To err is human and crossing the quality chasm

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Instructions
Write your responses where it reads “Enter your response here.” Write as much as needed to satisfy the requirements indicated. Each item contains the Rubric, which will be used to evaluate your responses.

1. The IOM Reports In 2000 the Institute of Medicine (IOM) published To Err Is Human: Building a Safer Health System, and in 2001 a follow-up report, Crossing the Quality Chasm. The resulting efforts to reduce medical mistakes have dramatically changed the face of healthcare in the United States. Understanding the content of these reports is foundational to effective leadership in healthcare. With that in mind, respond to the following:

· Briefly explain the key focus of To Err Is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century. What were the objectives of each? How did the reports differ? (3 paragraphs)

· Explain the impact of each of these reports. What changes have occurred that can directly be tied to their dissemination? Access some of the recent State of Health Care Quality Reports to explore improvements in quality. (3 paragraphs)

· Identify IOM’s six aims for improving healthcare quality, and describe subsequent advances made in delivering quality healthcare related to IOM’s six aims. (3 paragraphs)

Your Response
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Rubric
0

Not Present

1

Needs Improvement

2

Meets Expectations

3

Exceeds Expectations

Sub-Competency 1: Analyze the Institute of Medicine (IOM) reports, To Err is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century, and their impact on healthcare.

Learning Objective 1.1:

Explain the key objectives of and differences between the IOM reports, To Err Is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century.

Explanation of the key objectives of and differences between the IOM reports, To Err Is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century, is missing.

Response inaccurately explains the key focus and three objectives of To Err Is Human, or it explains fewer than three objectives.

Response inaccurately explains the key focus and three objectives of Crossing the Quality Chasm, or it explains fewer than three objectives.

Response inaccurately explains three differences between To Err Is Human and Crossing the Quality Chasm, or fewer than three differences are explained.

Response accurately explains the key focus and three objectives of To Err Is Human.

Response accurately explains the key focus and three objectives of Crossing the Quality Chasm.

Response accurately explains three differences between To Err Is Human and Crossing the Quality Chasm.

Demonstrates the same level of achievement as “2” plus the following:

Response accurately explains four or more objectives of each of the two reports, and four or more differences between the two reports.

Learning Objective 1.2:

Explain the impact of the 2001 IOM reports, To Err Is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century.

Explanation of the impact of the 2001 IOM reports, To Err Is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century, on healthcare is missing.

Response inaccurately explains the impact of the two reports or includes fewer than three changes resulting from their dissemination.

Response accurately explains the impact of the two reports, including at least three changes resulting from their dissemination.

Demonstrates the same level of achievement as “2” plus the following:

Response describes four or more changes and explains how the changes occurred as a result of the dissemination of the reports.

Learning Objective 1.3:

Identify IOM’s six aims for improving healthcare quality, and describe subsequent advances made in delivering quality healthcare.

Identification of IOM’s six aims for improving healthcare quality and description of related advances made in delivering quality healthcare are missing.

Evaluation does not identify all of the IOM’s six aims and/or does not sufficiently or accurately describe advances made.

Response accurately identifies the IOM’s six aims for improving healthcare quality.

Response describes three subsequent advances made in healthcare quality related to the IOM’s six aims.

Demonstrates the same level of achievement as “2” plus the following:

Response includes examples of two or more of the advances made and explains why these changes are critical to quality care.

2. System-Wide Safety Failures Every system is perfectly designed to achieve the results it gets. —Dr. Paul Batalden

In the years following the publications of To Err Is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century, increased attention was given to mitigating the circumstances in which patient safety is compromised. Increasingly, adverse events that occur within healthcare organizations are recognized, not as the failure of any individual (health provider or patient) but as system-wide failures. High-profile sentinel events, such as Libby Zion, Josey King, and the Quaid twins, to name a few, have attracted public attention and spotlighted the tangled or missing systemic threads that can lead to serious outcomes. Likewise, in this environment, adverse events that might cause little or no harm are gaining increased attention. This shift in perspective is having a profound and ongoing impact on how healthcare is delivered, regulated, and reimbursed.

Bring to mind an adverse event that has been publicized or one with which you are familiar, one for which there was a resulting systems change. With this event in mind, respond the following:

· Analyze the adverse safety event that became an impetus for systems changes related to patient safety as follows:

· Describe the event and its effects on key persons involved. (3 paragraphs )

· Explain the systemic failure that allowed the event to occur. (3 paragraphs)

· Explain system changes that were made as a result of this event as well as the outcomes of those changes. (3 paragraphs)

Your Response
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Rubric
Sub-Competency 2: Analyze adverse events to determine system-wide safety failures.

Learning Objective 2.1:

Describe an adverse event and its effects on key persons involved

Description of an adverse event and its effects on key persons involved is missing.

Response provides a general or incomplete account of the adverse event.

Response is missing key people involved in the adverse event.

Response provides a detailed account of the adverse event.

Response describes the effects that the adverse event had on the patient, the patient’s family, healthcare staff, the healthcare organization, and the community.

Demonstrates the same level of achievement as “2” plus the following:

Compelling examples are given of the effects that the adverse event had on key persons involved.

Learning Objective 2.2: Explain a systemic failure that allowed an adverse event to occur.

Explanation of a systemic failure that allowed an adverse event to occur is missing.

Response does not clearly explain a systemic failure that allowed the adverse event to occur and/or the reasoning for how the system failure allowed the adverse event to occur was weak.

Response clearly explains a systemic failure that allowed the adverse event to occur—either a breakdown in the system, or a functioning system that is causing the problem.

Response explains how the system failure allowed the adverse event to occur.

