To err is human and crossing the quality chasm

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
Enter your response here

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.