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Collaborative Education to Ensure Patient Safety

September 2000

The full version of this 150 page report is available in
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Executive Summary

This report describes the results of a joint meeting between national advisory councils in Medicine and Nursing on collaboration between physicians and nurses to enhance patient safety. It was carried out by the Council on Graduate Medical Education (COGME) and the National Advisory Council on Nurse Education and Practice (NACNEP). Both COGME and NACNEP are chartered advisory councils to the Congress and the Secretary of Health and Human Services. Under section 762 (COGME) and section 845 (NACNEP) of the Public Health Service Act, as amended, both Councils are mandated to assess the workforce trends in their respective professional bodies and recommend actions to address identified needs. The National Advisory Council on Nurse Education and Practice (NACNEP) was originally chartered in 1964. The Council on Graduate Medical Education (COGME) was established in 1986. The meeting was the second joint activity carried out by COGME and NACNEP. These two organizations undertook their first collaborative venture five years ago. That initiative focused on the interdisciplinary primary care workforce, leading to development of an analytic approach to estimating requirements for primary care providers and recommending further work toward eliminating barriers and facilitating collaboration. The results were published in December 1995 in the Report on Primary Care Workforce Projections. A second collaboration was discussed earlier this year, shortly after the Institute of Medicine (IOM) published its report: "To Err is Human: Building a Safer Health System." The report and the broad public reaction that followed its issuance prompted a joint COGME-NACNEP planning group to extend the examination of collaboration between physicians and nurses to look at "Collaborative Education Models to Ensure Patient Safety." The second Joint COGME-NACNEP meeting was held in Washington, D.C. on September 13-14, 2000. The meeting was planned to allow a free flowing debate on the issue of medical errors and to encourage discussion of new approaches that would reduce errors and enhance patient safety. Although education is the major focus of both advisory bodies, discussions and recommendations were encouraged on all relevant aspects of this important issue. The meeting produced substantive recommendations designed to foster interdisciplinary education and practice to promote patient safety, and concluded with a resolution to hold another collaborative meeting. Much as the Institute of Medicine report produced major themes related to achieving important gains in patient safety, the COGME-NACNEP meeting produced five major findings for which they suggest major changes will be required to achieve the needed improvements in patient safety.

Finding One: Patient safety cannot be accomplished without interdisciplinary practice approaches. Safety depends upon implementation of a unified interdisciplinary system that addresses the realities of practice and patient care. Education and practice methods must stress interdisciplinary team approaches.

Finding Two: Patient safety gains are unlikely to be achieved at a satisfactory pace in the absence of revolutionary changes. The more common, relatively slow evolutionary processes that tend to govern change in the health care system are considered to be inadequate to counter the present level of threat to patient safety.

Finding Three: Current system discontinuities need to be confronted towards the aim of building a true, safety-oriented system of care. Discontinuities exist often at the interfaces between various components of existing health care systems and significant improvements are required in the ways in which such interfaces are managed. Information has a major role to play in reducing the discontinuities and enhancing the ability of health care teams to manage successfully through the interfaces.

Finding Four: A significant cultural change in medicine and nursing is required to achieve the needed gains in patient safety. Culture in this instance refers to the language, ideas, beliefs, customs, codes, institutions, and tools employed by physicians and nurses in their practices. Existing professional cultural norms generally fail to support or encourage the types of changes implied by the interdisciplinary team approach endorsed herein. Further, even beyond the professional cultural norms that exist and are in need of change, the workforce itself must continue to become more ethnically diverse if the system is to be able to function effectively for the many ethnic and cultural subpopulations that now characterize the United States.

Finding Five: Patient safety requires that patients become acculturated in the need to participate actively in their own health care. The current "patient culture" implies that patients generally do not question the activities and interventions considered necessary by health care professionals. Physicians and nurses must adjust their own practice approaches to encourage patients to become educated and to participate in their own health care.

To Err is Human ¹ was completed by the IOM and the report issued in November 1999. The IOM study was commissioned because of the perceived apathy among all participants in the U.S. health care system, from physicians and nurses to insurers, licensing and accrediting bodies and the general public. Although the media picks up and publicizes especially tragic instances of medical errors, those cases disappear quickly, only to be replaced by other more recent events. The IOM asserts, "The goal of this report is to break this cycle of inaction. The status quo is not acceptable and cannot be tolerated any longer." Perhaps the most important point made by the IOM report, noted early in its Executive Summary is that, "A comprehensive approach to improving patient safety is needed. This approach cannot focus on a single solution, since there is no 'magic bullet' that will solve this problem, and indeed, no single recommendation in this report should be considered as the answer." Another key to the comprehensive approach discussed by the IOM is, "Building safety into processes of care is a more effective way to reduce errors than blaming individuals . . . The focus must shift from blaming individuals for past errors to a focus on preventing future errors by designing safety into the system." Blaming individuals does not make a safer system.

The IOM recommendations follow a four-tiered approach:

1. Establishing a national focus to create leadership, research, tools and protocols to enhance the knowledge base about safety;

2. Identifying and learning from errors through the immediate and strong mandatory reporting efforts, as well as the encouragement of voluntary efforts both with the aim of making sure the system continues to be made safer for patients;

3. Raising standards and expectations for improvements in safety through the actions of oversight organizations, group purchasers, and professional groups; and,

4. Creating safety systems inside health care organizations through the implementation of safe practices at the delivery level. This level is the ultimate target of all recommendations.