Demonstrates the same level of achievement as “2” plus the following:

Explanation of the system failure extrapolates to additional scenarios of what may happen if systemic changes are not made.

Learning Objective 2.3:

Explain system changes resulting from an adverse event and outcomes of those changes.

Explanation of system changes resulting from an adverse event and outcomes of those changes is missing.

Response vaguely describes system-wide changes made in response to the adverse event.

Response describes only one positive outcome achieved as a result of the changes.

Response describes system-wide changes made in response to the adverse event.

Response describes two or more positive outcomes achieved as a result of the changes.

Demonstrates the same level of achievement as “2” plus the following:

Response includes possible unintended consequences that may result from the system change.

3. Roles and Activities of Organizations in Ensuring Patient Safety and Quality

Many different organizations deal specifically with quality and safety in healthcare situations. These organizations include, among others, the Institute for Healthcare Improvement (IHI), the Agency for Healthcare Research and Quality (AHRQ), The Leapfrog Group, and the Institute for Safe Medication Practices (ISMP). It is important for healthcare administrators to be familiar with these organizations and understand their missions, what they can offer, and their approaches to ensuring patient safety and quality. Demonstrate your knowledge of these organizations as follows:

· Briefly describe two different organizations associated with the area of patient safety, including their mission, purpose, and values. (3 paragraphs)

· Describe the history of each organization. How and why was it begun? Who were its principal organizers? (3 paragraphs)

· Explain how the key activities of the organization align to its mission. (3 paragraphs)

· Describe two key achievements of each organization in the area of patient safety and the impact of those achievements on patient safety. (3 paragraphs)

Your Response
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Rubric
Sub-Competency 3: Explain the mission, activities, and achievements of organizations that focus on patient safety and quality.

Learning Objective 3.1: Describe two organizations associated with the area of patient safety.

Description of two organizations associated with the area of patient safety is missing.

Response insufficiently or inaccurately describes two organizations associated with the area of patient safety, or describes only one organization.

Response inaccurately explains the origins of each organization—the principal organizers and impetus for organizing.

Response inaccurately describes the mission, purpose, and/or values of each organization.

Explanation of how the activities of each organization are aligned to its mission is unclear or illogical.

Response identifies two organizations associated with the area of patient safety.

Response accurately explains the origins of each organization—the principal organizers and impetus for organizing.

Response accurately describes the mission, purpose, and values of each organization.

Response explains how the activities of each organization are aligned to its mission.

Demonstrates the same level of achievement as “2” plus the following:

Response describes one or two examples of how a healthcare administrator might utilize the organizations described to enhance patient safety

Learning Objective 3.2:

Describe key achievements of organizations that are associated with the area of patient safety and the impact of those achievements on patient safety.

Description of key achievements of organizations that are associated with the area of patient safety is missing.

Response describes only one achievement of organizations associated with patient safety or the description is inaccurate.

Response does not explain the impact these achievements have had on patient safety, or the explanation does not demonstrate the connection between the achievement and patient safety.

Response accurately describes two achievements of organizations associated with patient safety.

Response explains the impact these achievements have had on patient safety.

Demonstrates the same level of achievement as “2” plus the following:

Response accurately describes more than two achievements of organizations associated with patient safety, and their impact on patient safety.

4. Victims of Errors: A Broader Perspective No one goes into healthcare to hurt people, and yet healthcare is a high-stakes arena in which adverse events occur. Based on your understanding of the concept of “victim” in terms of medical errors (as presented in the Learning Resources), complete the following:

· Articulate the pros and cons of this statement: Those who make errors that harm patients themselves are victims and need support and perhaps counseling. Then, state your position on the statement. (3 paragraphs)

· Provide a rationale for your point of view that references the larger context of patient safety, including transparencies, reporting of errors, and accountability. (3 paragraphs)

· Write a brief analysis of the impact of “no-blame” systems in encouraging providers to report their own mistakes. (3 paragraphs)

Your Response
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Rubric
Sub-Competency 4: Analyze multiple perspectives on the notion of viewing as victims those who make errors that harm patients.

Learning Objective 4.1:

State pros and cons regarding the notion that “those who make errors that harm patients are themselves victims.”

Statement of the pros and cons regarding the notion that “those who make errors that harm patients are themselves victims” is missing.

Response does not address both pros and cons of the statement.

Response does not include a logical rationale for each pro and con, and/or does not sufficiently or accurately reference transparencies in the healthcare environment, reporting/disclosure of errors, and personal accountability.

Response clearly states both pros and cons of the statement “those who make errors that harm patients are themselves victims.”

Response includes logical rationale for each pro and con.

Response includes references to transparencies in the healthcare environment, reporting/disclosure of errors, and personal accountability.

Demonstrates the same level of achievement as “2” plus the following:

Response provides an organization-centered rationale for supporting and counseling those who make errors that harm patients from the perspective of a healthcare administrator.

Learning Objective 4.2:

Analyze the impact of “no-blame” systems on patient safety.

Analysis of the impact of “no-blame” systems on patient safety is missing.

Analysis does not accurately explain the history and/or meaning of “no-blame” systems in healthcare.

Analysis does accurately describe positive results and/or criticisms and/or impact of “no-blame” systems.

Analysis briefly explains the history and meaning of “no-blame” systems in healthcare.

Analysis accurately describes two positive results of “no-blame” systems.

Analysis explains one criticism of the “no-blame” approach.

Analysis describes the impact of “no-blame” systems in encouraging providers to report their own mistakes.

Demonstrates the same level of achievement as “2” plus the following:

With regard to “no blame,” the analysis explains why hand hygiene might be viewed as an accountability problem rather than a systems problem.