Quality Interagency Coordination Task Force Research Articles

Teamwork and Teamwork Training in Health care: An Integration and a Path Forward

Although teamwork is prevalent and important in almost every industry, this is particularly the case within the health care industry (e.g., Leonard & Frankel, 2011). Enhancing teamwork has been heralded as a prime factor in addressing the troubling pronouncement made by the Institute of Medicine’s (IOM) 1999 report, “To Err is Human: Building a Safer Health System,” which found that as many as 98,000 deaths occur annually as a result of medical errors (Kohn, Corrigan, & Donaldson, 1999). In fact, the Quality Interagency Coordination Task Force (which was established in response to the IOM 1999 report) suggested that improving teamwork dynamics was a key way to improve patient safety. [...]

Continuing Education Meets the Learning Organization: The Challenge of a Systems Approach to Patient Safety.

Since the release of the report of the Institute of Medicine on medical errors and patient safety in November 1999, health policy makers and health care leaders in several nations have sought solutions that will improve the safety of health care. This attention to patient safety has highlighted the importance of a learning approach and a systems approach to quality measurement and improvement. Balanced with the need for public disclosure of performance, confidential reporting with feedback is one of the prime ways that nations such as the United States, Canada, the United Kingdom, and Australia have approached this challenge. In the United States, the Quality Interagency Coordination Task Force has convened federal agencies that are involved in health care quality improvement for a coordinated initiative. Based on an investment in a strong research foundation in health care quality measurement and improvement, there are eight key lessons for continuing education if it is to parlay the interest in patient safety into enhanced continuing education and quality improvement in learning health care systems. The themes for these lessons are (1) informatics for information, (2) guidelines as learning tools, (3) learning from opinion leaders, (4) learning from the patient, (5) decision support systems, (6) the team learning together, (7) learning organizations, and (8) just-in-time and point-of care delivery.

Medical and Medication Errors: A Partial Summary of Reports by the Institute of Medicine and the Quality Interagency Coordination Task Force

Medical and Medication Errors: A Partial Summary of Reports by the Institute of Medicine and the Quality Interagency Coordination Task Force

A secure and expandable electronic patient record system using web-based technology

Introduction: In its 2000 report regarding medical errors, the Quality Interagency Coordination Task Force highlighted the unacceptably high rate of errors in health care. The report recognized that information technology (IT) offers a tremendous opportunity to reduce errors and recommended the adoption of electronic patient records (EPRs). However, providing EPR-enabled solutions is challenging due to the constraints of security and confidentiality imposed by the healthcare domain. Adding to the complexity is the need for healthcare organizations to exchange confidential EPRs safely across the security policy boundaries of healthcare enterprises and its partners (e.g. insurance companies).Methods: We developed an EPR system that utilizes Microsoft Web Services architecture.Results: The current system has three components: OR-Eye, OR-Med and OR-Track. The system was built using Webbased communication technology; it offers the security, stability and expendability required for a hospital EPR system. Our most developed component of the EPR system, OR-Eye, allows authorized users to view real-time and achieve intraoperative patient data wirelessly in a graphical form similar to an intraoperative anesthesia record on a variety of available devices. A unique feature of OR-Eye is a time line graphic that displays the sequence of patient and hospital actions that can be viewed in detail and strung together to form various hospital records.Conclusion: Our EPR system is secure, stable and expandable. It interfaces with our existing hospital wireless network. It has the potential to improve patient care, patient safety and hospital efficiency as well as enhance medical research and medical education.

Medication safety Part 2

The federal government has been setting up new programs to prevent errors since the Institute of Medicine (IOM) report “To Err Is Human: Building a Safer Health System” was published in 1999. 1 Kohn LT Corrigan JM Donaldson M To err is human: building a safer health system. National Academy Press, Washington, DC1999 Google Scholar The Quality Interagency Coordination Task Force was formed in 2000 and developed an action plan for reducing medical errors. 2 Meadows M Strategies to reduce medication errors. FDA Consumer. May-June 2003; (Accessed March 2, 2006.)Available at: www.fda.gov/fdac/features/2003/303_meds.html Google Scholar In 2001, the Department of Health and Human Services formed a patient safety task force to coordinate a joint effort to improve data collection on patient safety. The lead agencies were the Food and Drug Agency (FDA), the Centers for Disease Control and Prevention (CDC), Centers for Medicare and Medicaid Services (CMS), and the Agency for Healthcare Research and Quality (AHRQ).

Newsview

The Quality Interagency Coordination Task Force (QuIC) was established in 1998 to enable the participating federal agencies to coordinate their activities to study, measure, and improve the quality of care delivered by federal health programs; provide people with information to help them in making more informed choices about their care; and develop the research base and infrastructure needed to improve the health care system, including knowledgeable and empowered workers, well-designed systems of care, and useful information systems.The QuIC’s initial efforts to improve the care delivered in federal health care programs have focused on diabetes, depression, and the effect of working conditions on quality of care. More recently, patient safety efforts are under way to establish a coordinating center that will enable those who are testing methods of reducing errors to share information across their projects and with experts in error reduction.The QuIC has coordinated efforts in credentialing, information on measures of quality, a taxonomy of quality improvement methods, and errors data collection.The QuIC agencies are developing products that will enhance their ability to communicate with the American people about their health care choices: improved gateways for consumer information available from federal agencies, a glossary of commonly used terms, and guidance for producing report cards on quality of care.Federal efforts to improve quality of care are moving forward in a more integrated fashion on a wide number of fronts.

Tribute to John M. Eisenberg

This issue is dedicated as a tribute to John M. Eisenberg, M.D., M.B.A., in recognition of his lifelong achievements in health services research. We have selected six articles, described below, which represent areas where John made significant contributions, either as a researcher and administrator or as a champion and mentor. In addition, on behalf of the entire Editorial Board of HSR, our publisher, and the leadership at AcademyHealth, we would like to announce the establishment of an award for excellence in health services research, designed to recognize exceptional articles from HSR which advance our understanding in an area championed by John. Selection of these awards will be announced periodically in HSR, beginning in 2004. We also gratefully acknowledge support for the publication of this tribute provided by a grant from The Robert Wood Johnson Foundation in Princeton, NJ, and funding by W.K. Kellogg Foundation in Battle Creek, MI. John Meyer Eisenberg was born in Atlanta, Georgia, in 1946 and died from a brain tumor on March 10, 2002. From 1997 until shortly before his death, John served as Director for the Agency for Healthcare Research and Quality (AHRQ; formerly called the Agency for Health Care Policy and Research) of the U.S. Department of Health and Human Services (HHS). He also served as the Senior Advisor to the Secretary of HHS on Quality; cochaired the Department's Data Council; chaired the Federal Quality Interagency Coordination Task Force; and served as Principal Deputy Assistant Secretary for Health and as Acting Assistant Secretary for Health. Although this partial list of his titles illustrate the breadth and importance of his many contributions to the nation's health care system, it fails to capture the charisma, enthusiasm, and strengths with which he tackled these roles and policy areas. He was a champion of policy-relevant research in order to increase the “value” of health care services by improving its appropriateness, safety, and effectiveness while also monitoring and improving its accessibility to all. In taking on these challenges, he managed to engage researchers, clinicians, and policymakers alike in his vision for excellence in research to improve the nation's health care. He recognized that such efforts required continuous encouragement and mentoring of those who would undertake them. He was a magna cum laude graduate of Princeton University (1968) and the Washington University School of Medicine in St. Louis (1972). He was also a Robert Wood Johnson Foundation Clinical Scholar, earning a Master of Business Administration degree with distinction at the Wharton School. A clinician and researcher from the beginning of his career, John held many key positions in academic and clinical medicine and was widely recognized as a leader in both medicine and health services research. His positions included Chair, Physician Payment Review Commission; President, Association for Health Services Research (now AcademyHealth); President, Society for General Internal Medicine; and Vice President, Society for Medical Decision Making. He was also a member of the Institute of Medicine of the National Academy of Sciences and published over 250 articles and book chapters on topics such as physicians' practices, test use and efficacy, medical education, and clinical economics, as well as writing a seminal book that influenced how many of us view medical decision making: Doctors' Decisions and the Cost of Medical Care (Eisenberg 1986). John dedicated his career to ensuring that health care is based on a strong foundation of research. He challenged the field to address topics important to policymakers—both inside the clinic and inside the “Beltway”—with research that was methodologically sound, grounded in the “real world” and accessible to a broad audience. The first six articles in this issue were selected as a tribute to his contributions in these arenas:

