From To Err Is Human to Improving Diagnosis in Health Care: The risk management perspective

The publication of To Err Is Human in 2000, followed by Crossing the Quality Chasm in 2001, marked a watershed in patient safety. The Institute of Medicine (IOM) reports intensified the focus on patient safety and demanded a redesign of the healthcare system to improve quality and safety. Since publication of these reports, the focus has been on improving processes—those methods of healthcare delivery prone to failure and errors. Recently, there has been a concerted and sustained drive to add cognitive (diagnostic) errors to the focus. The recent publication of the IOM's Improving Diagnosis in Health Care has expanded the focus on patient safety and quality improvement. A new focus on diagnostic errors augments rather than replaces the previous focus. In this article, the authors offer a brief review of To Err Is Human and Crossing the Quality Chasm to lay a historical foundation. They then discuss a transition into the focus on diagnostic errors and summarize the latest recommendations from Improving Diagnosis in Health Care. This collated synthesis of 3 powerful IOM reports should guide risk managers and other healthcare personnel as they strive to improve every aspect of healthcare delivery.     

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?     

Keeping patients safe: Institute of Medicine looks at transforming nurses' work environment

In November 1999, the Institute of Medicine (IOM) released To Err Is Human: Building a Safer Health System, which brought to the public's attention the serious--and sometimes deadly--dangers posed by medical errors occurring in healthcare organizations. Exactly 4 years later, an IOM committee released a new report that focuses on the need to reinforce patient safety defenses in the nurses' working environments.     

Transforming healthcare in Ontario through integration,evidence, and building capacity for improvement

Since 2005, the Ontario Health Quality Council (OHQC) has been reporting on healthcare quality in the province and supporting quality improvement activities. The 2010 Excellent Care for All Act added the evaluation of clinical evidence and making of recommendations on funding to the Council's responsibilities. In April 2011, Health Quality Ontario (HQO) was formed from a merger of OHQC and three other quality-focused organizations. The agency is now focusing on integrating the functions of all of these organizations on a quality agenda.     

Position of the American Dietetic Association: nutrition services in managed care

It is the position of the American Dietetic Association that medical nutrition therapy is an essential component of disease management and healthcare provided by managed care organizations, and that such care must be provided by qualified nutrition professionals. Compared with traditional fee-for-service reimbursement systems, managed care presents new opportunities for dietetics professionals. Until recently, the lack of billing infrastructure has handicapped nutrition providers who wish to bill for their services and has made it difficult to track the outcomes of nutrition care. With the publication of current procedure terminology codes for medical nutrition therapy (MNT) and the implementation of MNT benefits in Medicare part B for diabetes and nondialysis kidney disease, commercial payers, including managed care organizations (MCOs) are likely to implement or expand their coverage of MNT. A large body of evidence supports the efficacy and cost-effectiveness of MNT coverage within managed care plans. This evidence includes cost analyses of conditions treated by MNT, and clinical trial data confirming the efficacy of MNT in improving patient outcomes. MNT is also an important part of national standards of care for many chronic disease conditions. Based on evidence supporting the role of MNT in improving patient outcomes, the Institute of Medicine (IOM) recommended that MNT services be reimbursed by Medicare when patients are referred by a physician. Provision of appropriate MNT can also help MCOs meet accreditation and quality standards established by entities such as the National Committee for Quality Assurance and the Joint Commission for the Accreditation of Health Care Organizations. Much of the work required to secure a place for MNT in MCOs will be done at the practitioner level, by nutrition professionals themselves. Registered dietitians must market MNT to their customers in managed care by addressing the needs of each player. By emphasizing the importance of MNT and other cost-effective forms of preventive care and disease management, MCOs will be well positioned to improve population health at modest cost.     

Seven steps for adding value to integrated delivery systems

"Value is a spectrum of needs that you seek to fulfill," says Dean C. Coddington, senior author of Making Integrated Health Care Work. And adding value to products and services is becoming more crucial as healthcare organizations look for ways to stand out among competitors. The seven basic components of value for an integrated system, says Mr. Coddington, are improving quality of care, improving service, improving accessibility, reducing unit costs, increasing operating efficiency, strengthening customer ties and enhancing product offerings. In this issue, The Quality Letter reports on how several systems have used these seven components to increase patient and purchaser satisfaction.     

国外健康素养型医疗机构建设与评价及对我国的启示

介绍了美国医学研究所(Institute of Medicine,IOM)发布《健康素养型医疗机构的10个特征(Ten Attributes of Health Literate Health Care Organizations,HLHO 10个特征)》文件的背景及健康素养型医疗机构(health literate health care organization,HLHO)概念,并以Donabedian的理论为指导综述了HLHO的特征和建设措施及HLHO评价的研究进展。提出了我国医疗机构可借鉴《HLHO 10个特征》文件与国外HLHO评价现状,从人员培训、文化、制度、物理和信息环境建设,要求员工应用健康素养策略,促进服务对象参与健康材料的开发及医务人员健康教育工作的考核等措施入手,践行《健康中国行动(2019—2030年)》提出的“医务人员在诊疗过程中主动提供健康指导”和“建立医务人员开展健康教育绩效考核机制”两项指标。     

A shared vision of healthcare quality improvement.

