Mean hospital costs were lower for intervention patients than for controls at days Coleman et al. The model is implemented by a single advanced practice nurse using evidence-based protocols and with a focus on long-term outcomes. The model was initially tested in a randomized controlled trial of older adults at the University of Pennsylvania Hospital Naylor et al.
It resulted in fewer hospital readmissions, fewer total days rehospitalized, lower readmission charges, and lower charges for healthcare services after discharge. The final model emerged from a collaboration among the American College of Physicians, the Society of Hospital Medicine, the American Geriatric Society, the American College of Emergency Physicians, and the Society for Academic Emergency Medicine to develop consensus standards to address quality gaps in care transitions.
Although efforts to improve care transitions had been ongoing for some time, those efforts were fragmented and uncoordinated. About 3 years ago, a small group of clinicians, healthcare administrators, and government agency staff, coordinated by the Massachusetts Health Data Consortium and Massachusetts Senior Care Foundation, came together to discuss gaps in such efforts and how to disseminate individual work more broadly.
That group grew to more than stakeholders and is now known as the Care Transitions Forum, representing a community of interest that meets quarterly to share best practices and provide mentorship to institutions and organizations across the state. Concurrently, senior policy staff from the Massachusetts Executive Office of Health and Human Services had been developing statewide initiatives around patient-centered medical homes and accountable care organizations. They determined that none of these reforms would attain maximum effectiveness unless coordination across care settings was improved.
The development work was a learning process involving public and private stakeholders from across the Commonwealth. A working group composed of senior administration officials working together with the policy community began by reviewing the. To effect system change, the group explored innovations along multiple dimensions—medical practice, public health, and healthcare financing—and eventually composed a vision for the future Box A strategic plan was drafted over the subsequent months.
The strategic plan 2 contains five main sections. The next section reviews what is known about effective transitions based on national models and randomized trials. The next two sections summarize current projects in Massachusetts that form the infrastructure for future work, and place them in the state and federal policy context. The final section presents the vision for improving care transitions, including principles, recommendations, action steps, and measures for consideration. One goal is to weave the many currently fragmented care transition projects in Massachusetts into a fabric that covers the state.
We believe Massachusetts can be a model healthcare learning state and can lead the nation in improving care transitions and reducing avoidable hospitalizations. We had a number of objectives in writing the strategic plan. To this end, we. Still, the first few drafts appeared to lack a strong enough patient focus, so an unfolding case study was added to the document. Another objective was to build consensus among the many stakeholders as to the most important care transition principles; to this end, it was necessary to get people to agree to work together outside of their individual institutions for the good of state health policy.
For example, many institutions have their own patient transfer form or process. Numerous forms, very similar but each somewhat unique, exist. To improve consistency and institute a standardized, evidence-based process, each institution must agree to give up some customization so that a unified form and process can be adopted statewide. Bringing stakeholders in early, obtaining their input, and listening to their concerns have been essential parts of our process. We are currently moving forward with final development and deployment of our statewide resident transfer form, which we anticipate will be posted on the Massachusetts Department of Public Health website in the next few months.
A third objective was to include guidance addressing accountability between sending and receiving institutions. When a patient leaves one setting of care, someone must be prepared to receive that patient in the next setting of care. Longitudinal responsibility rests with the sending provider until the receiving provider has acknowledged and accepted the patient. While we anticipated that hospitals and physicians would be resistant to this concept, they accepted the significance of this component of care transitions and the need to address this difficult problem.
Ongoing discussions in 22 communities are currently under way as part of the State Action to Avoid Rehospitalizations project, supported by a grant from the Commonwealth Fund. As a learning healthcare system and state, we must be able to measure performance improvement in care transitions. Put simply, how will we know a safe and effective transition when we see it?
The Massachusetts strategic plan for care transitions outlines a strategy for tracking progress and measuring successes and challenges. Performance measurement is essential if the best practices and lessons learned from state demonstrations and national research and care models are to be implemented effectively on a statewide basis. The measures described in the plan have been endorsed by recognized national and state panels of experts.