“To Err is Human”: Uniformly Reporting Medical Errors and Near Misses, a Naïve, Costly, and Misdirected Goal

Three years ago, the Institute of Medicine (IOM) in To Err Is Human—Building a Safer Health System reported an estimate of 44,000 to 98,000 annual deaths directly attributable to preventable medical errors. In subsequent conferences, discussions, and scientific articles, the media, the medical profession, national health care organizations, and Congress have scrutinized this staggering figure. Individual hospital risk management programs, medical error reporting systems, and national patient safety oversight projects have been created to systematize purportedly anonymous, nonpunitive methods that encourage universal reporting of medical errors and “near-misses.” Using the 26-year-old Aviation Safety Reporting System (ASRS), the National Aeronautics and Space Administration (NASA)-directed reporting system for the Federal Aviation Administration (FAA) as the “gold standard,” such methodologies have operated on the assumption that if a system claims to be anonymous, nondiscoverable, nonpunitive, and in the best interests of the patient, health care personnel will willingly report. Unfortunately, as Dr James Bagian, former astronaut and now director of the National Center for Patient Safety, Veterans Health Administration (VHA), eloquently stated recently before the joint annual meeting of the Association of Program Directors in Surgery and the Association for Surgical Education, the ASRS works not only because it is voluntary, nondiscoverable, anonymous, and nonpunitive, but also because the pilot is always the first to the crash site. In any medical error reporting system, it is usually the individual patient who is physically at risk, not the medical personnel. Yet our nation’s hospitals, medical systems, and governmental organizations have invested much time, money, and effort in establishing such error-reporting systems modeled after the ASRS in which the primary incentive to report—the preservation of one’s own life (as opposed to one’s own livelihood)—is missing. To one degree or another, existing error-reporting systems have tried to incorporate three principles thought to be basic to any system: it should be anonymous, nondiscoverable, and nonpunitive. But, for any program to be successful it must include a fourth principle: a guarantee of immunity for those who commit errors and those who report them. In our litigious society, any reporting system we create is bound to be besieged by lawyers and the press. There will be a natural reluctance to report errors. Yet, if we are going to create a system that is of any help at all in improving patient care, it must be as thorough and honest as we can make it. The history of error-reporting systems makes it clear that any system than ignores immunity cannot operate effectively, especially on a voluntary basis. On December 7, 1999, in response to the report by the Institute of Medicine, the Quality Interagency Coordination Task Force (QuIC), a presidential commission established to implement quality improvement initiatives, was directed by President Clinton to report to the Administration recommendations on how to improve health care outcomes and prevent medical errors. Outlined in The White House press release of February 22, 2000, the QuIC endorsed virtually every IOM recommendation and called for implementation of patient safety programs throughout the federal government, but especially the Departments of Veterans Affairs and Defense. Perhaps the best example of the development of well-intentioned quality assurance and error-reporting systems in patient care in the United States has occurred within the Department of Veterans Affairs (VA). The No competing interests declared.

Fatigue in anesthesia: implications and strategies for patient and provider safety.

