Fourteen years have passed since the Institute of Medicine released its seminal report, To Err Is Human: Building a Safer Health System. Almost overnight, an intense scrutiny occurred in U.S. hospitals with a focus on measurements of clinical quality and patient safety. That the IOM message was taken to heart clearly can be seen in the results of the HealthLeaders Media 2013 Clinical Quality and Patient Safety Survey.
The commitment to performance metrics, organizational accountability, and diverse resources comes through in the survey results. Great progress has been made to ensure that things are done right (quality) and that the right things are done (safety). But as also is seen, challenges for the future remain.
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When looking at the present state, the survey findings correlate tightly whether the question posed addressed "clinical quality" or "patient safety." For example, when asked about experience with metrics, the survey showed 95% of reporting organizations indicating either a "great deal of experience" or "some experience" with both clinical quality metrics (Figure 5) and patient safety metrics (Figure 6).
Likewise, the importance of these initiatives in organizations is demonstrated by the "highest level of leadership" to be at or above the vice president level in 83% of organizations for clinical quality (Figure 1) and 76% for safety initiatives (Figure 2).
A further parallel showed that 79% of organizations surveyed felt that the level of resources committed to clinical quality was "exceptional" or "adequate"; for patient safety it was 80% (Figures 11 and 12). The survey indicates that most organizations have taken seriously the IOM's call to arms.
When addressing the future, greater divergence of opinion emerges. When asked to cite their organization's biggest challenges in Hospital Compare clinical quality metrics (Figure 14), 68% of respondents identified 30-day readmission rates as the No. 1 concern.
The other closely associated value-based purchasing "outcome metrics" include serious complications and mortality and yet few respondents list these concerns among their top three: just 22% and 11%, respectively. Why such a disparity? Readmissions may represent the angst of a provider having to bear financial risk for a whole spectrum of care that they may not control. For some, this may include patient behavior/preferences, and an entire host of postacute care options that may not be well integrated.
A further disparity is noted when leaders were asked to address the three biggest challenges in advancing to the next level of quality (Figure 15). Integrating clinical data with IT is the only item registering above 50%. Below that is a smattering of different concerns, such as limited personnel or financial resources.
Similar scatter is noted when healthcare executives identified the three biggest stumbling blocks to adopting an effective safety program (Figure 17), where the highest score was 35% for fear of punishment for self-reporting errors and fear of retaliation for reporting others' errors. Additional roadblocks included concerns about leadership, communication, and buy-in.
So, while great progress has been made since the 1999 IOM report, there also is a long road yet to go. Future challenges include both external and internal concerns. The external concern is the need to integrate care in order to provide clinical quality and patient safety across an entire continuum of care settings.
The internal challenges concern culture, that stew of behaviors, beliefs, and actions that define an organization. Concerns about fear and retaliation and communication and leadership clearly are identified. The challenge for leaders is to drive the changes necessary to align external forces and address internal culture to achieve the next level in both clinical quality and patient safety.