Certain process measures are linked to successful outcomes: the timely transfer of information across settings and professionals involved in care transitions, the effective coordination of transitions across settings and professionals, the timely delivery of care, improvement in patient understanding of and adherence to the treatment plan, improvement in patient awareness of emergency provider contact information, and improvement in patient engagement in care ABIM, Ongoing work to refine measures is part of the Massachusetts strategic plan.
In his book Agendas, Alternatives, and Public Policies, John Kingdon explains how policy issues rise and fall on public agendas Kingdon, He describes three independent streams of activities—problems, policies, and politics—that must occur before effective decision making takes place in government. For a problem to be identified, there must at some point in time be agreement that solutions exist.
Policies are generated by specialists, staffers, academics, and interest groups. The creation of the strategic plan accomplished these first two activities. The third required careful vetting of the plan with interested parties. With the Kingdon policy hurdles passed, Massachusetts has now moved into the implementation phase, with workgroups already engaged in the refinement and deployment of a statewide interfacility transfer form and process, as well as state surveyor education around effective care transitions.
As more cross-continuum teams are established in more communities, Massachusetts will continue to evolve as a learning health system at the state level. Care transitions performance measurement set. Batalden, P. What will it take to lead the continual improvement and innovation of health care in the twenty-first century? Quality Management in Healthcare 11 1 Beck, A.
The Journey to High-Reliability Anesthesia Outside of the Operating Room
The Flexner report and the standardization of American medical education. Journal of the American Medical Association Bodenheimer, T. Wagner, and K. Improving primary care for patients with chronic illness: The chronic care model, part 2. Journal of the American Medical Association 15 Brooks, R. Continuing medical education: Let the guessing begin. Coleman, E. Parry, S. Chalmers, and S. The care transitions intervention: Results of a randomized controlled trial.
Archives of Internal Medicine 17 Cooper, J. No myth: Anesthesia is a model for addressing patient safety. Anesthesiology Davenport, T. Just-in-time delivery comes to knowledge management. Harvard Business Review Dekker, S. The field guide to human error investigations Hampshire: Ashgate Publishing. Deming, E. The new economics for industry, government, education. Elmendorf, D. House of Representatives. Options for controlling the cost and increasing the efficiency of health care. Enthoven, A. A vision of quality in health care delivery.
Health Affairs Flexner, A. Medical education in the United States and Canada. Frankel, A. Leonard, T. Simmonds, C. Haraden, and K. The essential guide for patient safety officers. Grumbach, K. Can health care teams improve primary care practice? Journal of the American Medical Association 10 Helmreich, R. Cockpit resource management. London: Academic Press. Managing human error in aviation. Scientific American On error management: Lessons from aviation.
BMJ IOM Institute of Medicine. To err is human. Crossing the quality chasm: A new health system for the 21st century. Health professions education: A bridge to quality. The learning healthcare system: Workshop summary. Juran, J. A history of managing for quality: The evolution, trends and future direction of managing for quality.
Milwaukee: Irwin Professional Publishing. Kingdon, J. Agendas, alternatives and public policies. Langley, G. The improvement guide—a practical approach to enhancing organizational performance. San Francisco: Josey-Bass. Leape, L. Berwick, C. Clancy, J. Conway, P. Gluck, J. Guest, D. Lawrence, J. Morath, D. Pinakiewicz, and T. Transforming healthcare: A safety imperative. Quality and Safety in Health Care 18 6 Leonard, M.
Frankel, T. Simmonds, and K. Achieving safe and reliable healthcare: Strategies and solutions , Management. Graham, and D. The human factor: The critical importance of effective teamwork and communication in providing safe care. Quality and Safety in Health Care 13 1 Lucian Leape Institute. Unmet needs: Teaching physicians to provide safe patient care. Mathieu, J. Maynard, T. Rapp, and L. Team effectiveness A review of recent advancements and a glimpse into the future. Journal of Management 34 3 Meyers, F. Weinberger, J. Fitzgibbons, et al. Redesigning residency training in internal medicine: The consensus report of the alliance for academic internal medicine education redesign task force.