Received from the Anesthesia Service, VA Palo Alto Health Care System, Department of Anesthesia, Stanford University School of Medicine, Palo Alto, California; the Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut; and the Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia.HEALTHCARE delivery takes place 24 h a day, 7 days a week, and is colloquially termed a “24/7” operation. Anesthesia providers are required to deliver critical around-the-clock care to a variety of patients. This parallels the situation in many other domains that provide such services, e.g ., transportation, law enforcement, communications, fire fighting, technology, manufacturing, and the military. Even “convenience” industries (e.g ., gas stations and grocery stores) now provide uninterrupted access. These continuous operational demands present unique physiologic challenges to the humans who are called on to provide safe operations within these systems. Human physiologic design dictates circadian patterns of alertness and performance and includes a vital need for sleep. Human requirements for sleep and a stable circadian clock can be, and often are, in direct opposition to the societal demand for continuous operations.Recently, patient safety has taken center stage in health care. The Institute of Medicine's report “To Err Is Human: Building a Safer Health System,” revealed that medical errors contribute to many hospital deaths and serious adverse events. 1The response to this report was widespread and included the Quality Interagency Coordination Task Force's response to the President of the United States, “Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact.”∥2This report listed more than 100 action items to be undertaken by federal agencies to improve quality and reduce medical errors. One action promised by the Agency for Healthcare Research and Quality was “the development and dissemination of evidence-based, best safety practices to provider organizations.” In addition to the multiple recommendations to improve patient safety, the report from the Agency for Healthcare Research and Quality included a review chapter on sleep, fatigue, #and medical errors. **There is evidence that the issue of fatigue in health care is coming to prominence on a national level. In April 2001, Public Citizen (a consumer and health advocacy group) and a consortium of interested parties petitioned the Occupational Safety and Health Administration to implement new regulations on resident work hours (table 1). The primary intent of the regulations is to provide more humane working conditions, which the petitioners declare will result in a better standard of care for all patients. Also, the Patient and Physician Safety and Protection Act of 2001, which would limit resident physician work hours, was introduced in Congress. Recently, the Accreditation Council on Graduate Medical Education, the accrediting organization for residency training programs in the United States, has approved common program requirements for resident duty and rest hours that will take effect in July 2003. ††The potential impact of sleep loss and fatigue, specifically among anesthesiologists, has received only sporadic attention. 3,4The cognitive demands of intraoperative patient care requires an iteration of data collection, evaluation of its relevance to patient status, development and implementation of plans to maintain the desired patient status, and monitoring the outcome of interventions. These complex tasks require sustained attention or “vigilance” and are particularly vulnerable to the effects of fatigue. 5–8The purpose of this article is to review the physiology of prolonged work cycles and fatigue, to relate this to the work milieu of the practice of anesthesiology, and suggest economically feasible recommendations to mitigate the effects of fatigue.Sleep loss and disruption of circadian rhythm that result from arduous work schedules can lead to reduced safety, performance, and health. While some of these outcomes are well documented, much remains to be learned about the short- and long-term effects of sleep and circadian disruption. The following nonmedical examples of the safety, performance, and health risks associated with around-the-clock operations illustrate the increasing human and economic costs related to ignoring the effects of these physiologic disruptions.There have been several high-profile accidents where fatigue was identified as either causal or contributory. For example, although alcohol is often cited as the central reason in the Exxon Valdez marine grounding, the National Transportation Safety Board investigation identified fatigue as one of the probable causes of the accident. 9Similarly, circadian factors were identified as contributing to the errors that resulted in the nuclear accidents at Three Mile Island and Chernobyl. 10,11Fatigue resulting from the work–rest patterns of managers was also acknowledged as an important component of the flawed decision-making that contributed to the space shuttle Challenger accident. 12Fatigue-related accidents have been identified in every mode of transportation and can be found in many around-the-clock operational settings. Clearly, there are a variety of adverse outcomes such as economic costs, disrupted service, injuries, and even fatalities that result from these accidents. For example, the Exxon Valdez grounding was associated with environmental cleanup operations and legal cases involving billions of dollars, and Space Shuttle operations were suspended for several years after the Challenger disaster.Fatigue-related safety risks affect us at both individual and societal levels. A recent poll by the National Sleep Foundation indicated that one of two drivers reported having driven while drowsy in the past year, ‡‡and one of five acknowledged having “nodded off” while driving. Fatigue contributes to 100,000 crashes annually that result in 76,000 injuries and 1,550 fatalities, according to estimates by the National Highway Traffic Safety Administration. 13Recently, an international group of scientists estimated that fatigue is causal in 15–20% of all transportation accidents, that official statistics underestimate the scope of the problem, and that fatigue exceeds the combined contribution of alcohol and drugs in transportation accidents. 14Fatigue caused by sleep loss and circadian disruption can degrade performance and reduce many aspects of human capability. 15Known performance effects include reduced attention–vigilance, impaired memory and decision-making, prolonged reaction time, and disrupted communications. 16–20These degraded performance outcomes create a situation where there is increased risk for the occurrence of errors, critical incidents, and accidents. 15Fatigue also creates increased performance variability, with cyclic reductions in alertness and performance. 21Fatigued workers have a tendency to slow down work processes to maintain accuracy, a classic effect known as the speed-accuracy trade-off. 22It takes only a moment of reduced performance during a critical task to have a negative outcome. Even if a lapse in performance occurs during a noncritical task, the system vulnerability shifts to a less safe state.Fatigue-related accidents are sometimes considered to be a result of falling asleep. Performance gaps can be the result of these “microsleeps,” which are brief, uncontrolled, and spontaneous episodes of physiologic sleep. 8There can be significant performance reductions that are sufficient to create safety risks prior to and immediately after the occurrence of a microsleep. 23,24Slowed cognitive throughput, reduced memory, slowed reaction time, lowered optimal responding, and attention lapses can create an increased opportunity for errors to occur. 25Consider the circumstance where an anesthesiologist's response to an alarm is slowed and an inappropriate decision guides an incorrect action. The practitioner may have been “awake,” but fatigue-related performance decrements could be contributory to the occurrence of any error, incident, or accident that resulted from the action.The decrement in psychomotor performance resulting from sleep deprivation have been correlated with those resulting from the impairments associated with ethanol ingestion. 26Performance on a hand–eye tracking task declined such that the impairment was equivalent to a blood alcohol level of 0.05% after 17 h of wakefulness. At 24 h of sustained wakefulness, the impairment in psychomotor function was equivalent to a blood alcohol concentration of 0.1%, at or above the legal limit for driving in most states. These data could be useful to help quantify fatigue-related effects with a drug that the public and policy makers better understand.Specific clinical skills of importance to the practice of anesthesiology deteriorate as a result of fatigue. On a simulated monitoring task where subjects were asked to monitor and record the time of significant deviation of clinical variables (e.g ., heart rate, blood pressure), Denisco et al . reported lower “vigilance scores” in the group that had been on call. 27The ability to interpret electrocardiographic changes and to do simple mathematical calculations is compromised among sleep-deprived house officers. 28The speed and quality of intubation was diminished among emergency department physicians working the night shift as compared with their performance while working during the day. 29,30Many of the fatigue-related decrements in performance identified in residents are potentially worse in older physicians. Aging is associated with a tendency toward early awakening, an exaggerated dip in arousal midafternoon, and a decreased tolerance of late-night and shift work. 31The unique demands of night call on older anesthesiologists are more onerous than those found in other specialties. 