI; calculated as kg/m(2)). A recent IOM report, however, expressed concerns regarding application of adult criteria (prepregnancy BMI and gestational weight gain recommendations) to categorize pregnant adolescents. To draw attention to the assessment of prepregnancy weight status among adolescents and to its potential clinical implications, we estimated the percent discordance between the Centers for Disease Control and Prevention (CDC) BMI-for-age categories currently used for the assessment of adolescent weight status (underweight, healthy weight, at risk of overweight, and overweight) and the IOM-based categories (low, average, high, obese) among 11,656 adolescents 12 to 20 years old from a birth registry. Approximately one quarter of all adolescents in this sample and 40% of young adolescents (12 to 15 years old) were "misclassified." Among healthy weight adolescents, 23.4% and 0.6% were "misclassified" as low and high, respectively, by IOM categories. Among at-risk of overweight adolescents, 13.5% and 26.9% were "misclassified" as average and obese by IOM categories. Based on our findings, we suggest that adolescent prepregnancy weight categories be assessed using the CDC BMI charts and to examine gestational weight gain distributions exclusively among adolescents according to the CDC BMI categories.     

The future of best investing in vaccines: the Health Technology Assessment approach

Over the past two decades, scientific research has led to the development of a huge number of new health technologies, among which new vaccines. The decision process underlying the introduction of a new vaccine will be of particular concern in the future and a useful tool is needed to orientate decision makers towards better allocation of economic resources. Health Technology Assessment (HTA) is a multidisciplinary tool that aims to examine the clinical, economic, organizational, ethical, juridical, social and cultural implications of the introduction or the implementation of a specific technology; it could so represent an innovative and effective approach in order to support decision-making processes.     

Crossing the quality chasm: implications for health services administration education

Programs in Health Services Administration (HSA) should respond to the mandate to improve patient care as put forth by the Institute of Medicine (IOM) and other reports on the proliferation and consequences of medical errors. This article will identify a framework to base curriculum change, competency areas, and educational methods to impart quality improvement knowledge and skills. The first six competency areas reflect the six redesign imperatives from the IOM report, Crossing the Quality Chasm: A New Health System for the 21st Century (2001): redesign of the care process; use of information technologies; knowledge and skills management; development of effective teams; coordination of care; and use of performance and outcomes measurement. Based on a literature review, five additional areas were identified: strategic quality planning; programs for patient safety and risk management; change management; roles of stakeholders, payers and regulators; and development of a learning environment and blame-free culture. Examples of curriculum content are provided from HSA programs at Georgetown University, University of Washington, and University of California at Berkeley.