SHEA and the American Society for Quality's Health Care Division have been collaborating in areas of common concern to improve healthcare quality. We each possess a heritage of different but complementary approaches and stand a better chance of success together than apart. This presentation describes rapid growth of our interdisciplinary, international, special interest group and progress made thus far, as well as challenges facing hospital epidemiologists and quality improvement professionals.     

An educational response to assisted suicide. Catholic systems reach out to advance compassionate care of the dying

The future of "The Oregon Death with Dignity Act" is uncertain since a preliminary injunction blocking the law's enactment has been granted. Still, three Catholic healthcare systems in the Pacific Northwest are quite clear about their commitment to providing optimal care to persons at the end of life. Bellevue, WA-based PeaceHealth; Seattle-based Sisters of Providence Health System; and Aston, PA-based Franciscan Health System have formed the Committee on Care of the Dying of the Franciscan, PeaceHealth, and Providence Health Systems. The three organizations have collaborated to develop and offer comprehensive educational outreach on compassionate care of the dying throughout Oregon. Twenty system representatives met in Portland, OR, in January 1995 and developed a vision statement, "Care at the End of Life." In addition, a steering committee of 12 representatives has identified the goals of the Committee on Care of the Dying. The steering committee has also identified seven "Organizational Commitments and Common Elements" to ensure quality and excellence in compassionate care of the dying. Recently, the Daughters of Charity National Health System, the Carondelet Health System, and the Catholic Health Association-all based in St. Louis-have joined this collaborative effort to educate healthcare providers and the public.     

健康素养型医疗机构评价工具的研究进展

健康素养型医疗机构(health literate health care organization, HLHO)建设是提升居民健康素养的必要途径。《健康中国行动（2019—2030年）》把医疗机构及医务人员在“健康知识普及”行动中发挥重要作用列为行动目标及评价指标。通过回顾国内外文献,从应用目的、评价内容及方法、评价标准、信效度和应用现况对纳入的7项HLHO评价工具进行介绍,并对工具的评价维度、调查对象与应用场景进行比较分析,以期为评价医疗机构在居民健康素养促进中的作用以及为践行《健康中国行动》中的相关内容提供参考。     

Achieving and sustaining quality in healthcare

SSM Health Care (SSMHC), the first healthcare recipient of the Malcolm Baldrige National Quality Award, has been cited by both Baldrige and the Joint Commission on Accreditation of Healthcare Organizations as having a culture of continuous quality improvement (CQI). SSM Health Care began to implement CQI systemwide in 1990. CQI provided the foundation for other strategies that served to further weave quality improvement into the fabric of the organization's culture. It gave SSMHC's people the tools and techniques to make improvements, created an environment of teamwork, and introduced the concept of improving processes. Using the Baldrige Criteria for Performance Excellence as a business model helped SSMHC to see how various organizational functions should link and to discover gaps in the linkage within its own organization. Baldrige feedback reports identified opportunities that could then be prioritized and the resulting improvements implemented. Overall, the Baldrige model gave a focused approach to what had been scattered improvement efforts. SSM Health Care considers the Baldrige model the best way for an organization to get better faster.     

Does money really matter? The effects of fiscal margin on quality of care in military treatment facilities

This study was prompted by an escalating interest in the quality of healthcare provided within the United States. The authors hypothesized that one determinant of quality is the adequacy of financial resources available to the healthcare organization. The authors addressed their question by using data from two Defense Department sources: the 2003 Health Care Survey of Defense Department Beneficiaries (HCSDB) and 1999-2003 data from the Department of Defense Medical Expense Performance Reporting System (MEPRS). The authors used a measure of military treatment facility fiscal margin to predict seven Consumer Assessment of Health Plan Satisfaction (CAHPS) quality dimensions. Regression analysis and multilevel modeling are the primary statistical methods. Results indicate a significant and positive association between organizational financial strength and quality outcomes. This finding indicates that organizations with more financial flexibility may be more adept at meeting or exceeding patient care expectations.     

Providers question PROs' effectiveness. Critics contend peer review organizations are too costly and fail to improve the quality of care

The Health Care Financing Administration (HCFA) established physician review organizations (PROs) to ensure that Medicare recipients receive care that is medically necessary, of high quality, and provided in the appropriate setting. While arguing that oversight is necessary, many healthcare professionals believe PROs do not accomplish what they were set up to do because physicians focus on the possibility of being penalized rather than on improving patient care. PRO critics claim that the program's peer reviewers are not peers of the physician under review and that, to be effective, they should come from the same local area. They contend the best peer review is conducted within the hospital. They believe intrafacility review can be more effective at bringing about improvement because hospital peer reviewers act as supportive, nonthreatening consultants. The confidentiality of the physician-patient relationship is another issue PRO critics raise. HCFA staffers say hospitalized Medicare patients are required to sign a waiver allowing inspection of their charts, but critics counter that waivers are only for the release of records for payment claims. Changes encouraging cooperation between PROs and hospitals could improve the PRO program and enhance quality of care.     