32Among recently retired anesthesiologists, night call was identified as the most stressful aspect of anesthetic practice and the most important reason for retirement. 33,34Beyond the safety risks and performance decrements associated with sleep loss and circadian disruption, there are a variety of personal health concerns. Several studies have shown that long-term exposure to shift work represents an independent risk factor for the development of both gastrointestinal and cardiovascular diseases. 35–39A recent study found that women working the night shift had a 60% greater risk for breast cancer compared with women who never worked the late shift. 40There is evidence that some adverse pregnancy outcomes are related to working conditions. 41A meta-analysis of 29 studies, including more than 160,000 women, evaluated the association of physically demanding work, prolonged standing, long work hours, and cumulative “fatigue score” with preterm delivery, pregnancy-induced hypertension, and small-for-gestational-age infants. There was a positive association between physically demanding work and preterm births, pregnancy-induced hypertension, and delivery of small-for-gestational-age infants. Shift work alone was found to increase the incidence of preterm births. 41There is evidence that sleep restriction alters physiologic function. Significant detrimental effects on immune function can be found after a few days of total sleep deprivation or after several days of partial sleep loss. 42,43Sleep restriction of 4 h per night for six nights is associated with harmful effects on carbohydrate metabolism and endocrine function. 44This degree of sleep restriction resulted in abnormal glucose tolerance, decreased thyrotropin concentrations, increased evening cortisol concentrations, and increased sympathetic nervous system activity (as measured by heart rate variability). Sleep deprivation and circadian disruption affect cerebral metabolic and cognitive function. In a study of changes in regional cerebral glucose utilization (i.e ., positron emission tomography) during 85 h of consecutive sleep loss, decreases in cerebral metabolic rate were observed primarily in the thalamus and prefrontal and posterior parietal cortices. Alertness and cognitive performance declined in association with these brain deactivations. 45A recent study of aircrew members suggests there may be a linkage between long-term exposure to time-zone changes (i.e ., circadian disruption), temporal lobe atrophy, and deficits in learning and memory. 46Investigations using functional magnetic resonance imaging technology contradict some of the aformentioned findings and reveal compensatory changes of increased activation in the prefrontal cortex and parietal lobes during verbal learning after sleep deprivation. 47–50Studies show altered mortality with sleep loss and circadian disruption. Circadian disruption in hamsters and Drosophila reduce life span from 11 to 15%. 51,52A prospective investigation of more than one million individuals conducted by the American Cancer Society found that men who reported “usual” daily sleep times of less than 4 h were 2.8 times more likely to have died within a 6-year follow-up as men who obtained 7.0–7.9 h of sleep. 53The risk for women was increased by 48%. Conversely, men and women who reported sleeping 10 h or more per day had about 1.8 times the mortality rate of those who reported 7.0–7.9 h of sleep.The two primary determinants that underlie fatigue and interact in a dynamic manner are sleep homeostasis and circadian rhythms. 54An individual's level of alertness (e.g ., on the job) or potential for sleep (e.g ., during a rest period) will be determined by a complex interaction of these factors. Performance and alertness decrements may occur when either of these elements is disrupted. 55Factors other than fatigue, such as workload, environment, stress, boredom, motivation, and professionalism, also influence the ability to perform. 4In addition, there are large interindividual differences on the effects of fatigue. 56Sleep serves a vital physiologic need. 57Like other basic physiologic requirements such as food and water, sleep plays a fundamental role in survival. Sleep homeostasis is the balance between sleep need and quality and quantity of sleep obtained by an individual. On average, the adult human requirement for sleep appears to be greater than 8 h (8 h:14 min) per 24-h period. 58,59The range of sleep need varies from 6 to 10 h, and this requirement is probably genetically determined and cannot be “trained” to a different sleep need. 60Estimates suggest that most American adults obtain about 1–1.5 h less sleep than needed. §§This lost sleep accumulates to produce a “sleep debt.”8,58For example, an individual who obtains 1.5 h less sleep per night over a 5-day work week will begin the weekend with 7.5 h of sleep debt. This deficit is roughly equivalent to the loss of a full night of sleep and requires about two nights of at least 8 h of sleep for recovery. 20Sleep debts are not repaid hour for hour, but instead through an increase in deep sleep or nonrapid eye movement stages 3 and 4. 20A variety of factors can affect sleep quantity and quality. Perhaps some of the most dramatic changes in sleep occur as a normal function of aging. Approaching age 50 and beyond, sleep becomes more disrupted with frequent awakenings. There are reduced amounts of deep sleep, and sleep becomes less consolidated. 61Nocturia in men and menopausal symptoms in women are likely to contribute to sleep disturbances in older individuals. There are also age-related increases in complaints of insomnia and depression that negatively impact sleep. Sleep need does not necessarily decrease with age, and increased daytime sleepiness can be the consequence of reduced sleep quantity and quality. There have been no formal studies assessing whether these changes in sleep quantity and quality affect the performance of older anesthesia providers.There are approximately 90 known sleep disorders that have been described and classified in a diagnostic nosology. 62The causes for these disorders range from physiologic to psychological to environmental. Some sleep disorders are relatively prevalent in the population and have well-documented negative effects on waking alertness and performance. 63–65Often, the affected individual is unaware of their disorder, and the bed partner may be the first to identify the problem. Obstructive sleep apnea is a common example of a sleep disorder that has implications in operational settings. There are many health consequences associated with sleep apnea, but, in addition, it has been shown to be associated with a twofold to sevenfold increase in risk for automobile accidents. 66,67Consistent with this, Powell et al . demonstrated that individuals with mild to moderate sleep apnea had a decrement in performance equivalent to that of an individual with a blood alcohol concentration of 0.05–0.08 g/dl. 68Alcohol is the most widely used sleep aid, and its use is typically intended to provide relaxation or to promote sleep. 69However, alcohol is a potent suppressor of rapid-eye-movement sleep, especially in the first half of the night. 70As the blood alcohol concentration declines, there is a rapid-eye-movement rebound in the second half of the night, producing more rapid-eye-movement sleep with increased awakenings and a reduction in total sleep time. Therefore, although alcohol may be consumed as an aid to promote sleep, it actually has the potential to significantly disrupt it.Sleep can be measured both subjectively, using a variety of questionnaires, and objectively, using standardized physiologic measures. Generally, humans are inaccurate subjective reporters of alertness. 71,72Individuals can report being awake and alert, when physiologically they could be asleep in minutes. This discrepancy between self or subjective reports and physiologic levels of alertness can have significant operational implications. First, it indicates that verbal reports of subjective alertness are generally unreliable sources to determine an individual's fitness for duty. Second, an individual with the subjective experience and report of being alert might be less likely to engage an alertness strategy (e.g ., strategic caffeine or nap opportunity, as discussed in the section on alertness strategies) that could address the underlying disturbed physiologic state. It is important to note that when an individual reports a subjective experience at either end of the continuum (e.g ., extreme fatigue or sleepiness), it is more likely to reflect the actual physiologic status. 71The human circadian (circa = around, dies =a day) timekeeper is located in the suprachiasmatic nucleus (SCN) of the hypothalamus and is an active pacemaker for internal 24-h rhythms. 73The most powerful and well-studied synchronizer of the SCN is light, while melatonin, a complementary synchronizer of the SCN, is secreted by the pineal gland at night and is suppressed by light. 74A retino-hypothalamic pathway to the SCN provides direct access for light and dark exposure to affect the circadian clock. The daily light–dark cycle entrains the SCN to its 24-h pattern. The natural tendency of the circadian clock is to run slightly slower (24.18 h) than our 24-h day, 75which is the physiologic rationale to phase delay rather than phase advance work–rest cycles. In other words, rotation of shift assignments going from days to evenings to nights has a circadian physiologic justification, but this has not been a major solution to the problems of shift work. 76The SCN controls a broad range of physiologic, behavioral, and mood functions. For example, it drives the 24-h sleep–wake pattern, daily digestive activity, hormone secretions, and mood, as well as alertness and performance levels. 55The underlying mechanisms regulating the cellular neurobiology of sleep are important and complex but are beyond the scope of this article and are reviewed elsewhere. 