Academic Medicine Mohr, J.
Improving safety on the front lines: The role of clinical microsystems. Quality and Safety in Health Care 11 1 Morrison, G. Goldfarb, and P. Team training of medical students in the 21st century: Would Flexner approve? Naylor, M. Brooten, R. Campbell, G. Maislin, K. McCauley, and J.
Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial. Journal of the American Geriatric Society 52 5 Safe practices for better healthcare update, a consensus report. National transitions of care coalition. Ponte, P. If the address matches an existing account you will receive an email with instructions to retrieve your username.
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Achieving Safe and Reliable Healthcare — Safe & Reliable
Log in to Wiley Online Library. Purchase Instant Access. View Preview. In , the CDC reported that one in 25 patients in acute care hospitals in the U. Worse, approximately 75, patients with HAIs died during their hospitalization. Medical errors are a major killer in the U. In addition to HAIs, there are other preventable risks in the healthcare environment that could be improved by the adoption of HRO principles.
For example, healthcare workers routinely face serious safety and health hazards in the workplace. These hazards may include blood-borne pathogens, biological hazards, chemical and drug exposures, ergonomic hazards from lifting patients, and workplace violence, to name a few Occupational Safety and Health Administration, According to the Bureau of Labor Statistics, in , there were more injury and illness cases in healthcare than in any other industry Benefits to patient outcomes, financials, safety, and the work environment In the healthcare industry, the benefits of integrating HRO principles and practices are significant.
HRO phenomena are mainly present in large systems that would benefit greatly from anticipating unexpected events to prevent large system failures La Porte, Equally, healthcare systems and hospitals have the potential risk of experiencing large system failures. These risks may include financial and human loss, negative impact on the workforce, or a loss of confidence and trust among members of the community, which could have a devastating effect on any health system or hospital. In embracing HRO practices, health systems and hospitals gain a culture with a strong sense of mission and commitment to reliability in operations and capacity.
Organizations that have adopted HRO practices have seen improvement in organizational effectiveness, efficiency, and culture, as well as in customer satisfaction and documentation The Joint Commission Center for Transforming Healthcare, Such organizations foster and value safety, quality, and management accountability. They also gain a workforce that is highly skilled, knowledgeable, and engaged in the solutions to make their practice and organization safe Shabot, There is also benefit on the cost side.
A further decline in HAI incidence would have a positive financial impact on the healthcare budget, to be reallocated to health programs. As well, a collaborative environment and reward and recognition programs, which are both needed for HRO environments to be successful, could have a positive impact on the work environment and employee turnover. Nurses thrive in environments that provide autonomy and allow for their empowerment, that offer a supportive leadership team, and that promote collegial relationships with their team, and evidence shows that satisfied nurses can have a positive impact on patient outcomes Twigg and McCullough, Summary The current healthcare system is complex and is burdened with inefficiencies.
Overwhelming economic and quality barriers hinder progress in improving quality, safety, and service. The dynamics of the healthcare system are shifting such that HRO is a viable approach to creating a reliable healthcare system for providers, caregivers, and consumers. Evidence suggests that HRO principles create environments that are mindful of anticipating unexpected events and resilient in responding quickly to minimize exposure. In addition, the use of incident reviews in HROs builds institutional knowledge.
Many organizations outside of healthcare have achieved HRO status and have sustained their results over long periods of time Chassin and Loeb, Although many healthcare organizations are on the path to adopting HRO principles—and an elite few are close to becoming HROs—we know for sure that the road to an HRO starts and ends with leadership. Key points. Jane S. Understanding the U. Birk, S. Accelerating the adoption of a safety culture. The Joint Commission.