Leadership: The Winnipeg Community and Long Term Care Authority

The Winnipeg Community and Long Term Care Authority (WCA) was established in 1998 under the Regional Health Authorities Act of the Province of Manitoba. The WCA's role is to provide for the successful integration of Winnipeg's community-based healthcare delivery services through its three main portfolios: Community Care and Public Health, Home Care and Mental Health, and Long Term Care and Specialized Services. The WCA is dedicated to building a quality health future for Winnipeg. Various initiatives undertaken in the pursuit of quality are described.     

Spreading the word about the unique and valuable role of healthcare risk managers

Here I am three‐quarters through my year as president of ASHRM and I am still pinching myself that I am where I am! How has your year been? It has been a tough year for everyone in healthcare. With the Affordable Care Act demands on healthcare and the public, concerns about funding, quality initiatives, and overall potential loss of revenue, it's a wonder we are still in healthcare. But would you be doing anything different? I don't think so. I love that I can help make a difference by assisting staff with a difficult patient or situation or help a patient with a care concern that they are totally frustrated with or explain to a fellow risk manager what I would do in the situation they are dealing with. Although we feel like we are being pulled into new healthcare territories for our insight and recommendations, it is an indication of the value we bring to our organizations. We will get through this and there will be more challenges, but as risk management professionals, we can help solve problems and create value in the upcoming changes in healthcare.     

Organized systems of care. A vision of a future healthcare delivery system

Policymakers no longer question that healthcare system reform will occur; rather they differ on the timing and direction of change. The Washington Business Group on Health envisions a future healthcare delivery system called an organized system of care (OSC). An OSC is an integrated financing and delivery system that uses a panel of providers selected on the basis of quality and cost management criteria to furnish members with comprehensive healthcare services. The most important system attribute of the OSC will be the commitment of all involved to the mission of promoting the health of system members. To accomplish this mission, OSCs will incorporate the principles of continuous quality improvement. Care will be delivered through care management teams, which integrate the physical, psychological, and administrative needs of the member. Such teams might be made up of primary care physicians, nurses, and mental health professionals. Although the entire team would be responsible for the OSC member, one team member would be assigned primary responsibility for overseeing and planning care with the member.     

Patients report positive impacts of collaborative care

Collaborative Care refers to a partnership between healthcare professionals and patients who feel confident to manage their health conditions. Using an Internet-based assessment of health needs and healthcare quality, we surveyed 24,609 adult Americans aged 19 to 69 who had common chronic diseases or significant dysfunction. In these patients, we examined the association of Collaborative Care with specific measures for treatment effect, disease control, prevention, and economic impacts. These measures were adjusted for respondents' demographic characteristics, burden of illness, health behaviors, and overall quality of healthcare. Only 21% of respondents participated in good Collaborative Care, 36% attained fair Collaborative Care, and 43% experienced poor Collaborative Care. Regardless of overall care quality or the respondents' personal characteristics, burden of illness, or health behaviors, good Collaborative Care was associated with better control of blood pressure, blood glucose level, serum cholesterol level, and treatment effectiveness for pain and emotional problems. Some preventive actions were better, and some adverse economic impacts of illness were mitigated.     

Integrated Health Care Barcelona Esquerra (Ais-Be): A Global View of Organisational Development,Re-Engineering of Processes and Improvement of the Information Systems. The Role of the Tertiary University Hospital in the Transformation

The Integrated Health Area “Barcelona Esquerra” (Área Integral de Salud de Barcelona Esquerra – AIS-BE), which covers a population of 524,000 residents in Barcelona city, is running a project to improve healthcare quality and efficiency based on co-ordination between the different suppliers in its area through the participation of their professionals. Endowed with an Organisational Model that seeks decision-taking that starts out from clinical knowledge and from Information Systems tools that facilitate this co-ordination (an interoperability platform and a website) it presents important results in its structured programmes that have been implemented such as the Reorganisation of Emergency Care, Screening for Colorectal Cancer, the Onset of type 2 Diabetes Mellitus, Teledermatology and the Development of Cross-sectional Healthcare Policies for Care in Chronicity.     

The revolution in hospital management

Five healthcare systems that have either won the Malcolm Baldrige National Quality Award in Health Care or been documented in extensive case studies share a common model of management: they all emphasize a broadly accepted mission; measured performance; continuous quality improvement; and responsiveness to the needs of patients, physicians, employees, and community stakeholders. This approach produces results that are substantially and uniformly better than average, across a wide variety of acute care settings. As customers, courts, and accrediting and payment agencies recognize this management approach, we argue that it will become the standard for all hospitals to achieve. This article examines documented cases of excellent hospitals, using the reports of three winners of the Baldrige National Quality Award in Health Care and published studies of other institutions with exceptional records.