77,78Humans are programmed for increased sleepiness at two approximate times each day: 3–7 am and 1–4 pm 55,79The circadian nadir, associated with the lowest levels of activity, alertness, and performance and greatest vulnerability to errors, incidents, and accidents, occurs at about 3–7 am. As an example, it has been well established that a peak in fatigue-related single car accidents, without alcohol involvement, occurs roughly between 3 and 5 am. 80–83The complementary periods of maximal alertness occur at approximately 9–11 am and 9–11 pm.Rotating to a different work schedule such as the night shift or crossing time zones disrupts the entrained circadian pattern. Jet lag will occur for days as the SCN synchronizes to the new local environmental cues (e.g ., the light–dark cycle) after traveling through several time zones. Night work creates a different challenge by its disruption of the circadian pattern. When individuals are working at night, circadian programming drives sleep, and when they attempt to sleep during the day, the circadian clock is programmed for wakefulness. Generally, studies have shown that “adaptation” does not occur despite prolonged exposure to night work. 84After an all-night shift, the individual returns home and is exposed to daytime light cues that maintain SCN programming for a day–active, night–sleep pattern. Social factors such as interacting with family and performing duties that can only be done during daytime hours also play a major role in the inability to readily alter the endogenous rhythm to night work. 85A study of unintentional dural puncture during epidural anesthesia has provided further support for a circadian difference in clinical performance among anesthesiologists. 86The risk of dural puncture was greater at night (midnight to 8:00 am) and among inexperienced practitioners. Although this investigation is supportive of a negative circadian effect on performance, it was limited by the low frequency of unintentional dural punctures as well as by not including important covariants such as patient body habitus and physician workload.Subjective data from surveys of anesthesiologists 87–89and other healthcare personnel 90,91reveal that fatigue is perceived by practitioners as creating a significant risk for patients. In two studies of anesthesia caregivers, more than 50% reported having committed an error in medical judgment that they attributed to fatigue. 88,89Cooper et al ., using the critical incident method of evaluating anesthetic errors, estimated that human error played a role in more than 80% of anesthetic mishaps and that fatigue was an associated factor in 6% of reported critical incidents. 92In a survey of New Zealand anesthesiologists, 58% reported that they exceeded their self-defined limit for safe continuous administration of anesthesia, and 86% reported having committed a fatigue-related error. 87Data from 5,600 reports of critical incidents to the Australian Incident Monitoring Study from 1987 to 1997 revealed that fatigue was listed as a contributing factor in 152 reports (3%). 93These data suggest that there is a specific association between fatigue and medication errors (syringe swaps) occurring at circadian low points (2–4 am). The conclusions from these studies are limited since they are based on retrospective, self-report data, but the majority of respondents consistently indicate that quality of care is compromised and that some errors are attributed to working while fatigued.A recently litigated case clearly demonstrates the effect of fatigue in the operating room. An anesthesiologist was accused of literally falling asleep while his patient, an 8-yr-old child, died. 94During the litigation, testimony was given that the defendant had been repeatedly warned by supervisors about falling asleep during operations. He was convicted of criminal medical negligence and acquitted of felony counts of reckless manslaughter and criminally negligent homicide. The conviction was later overturned on a technicality as the statute of limitations on the misdemeanor charge had expired. Interestingly, using NTSB methods of accident analysis (table 2), the majority of errors and accidents that occur in the healthcare environment are likely to have fatigue as a contributing factor based on work schedules alone. 95There is a well-documented association between long work hours or late work and an increased potential for injury from industrial accidents. The risk of an accident increases exponentially with each hour after the ninth consecutive hour of work. 96This effect is exaggerated when extended work hours occur on a late shift. Needle stick injuries, among the most frequent of the occupational injuries suffered by anesthesia providers, are usually self-inflicted, occur during disposal or recapping of sharp devices, and are associated with carelessness from fatigue. Among residents and medical students, there is a 50% greater risk of sustaining a bloodborne pathogen exposure during night work than during days. 97Studies have extended the previously described risks associated with drowsy driving to physicians. 98–100Fatigued physicians are at risk for accident and injury as they drive home after completing their duty cycle. In a study of an academic pediatrics department, 49% of residents (averaging 2.7 h of sleep while on call) reported falling asleep at the wheel compared with 13% of faculty members. These residents had almost twice as many traffic citations for moving violations than did the better-rested faculty members. 98Residents in pediatrics and emergency medicine have been reported to suffer twice the expected number of accidents, in many cases while driving home after being on call. 98–100In a more recent retrospective study of driving-accident risk among anesthesia trainees, only eight accidents were reported, which did not differ from the control. 101The authors attributed this finding to the “protective” circadian alerting effect during the drive home (8–10 am).The effect of work hours on pregnancy outcomes in female resident physicians has been evaluated. These data reveal that there is an increased incidence of pregnancy-induced hypertension, 102preterm labor, 103and small-for-gestational-age infants. 104Another study documented an association between preterm delivery and residents who worked more than 100 h per week. 105As in other “24/7” settings, health care has experienced some high-visibility tragedies where fatigue was identified as causal or contributory. 94,106–110The most often referenced example is the death of Libby Zion, which focused attention on work hours and supervision of resident physicians. Although there has been much debate 106–110as to whether her death was related to the fatigued healthcare providers who cared for her, a high-profile commission was formed in 1987 that issued recommendations to limit house staff work hours and to increase their supervision. These recommendations became part of the revised Section 405 of the New York State Health Code (table 3). 111The Accreditation Council on Graduate Medical Education and its Residency Review Committees developed institutional and program requirements for resident supervision, duty hours, and work environment. ∥∥Institutions were required to ensure that each training program established formal policies for resident duty hours that fostered education and facilitated care of patients. The Residency Review Committee for Anesthesiology specifies that in-house duty hours should not be excessive and suggested that, on average, residents should have “at least 1 day out of 7 free of routine responsibilities and be on call in the hospital no more often than every third night.” Finally, if these policies are followed, residents are prohibited from “administering anesthesia on the day after in-house overnight call.”Subsequent evaluation suggests that the regulation of resident duty hours may not be the panacea that alone improves patient outcome. Data collected before and after implementation of the New York regulations found that there were no differences in in-hospital mortality rates, rate of patient transfer to intensive care units, or length of stay, and that there were more patients having at least one complication. 112Petersen et al . demonstrated that preventable adverse events were more common when cross-covering house staff were caring for patients compared with times when a resident knowing the patient was involved with the care. 113A follow-up study revealed that improving the quality of communication during patient sign-outs improved the quality of care. 114This suggests that during some circumstances, use of cross-covering residents to relieve tired house staff may introduce the possibility of more medical errors, but that these errors might be mitigated in other ways.There is little consensus among studies on the effects of fatigue on the performance of healthcare personnel. 3,4,115–119Previous authors have detailed the methodologic problems inherent in most of the studies (table 4). 115–118It is not surprising that the interpretation of this body of data are contradictory given these methodologic problems.There is a tremendous inconsistency across studies in the definitions used for fatigue or sleep loss. Although studies of partial sleep deprivation consistently reveal that measurable performance decrements occur if sleep is restricted by as little as 1 h, 120Bartle et al . used 4 h of sleep on the night prior to performance testing to distinguish between fatigued and rested subjects. 121There is no scientific basis for the assumption that sleep times of greater than 4 h should be considered as “rested.” Many other investigations use similarly arbitrary study conditions. 27,122–130An additional source of inconsistency in previous studies is the lack of a standardized instrument to test performance. A

