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Summary
Collaborative Education to Ensure Patient Safety
Continued
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IOM Theme 2: Identifying and learning from errors through immediate and strong mandatory reporting efforts, as well as the encouragement of voluntary efforts with the aim of making sure the system continues to be made safer for patients
Effective and efficient reporting systems that embrace advanced technology and that are integrated with care management are considered a vital and integral part of a transformed system of health care aimed at improved patient safety. Current systems tend to be archaic, given the state of technology available and frequently fail to include the information systems components already known to produce quality information for health care management purposes. Part of the problem in attempting to create an optimal information system in health care is cost. High quality systems are expensive and few health care organizations have been willing to invest the sums required to produce effective systems. But part of the reluctance to embark on new information systems approaches relates to the litigious nature of US society and to the punitive cast attached to current reporting approaches. If enhanced patient safety requires a substantially improved information base, it will be necessary to change the environment in which reporting of adverse events occurs. Conferees recommend the following:
DHHS should encourage the creation of an environment (i.e. academic settings and the public consciousness) conducive to the increased and improved usage of information technology in interdisciplinary education and practice. For example:
- Initiatives to support faculty development in the area of information technology and its applications as pedagogy. Faculty need both to understand the use of advanced information technology approaches and systems, and how best to teach it.
- Establishment of standardized patient record models for data encoding and sharing between health care providers and institutions involved in the care of individual patients. The interface problems earlier mentioned are exacerbated by discontinuities on the types of record systems maintained by the differentprovider groups and institutions. However expensive, we are well past the point at which we can afford to maintain our current archaic systems of record maintenance.
- Establishment of strong privacy protections to build public trust. The public is growing increasingly aware that its fundamental privacy rights are violated routinely. The health care establishment cannot afford privacy breaches and we must have security safeguards built in and well publicized to continue to sustain the public's trust.
IOM Theme 3: Raising standards and expectations for improvements in safety through the actions of oversight organizations, group purchasers, and professional groups
The development of a new approach to health care education and management will require the active involvement of the entire industry, including especially those groups and individuals in an oversight or fiscal policy position. New standards, new models, and new reward approaches are required to achieve the level of system transformation intended. To gain the active involvement of the key actors throughout the industry, the meeting participants agreed on the following recommendations:
- Design a new public-private partnership modeled after the Malcolm Baldrige Awards 3 that exist to reward excellence in private sector enterprise. In this case, the awards would be given to institutions that have demonstrated excellence in patient safety and initiatives to achieve gains in safety. Such a national awards model would elevate the subject to national prominence and create a valuable incentive system for innovations that deliver improved patient safety. The Baldrige Awards program was supported through Federal legislation, but is supported through a public-private foundation.
- It will be necessary to gain the active support of all the organizations that oversee the performance of health care institutions and, especially those organizations, such as HCFA and the private carriers, that set standards through their financial policies. HRSA should convene policy meetings with COGME and NACNEP leadership to begin a dialogue on how best to gain the support of the key oversight, professional, and financial institutions.
- Patient safety standards are affected by the wide range of professional licensing standards, which vary among states. Although the Federal government has exhibited understandable reluctance to engage this clear state prerogative, conferees believe that greater uniformity in performance standards leading to professional licensing decisions would eventually lead to greater patient safety. A path to a feasible action plan is not clear to the conferees, although HRSA is urged to initiate discussions with responsible policy officials involved in professional licensing to discuss alternatives to the current variable processes. This issue is potentially so contentious that a major policy-oriented study by the IOM might be required to make progress.
- Certification and accreditation processes should include specific requirements and criteria for interdisciplinary programs to promote patient safety in practice, professional education, graduate training, and continuing education. Team and collaboration skills, conflict resolution, training in continuous quality improvement, medical error prevention, and ethics should be included in all programs. Programs should be problem-based and require active participation rather than passive learning.
- Encourage professional organizations and certification bodies to explore the potential for joint MD-Nurse continuing education and training approach. A joint certifying/accrediting body or reciprocity in accreditation for interdisciplinary programs to promote patient safety might be potential mechanisms.
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The Malcolm Baldrige National Quality Award was created by Public Law 100-107, signed into law on
August 20, 1987. The Award Program, responsive to the purposes of Public Law 100-107, led to the
creation of a new public-private partnership. Principal support for the program comes from the Foundation
for the Malcolm Baldrige National Quality Award, established in 1988. The Malcolm Baldrige National
Quality Award is the centerpiece of the Baldrige National Quality Program. This award, which since 1988
has been presented annually by the President to recognize performance excellence, focuses on an
organization's overall performance management system. It does not certify product or service quality.
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