Employer-reported workplace injuries and illness. Just culture. Chronic diseases: The leading causes of death and disability in the United States. Hospital valued-based purchasing program. Hospital value-based purchasing. Fiscal year results for CMS value-based purchasing program.
Health care and high reliability: A cautionary tale. Chicago, IL. Chassin, M. High reliability in healthcare: Working toward zero harm. The ongoing quality improvement journey: Next stop, high reliability. Health Affairs, 30 4 , pp. High-reliability health care: Getting there from here. The Milbank Quarterly.
Budget and economic outlook — The 7 habits of highly effective people: Restoring the character ethic. DuPree, E. Leading change: The high reliability journey. Hospital Executive Briefing. Improving patient satisfaction with pain management using Six Sigma tools. Field, R.
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Why is health care regulation so complex? Pharmacy and Therapeutics, 33 10 , pp. Griffith, J. Understanding high-reliability organizations: Are Baldrige recipients models? Journal of Healthcare Management, 60 1 , pp. About us.
To err is human. The Richard and Hinda Rosenthel lecture New frontiers in patient safety. Best care at lower cost: The path to continuously learning health care in America. A new evidence-based element of patient harm associated with hospital care. Journal of Patient Safety, 9 3 , pp. Sentinel event data —3Q About the joint commission.
High reliability: The gold standard in health care. Considering complexity in healthcare systems. Journal of Biomedical Informatics, 44 6 , — Keckly, P.
Khatri, N. From a blame culture to a just culture in health care. Healthcare Management Review, 34 4 , pp.
La Porte, T. High reliability organizations: Unlikely, demanding and at risk. Journal of Contingencies and Crisis Management, 4 2 , pp. The Leapfrog Group. How safe is your hospital? The Medicare amendment to the Social Security Act. Understanding health care as a complex system: The foundation for unintended consequences. Journal of American Medical Association, 3 , pp. Mittler, J. The Milbank Quarterly, 91 1 , pp.
Nolan, T. Improving the reliability of health care. IHI Innovation Series white paper. Workplace violence. Normal accidents: Living with high-risk technologies.
Provera, B. British Journal of Management, 21 4 , pp. Rice, T. Challenges facing the United States of America in implementing universal coverage. Bulletin of the World Health Organization. Must accidents happen? Lessons from high-reliability organizations. Academy of Management Perspectives, 15 3 , pp. Rochlin, G. The self-designing high-reliability organization: Aircraft carrier flight operations at sea. Naval War College Review, 40 4 , pp. Schumock, G.
National trends in prescription drug expenditures and projections for American Journal of Health-System Pharmacy, 71 6 , pp. Shabot, M. New tools for high reliability healthcare. BMJ Quality and Safety, 24 7 , pp. Stewart, A. Risk management: The reactive versus proactive struggle. Journal of Nursing Law, 14 3 , pp. Sutcliffe, K. High reliability organizations HROs.
Twigg, D. Nurse retention: A review of strategies to create and enhance positive practice environments in clinical settings. International Journal of Nursing Studies, 51 1 , pp. Census Bureau. Annual and quarterly services. Department of Health and Human Services. Key features of the Affordable Care Act.
News and World Report. Best hospitals. Doing no harm: Enabling, enacting, and elaborating a culture of safety. Academy of Management Perspectives, 24 6 , pp. Wagner, K. Health care reform and leadership: Switching from volume to value. Physician Leadership Journal, 1 1 , pp. Weick, K. Organizational culture as a source of high reliability. California Management Review, 29 2 , pp. Managing the unexpected: Assuring high performance in an age of complexity.
Mindfulness and the quality of organizational attention. Organization Science, 17 4 , pp. Managing the unexpected: Resilient performance in an age of uncertainty 2nd ed. Wildavsky, A. Searching for safety. Piscataway, NJ: Transaction Publishers. Wilson, K. Promoting healthcare safety through training high reliability teams.