Does a Healthy Health Care Workplace Produce Higher-Quality Care?

The multiagency Quality Interagency Coordination Task Force (QuIC) coordinates activities and plans for quality measurement and improvement across all the U.S. federal agencies involved in health care. One of its working groups focuses on the health care workforce and ways to improve the quality of care that it provides. In October 1999 four government agencies, under the aegis of the QuIC, convened a conference to examine how health care workplace quality influences the quality of care. A healthy workplace is one in which workers will be able to deliver higher-quality care and in which worker health and patients' high-quality care are mutually supportive. In October 2000 a follow-up conference was held to focus on a specific aspect of health care quality-patient safety. Although enough is known to justify some initiatives to improve the quality of the health care workplace, participants in both meetings agreed that the evidence to prove these associations is weak and that there has been too little research to evaluate the impact of interventions intended to improve quality through improvements in the health care workplace. New evidence-based information is needed to test the theory of the nature of the relationship between working conditions and care quality. The tradition of evidence-based decision making needs to be applied to health care management as it has in medicine and nursing, to show how staffing, environment, organization, and culture can each can affect the quality of care.

Patient Safety: Grantmakers Join The Effort To Reduce Medical Errors

GrantWatch Health AffairsVol. 20, No. 2: Health Care Trends SPECIAL REPORTPatient Safety: Grantmakers Join The Effort To Reduce Medical ErrorsLauren LeRoy and Katherine M. TreanorPUBLISHED:March/April 2001Free Accesshttps://doi.org/10.1377/hlthaff.20.2.287AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSPatient safetyMedical malpracticeGrantmakersQuality of careHealth care providersSystems of carePharmaceuticalsOrganization of careGrantsHospital quality Medical errors have been documented for many years, but the evidence had not captured the public’s attention until the Institute of Medicine (IOM) report, To Err Is Human: B uilding a Safer Health System, was published in November 1999. 1 The report placed patient safety firmly on the nation’s health care agenda in part because of one startling statistic: Between 44,000 and 98,000 persons die in U.S. hospitals each year as a result of medical errors. The precise number of deaths and injuries that patients experience while receiving medical care is uncertain, but the magnitude suggested by the IOM study is clearly unacceptable. Improving patient safety is a shared responsibility that depends on cooperation and action by private-sector organizations, consumers, and government. Health grantmakers are well positioned to support these efforts both locally and nationally.Key IssuesMedical errors take many forms, from patient falls because of a lack of restraints, to mistakes in administering medications, to miscommunication among providers involved in a patient’s care. Medical errors occur in both inpatient and outpatient settings. Some errors have devastating consequences; others do not. Medical errors are not responsible for all poor outcomes but rather represent adverse events that could have been prevented given current knowledge. Health care lags behind some other high-risk industries, such as aviation and nuclear power, in making error reduction and safety central to its mission. Some models and success stories, however, suggest that the IOM’s national goal of cutting errors in half over the next five years is within reach. For example, efforts to improve surgical anesthesia outcomes have reduced the error rate nearly sevenfold. 2 Medication errors in the Veterans Health Administration have decreased by 70 percent since the introduction of a handheld, wireless bar-coding system. 3 Contrary to commonly held perceptions, medical errors are generally not the result of individual misconduct; they are caused by failures in the health care systems and organizations that we create. 4 Health care is both labor and technology intensive. The potential for preventable adverse events is exacerbated by both the complexity and fragmentation that characterize health care delivery. The key to reducing medical errors, therefore, is to focus on improving the systems of delivering care. Experience both within and outside of the health sector points to looking for solutions that seek to understand the underlying causes of errors, learn from reported errors or close calls, and work to eliminate the conditions that contribute to preventable adverse events. Shifting the focus from individuals to systems presents perhaps the greatest challenge in reducing the rate of medical errors. It will require a change in both health professional culture and public expectations. Historically, the most common approach to addressing errors has been to assign blame. Doing so, however, is counterproductive and has led to an environment that inhibits discussion of mistakes and close calls for fear of reprisals. Additionally, this culture prevents the reporting and systems examination needed to discover and correct the causes of errors. 5Grantmaker ActivitiesIncreased interest in patient safety provides new opportunities for grantmakers that support programs to improve health care quality. It may also attract funders that have not previously seen a role for themselves in addressing quality issues, particularly funders at the local level, where much of the improvement in patient safety must occur.Within this broader context of quality improvement, a number of grantmakers are pursuing improvements in patient safety. Their work takes place throughout the health care system, in hospitals, ambulatory care centers, nursing homes, and physicians’ offices. These grantmakers are also active in informing public policy development, in consumer education, and in advocacy. Because of its many facets, patient safety is an area in which foundations of different sizes and geographic focus can contribute. Some foundations might provide grants of several thousand dollars that support safety enhancement efforts within local hospitals, while others are able to fund national initiatives of millions of dollars.Convening.Convening providers, policymakers, employers, consumers, and advocates to develop strategies to improve patient safety is one of the most influential roles that grantmakers can play. This is an approach taken by the Jewish Healthcare Foundation, which, in partnership with local health care and business leaders, launched the Pittsburgh Regional Healthcare Initiative (PRHI). Recognizing that the area’s health care organizations are essential to maintaining quality of life and a strong workforce in Pittsburgh, but realizing that economic factors, such as operating losses and consolidations, were placing them at risk, the PRHI is working to establish the region as a model of health system performance, taking advantage of information technology and modern management tools. The PRHI’s quality goals encompass three strategies: improving health care outcomes in five clinical areas, creating safer hospitals by eliminating medication errors and hospital-acquired infections, and discouraging excess hospital service capacity that reduces the quality of clinical care. To demonstrate support for these strategies, Pittsburgh’s leading health care organizations and employers have embraced two community charters. Each charter defines specific actions that they will take to reduce medical errors, increase patient safety, and improve overall health care quality. The Robert Wood Johnson Foundation (RWJF) has provided a $1 million grant to support the PRHI, reflecting the funder’s commitment to improving the overall quality of health care and its interest in supporting public/private collaboration.Similarly, the W.K. Kellogg Foundation awarded a grant in 1999 to Harvard University to convene and mobilize national government, industry, academic, media, and consumer leaders to strategically improve patient safety. At the local level, the New York Community Trust contributed to the United Hospital Fund’s efforts to promote safety among New York City’s hospitals. The work includes reviewing the scope of medical errors and examining how providers, purchasers, regulators, consumers, and others respond to errors and enhance safety. This initiative will also convene health care leaders to identify and share best practices promoting patient safety within local hospitals.Policy research. Grantmakers also can contribute to public policy on patient safety. The Commonwealth Fund has stimulated interest in medical errors and patient safety at both the national and state levels. As a funder of To Err Is Human, the Commonwealth Fund helped to bring these issues to national attention. Additionally, Commonwealth, along with the RWJF, provided support to the National Academy for State Health Policy to review states’ medical error policies and regulations and evaluate their error-reporting systems. 6Educating and surveying consumers.Grantmakers are also positioned to educate the public about the quality of care provided by health care organizations and professionals. The California HealthCare Foundation’s (CHCF’s) Quality Initiative, focused on bettering the health of Californians, includes development and dissemination of publicly reported quality data across health care settings; promoting and evaluating consumers’ and purchasers’ use of quality data; and accelerating quality improvement and public accountability through collaboration among consumer groups, providers, purchasers, and policymakers. Also, within the initiative, the foundation is developing a strategic plan to address patient safety. In the meantime, the CHCF plans to collaborate with the Agency for Healthcare Research and Quality (AHRQ) to translate a patient fact sheet on avoiding medical errors into several Asian languages.Results of a consumer survey conducted by the Henry J. Kaiser Family Foundation and AHRQ were released in December 2000. The survey found increased public awareness of medical errors as a result of recent media attention, with medical errors becoming a leading measure of health care quality. Survey results suggest the opportunity for policymakers and others to make information on quality more readily available and the need to take care in assuring its validity and reliability.Improving delivery of care.Improving health care delivery so as to reduce errors is another area in which all types of grantmakers can contribute. The CHCF commissioned a primer on computerized physician order-entry systems, a technology that has been shown to reduce medical errors and increase cost savings. The primer, developed by First Consulting Group, was distributed to hospital trustees, hospital executives, nursing administrators, and pharmacists throughout the state. The RWJF has supported a number of patient safety studies examining communication, teamwork, and professional culture in health care organizations. For example, one project will introduce medical students to the professional and personal implications and responsibilities related to medical errors.Research on medical errors.Grantmakers are starting to take advantage of the momentum generated by the IOM report by funding research on how and why errors occur and on the development and evaluation of strategies to reduce errors. Aetna U.S. Healthcare and the Aetna Foundation awarded $840,000 in grants to researchers at five leading academic medical centers to examine topics such as reducing medication errors, improving safety for surgical patients, and controlling infection in long-term care facilities. One study, for example, is examining how tertiary care hospitals and their pharmacies collect information about medication events and errors. In a second program, surgeons, anesthesiologists, and nurses work collaboratively to resolve cross-disciplinary systemic problems affecting patient safety. The Blue Cross Blue Shield of Michigan Foundation is funding medical error research at the state level. It recently awarded approximately $500,000 to several Michigan researchers for epidemiological research, applied research, demonstration and evaluation projects, and strategies to disseminate best practices on reducing medical errors.A number of grantmakers have also partnered with the Quality Interagency Coordination Task Force (QuIC) to help shape a national research agenda on patient safety. QuIC brings all federal agencies involved in purchasing, providing, regulating, or examining health care into a cooperative effort to improve health care quality. In September 2000 it sponsored a National Summit on Medical Errors and Patient Safety Research to identify opportunities for publicly and privately funded research to obtain a better understanding of how and why errors occur and to design and promote safety-enhancing interventions. Private funders—including the Commonwealth Fund, Jewish Healthcare Foundation, the RWJF, the Kaiser Family Foundation, the CHCF, as well as Grantmakers In Health (GIH)—were among those hearing testimony at the summit.The GIH role.Heightened concern about patient safety prompted GIH to stimulate grantmakers’ interest in addressing this issue. Consistent with its mission to help grantmakers improve the nation’s health, GIH thus far has focused on fostering collaboration among public and private funders on agenda setting and information exchange, as well as educating the broader field of health philanthropy on medical errors and patient safety and strategies for addressing these critical issues.GIH’s participation in QuIC’s summit and in a second QuIC conference focused on concerns of clinicians and health system managers are examples of its efforts to identify potential roles and partnerships for health grantmakers. To raise the visibility of these issues within health philanthropy, as of this writing, GIH was planning an Issue Dialogue, funded by the RWJF, for late February 2001. This one-day working meeting sought to convene grantmakers, researchers, and experts from the public and private sectors to discuss the issues and explore steps that foundations can take to improve patient safety.Continued OpportunitiesGrantmakers are uniquely positioned to help to reduce medical errors and improve patient safety throughout our health care system. Beyond the programs described here, grantmakers can support demonstrations of promising interventions, education and training of health care professionals, and development of leadership for cultural change. Each of these efforts can be undertaken at the local, state, or national level and can involve a diverse array of new and established grantmakers with varying resources and programmatic focuses.Medical errors and patient safety are relatively new funding areas for grantmakers, but foundations are likely to find many opportunities consistent with their broader grantmaking agendas. Since grantmakers as a whole support projects within virtually all aspects of the health care system, they are able to advance patient safety in both inpatient and ambulatory settings and to reach out to providers, the public, and other stakeholders. As grantmakers contribute to reducing medical errors and improving patient safety, they also can advance the broader quality agenda.Lauren LeRoy is the president and chief executive officer of Grantmakers In Health, in Washington, D.C. Kate Treanor is a program associate at GIH.The authors appreciate the assistance of the grantmakers cited within this paper in providing information on their work.NOTES1 Institute of Medicine, To Err Is Human: Building a Safer Health System (Washington: National Academy Press, November 1999 ). The IOM defines medical errors as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.” Errors resulting in injury are considered to be preventable adverse events. The Quality Interagency Coordination Task Force defines patient safety as “initiatives designed to prevent adverse outcomes from medical errors”; and views safety as preventing errors, making errors visible, and mitigating the effects of errors. Google Scholar 2 Quality Interagency Coordination Task Force, Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact: A Report to the President (Rockville, Md.: QuIC, 2000 ). Google Scholar 3 Ibid. Google Scholar 4 L. Leape , “Can We Make Health Care Safe?” in Reducing Medical Errors and Improving Patient Safety: Success Stories from the Front Lines of Medicine , ed. S. Findlay (Washington: National Coalition on Health Care and Institute for Healthcare Improvement, 2000 ). Google Scholar 5 Ibid. Google Scholar 6 J. Rosenthal et al., Current State Programs Addressing Medical Errors: An Analysis of Mandatory Reporting and Other Initiatives (Portland, Maine: National Academy for State Health Policy, 2001 ). Google Scholar Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article Metrics History Published online 1 March 2001 InformationCopyright 2001 by Project HOPE - The People-to-People Health Foundation, Inc.PDF download

Federal Efforts to Improve Quality of Care: The Quality Interagency Coordination Task Force (QuIC)

FORMATION OF THE QUIC: The Quality Interagency Coordination Task Force (QuIC) was established in 1998 to enable the participating federal agencies to coordinate their activities to study, measure, and improve the quality of care delivered by federal health programs; provide people with information to help them in making more informed choices about their care; and develop the research base and infrastructure needed to improve the health care system, including knowledgeable and empowered workers, well-designed systems of care, and useful information systems. STUDY, MEASURE, AND IMPROVE CARE: The QuIC's initial efforts to improve the care delivered in federal health care programs have focused on diabetes, depression, and the effect of working conditions on quality of care. More recently, patient safety efforts are under way to establish a coordinating center that will enable those who are testing methods of reducing errors to share information across their projects and with experts in error reduction. DEVELOP A RESEARCH BASE AND INFRASTRUCTURE: The QuIC has coordinated efforts in credentialing, information on measures of quality, a taxonomy of quality improvement methods, and errors data collection. PROVIDE INFORMATION TO AMERICANS ABOUT HEALTH CARE QUALITY: The QuIC agencies are developing products that will enhance their ability to communicate with the American people about their health care choices: improved gateways for consumer information available from federal agencies, a glossary of commonly used terms, and guidance for producing report cards on quality of care. MOVING THE QUALITY IMPROVEMENT AGENDA FORWARD: Federal efforts to improve quality of care are moving forward in a more integrated fashion on a wide number of fronts.

4th Decennial International Conference on Nosocomial and Healthcare-Associated Infections: A challenge for change

Hala Fawal, MPH, MBA, CICView Large Image Figure ViewerDownload Hi-res image Download (PPT) A compilation of the richly complex and diverse science that has evolved within the field of health care epidemiology and infection control during the past 30 years comprised the program for the 4th Decennial International Conference on Nosocomial and Healthcare-Associated Infections held March 5-9, 2000, in Atlanta, Ga. The conference sessions were consistently informative, often thought provoking, and persistent in presenting us with challenges to change our thinking and vision for the future. Sponsored by the Centers for Disease Control and Prevention (CDC), and cosponsored by the Association for Professionals in Infection Control and Epidemiology, Inc (APIC), the Society for Healthcare Epidemiology of America, Inc (SHEA), and the National Foundation for Infectious Diseases (NFID), the Decennial Conference attracted more than 2500 attendees from the United States and throughout the world. More than 750 scientific presentations and abstracts were presented on a wide range of topics: those traditionally associated with health care–associated infections and infection control (eg, surgical site infections, bloodstream infections, and urinary tract infections), newer issues having an impact on infection control and infection prevention (eg, medical device reuse, biofilms, water quality, and measurement of cost-effectiveness), and controversies at the forefront of the practice of infection control (eg, control strategies for antimicrobial use, vancomycin-resistant Enterococcus isolation, and infection control dogma). This 4th Decennial Conference was not only a review of our current state of knowledge; it also presented a strong message for change. We, as professionals in health care epidemiology and infection control, are in the midst of change. Significant changes are occurring now in response to the public and decision-makers' demands for improved patient safety in health care. Additional change is forthcoming as we examine how we can measurably and effectively contribute to improving health care quality. We may need to reassess and repackage our roles and how we view our impact on patient health care quality and infection prevention for the future. What are the forces of change that are present and having an impact on our profession and our business? In her opening remarks, Dr Julie L. Gerberding, director of the CDC's Hospital Infections Program, set up several premises for the Decennial Conference. She described how health care and the practice of health care epidemiology have evolved during the past 4 decades as a result of “change drivers,” major forces that change societal perspectives and expectations. Currently, the change drivers affecting health care delivery are:1.The increasing emphasis on health care value purchasing2.The increasing complexity of the health care delivery system3.The rapidly changing and exigent information age These change drivers resulted in several themes that were highlighted throughout the Decennial Conference: (1) the need to measure value, prevention impact, and cost-effectiveness of our infection prevention activities, (2) the need to develop quality promotion and infection prevention activities across the continuum of the health care system, and (3) the need for further development of information networks, knowledge-based systems, and computer decision-support systems. It was through those themes that the challenges for change were presented. The Institute of Medicine (IOM) released a report in November 1999 entitled “To Err is Human,” which is already having an impact on the practice of infection control and prevention as we know it today.1Institute of Medicine To err is human. Advance copy. National Academy Press, Washington (DC)1999Google Scholar In the Decennial keynote address, Dr John Eisenberg, director of the federal Agency for Healthcare Research and Quality (AHRQ) (formerly the Agency for Healthcare Policy and Research), discussed the implications of the IOM report on health care quality promotion and patient safety. The report described the current state of health care delivery as a system in which medical errors and adverse events occur too frequently, which contributes significantly to patient morbidity and mortality. Much of the resulting discussion within the health care community and the media after the release of the IOM report has focused on medication and diagnostic errors. However, as Dr Eisenberg indicated in his address, “It's not just drugs or diagnostic errors, but also failure to order the right test in the first place. It's nursing procedure—simple things—like forgetting to pull the bed rails up. It's simple things like making sure the patient gets the right blood transfusion rather than somebody else's. And of course, it's infections in the hospital as well.” To respond to the IOM report, President Clinton and Vice President Gore charged the federal agencies with a stake in health care quality to provide a report to clarify what the government can do to address the problem. The Quality Interagency Coordination Task Force report was submitted to the president, who announced the elements of the federal response plan on February 22, 2000.2Quality Interagency Coordination Task Force Report to the president on medical errors: doing what counts for patient safety.http://www.quic.govDate: 2000Google Scholar Among the elements of the plan are requirements for:1.the creation of a national goal to reduce the number of medical mistakes by 50% during the next 5 years2.establishing a Center for Quality Improvement and Patient Safety at AHRQ3.developing a nationwide system of medical error reporting that includes both mandatory and voluntary components4.directing all health care facilities to have strong, clear, visible patient safety programs How is this changing our practice? Infection control professionals are being held accountable for providing proof that their prevention and intervention activities are successfully contributing to improving health care quality and patient safety. Integration of infection control programs into more broad-based programs designed to address patient safety and quality improvement may be imminent. Health care stakeholders, including the Joint Commission on Accreditation of Healthcare Organizations, the National Committee for Quality Assurance, the CDC, APIC, and SHEA, are all examining how to best promote their demonstrated scientific contributions to make an impact in improving patient care and promoting patient safety. The CDC's Hospital Infections Program has been addressing health care quality throughout its history of monitoring infections, developing evidence-based guidelines, and promoting clinical performance improvement at the local level. Dr Eisenberg described how the CDC's National Nosocomial Infection Surveillance (NNIS) system represents a model of success for developing and implementing voluntary systems for reporting adverse health events. A report published in the Morbidity and Mortality Weekly Report on March 3, 2000, illustrated a significant decline in device-associated infection rates in hospitals participating in the NNIS system from 1990-99.3Centers for Disease Control and Prevention Monitoring hospital-acquired infections to promote patient safety, United States, 1990-1999.MMWR Morb Mortal Wkly Rep. 2000; 49: 149-153PubMed Google Scholar The critical elements of the NNIS system that make it a model for other systems aimed at improving health care quality include (1) the use of standardized methodology, (2) targeted monitoring, (3) risk adjustment, (3) participation by trained professionals (ICPs), and (4) a link between the disseminated data and prevention efforts. Also forcing rapid changes in our hospitals and health care systems are societal demands for information exchange and improvements in information technology. In a Decennial Conference session that addressed the issues of health care information management, the developments that are changing our ability to access information were elucidated. The common message was that the control of information is central to the practice of infection control in this new century. Dr Walter Hierholzer described the changes occurring as health care systems develop needed health care-based information systems for quality promotion and infection prevention. Because our computer use in hospitals and health care systems at this time is often limited by many “stand-alone” systems, we need to identify our primary data needs (eg, pharmacy and laboratory) and integrate data and systems wherever possible (even if that integration is only partially complete). We need to develop systems to provide not only patient-specific information, but also to provide needed numerators and denominators and include components of error monitoring. Although our knowledge gap regarding intrinsic patient risk is more a problem of science than informatics, Dr Hierholzer challenged the audience to develop methods to use existing and changing data systems to gain a better understanding of patient intrinsic risk factors, which are largely responsible for contributing to the occurrence of infections and other adverse events and result in negative patient outcomes. Dr John Burke described how decision-support systems can greatly contribute to our efforts in quality promotion and infection prevention. “Decision support” refers to the use of computer technology to help reduce uncertainty in the clinical decision-making process. Critical to development of decision-support systems is integration of information systems within our health care systems. As described by Dr Burke, “Integration is the Holy Grail of clinical computing, and requires systems that allow individual departments and separate health care functions to communicate.” Currently, only 4% of US hospitals have the capacity for complete systems integration and decision support. Because many newly developed software and integration tools are coming on the market without proven track records, Dr Burke warned the audience to encourage potential purchasers of health care information software to visit another site where the new system is already operating to ensure that it can produce the desired results. Many problems that have traditionally been our focus for prevention and intervention efforts in infection control programs will undergo changes as we reevaluate our potential for impact. Dr Jean Carlet asked the question “Does ventilator-associated pneumonia (VAP) really affect patient outcomes?” In a comprehensive review of the literature, he described how VAP is a heterogenous disease. Early onset VAP, treated as soon as suspected, is associated with a low rate of mortality. Late onset VAP has been shown to be a result of different types of pathogens (eg, Acinetobacter and Pseudomonas species) and may be associated with increased mortality. Dr Carlet concluded that the impact of VAP on mortality may be overestimated as a result of limitations in study designs in assessing patient severity of illness. Past studies failed to adequately address case-mix problems, specifically, failures to control for persistent or worsening severity of illness throughout the stay in the intensive care unit. Recognizing our limited knowledge of the preventable impact of VAP and our questionable potential for intervention and prevention should encourage us to develop new paradigms for monitoring and addressing this problem in our critical care patients. How we address another problem familiar to infection control—improving compliance with hand hygiene—requires renewed assessment of where we can make changes to improve impact. Dr Elaine Larson provided a thorough review of hand ecology. She described studies that have contributed to our knowledge of how the skin flora of health care personnel is affected by hand care and hand hygiene products. Changes to be considered include incorporating the use of alcohol-based hand products and encouraging the use of suitable hand lotion products for health care personnel. Dr Larson concluded: More of the same is not better. More scrubbing, more brushing, more antiseptics are not necessarily better. Improved skin health is good for patients as well as staff. We need to minimize scrubbing and skin shedding. There are promising advances in technology with hand degermers, barrier creams, and new delivery mechanisms. And just because it feels good doesn't mean it's bad. Dr John Boyce described the studies addressing access to and acceptability of hand hygiene products and processes. Dr Didier Pittet challenged us to change the way we think of improving compliance among health care workers by moving the focus away from “handwashing” to increased emphasis on “hand hygiene” by using alcohol-based hand rubs or rinses. He described a systemic, comprehensive approach to improve hand hygiene compliance through institutional participation, feedback of hand hygiene compliance rates, and easing access to hand hygiene products. The consistent message from each speaker in this session is the need to change our thinking about hand hygiene issues based on a critical review of the evidence of the past 30 years. Change will occur as we take on new partners in our efforts to promote health care quality through infection prevention. Dr Richard Platt described how health maintenance organizations (HMOs) might be new partners. In his presentation, Dr Platt attempted to answer the question “Can managed health care help us manage health care-associated infections and should it?” He described the similarities between HMOs and public health systems: both address defined populations; both are responsible for overall health of its members (including preventive medicine); both have limited resources; both collect and use data to make decisions; and both are relatively information rich. By using data from ongoing CDC-sponsored studies, Dr Platt described several examples in which HMOs have already successfully collaborated with the infectious diseases community: (1) better management and compliance with guidelines for the prevention of Group B Streptococcus in neonates, (2) identification and public health reporting of patients with Mycobacterium tuberculosis, and (3) identification of surgical site infections posthospital discharge. HMOs may be able to provide many of the characteristics we are looking for to make systems improvements in health care delivery. They are able to assess the patients they cover, determine the services they offer, monitor outcomes of care across delivery sites, and intervene to improve care. Dr Platt concluded that managed care can help manage health care-associated infections by making infection control a priority, collaborating in epidemiologic research, enhancing surveillance and data management, and implementing control programs. However, APIC, SHEA, and the CDC need to:1.prove that infection control is sufficiently important to displace another important activity,2.advocate for active collaboration3.commit to a sustained engagement with managed care plans HMOs may have a lot to offer, but the relationship between managed care and infection control still needs to be built. As we form new partnerships, changes in the way we communicate are also necessary. Dr Julie Gerberding pointed out that although we are often talking about the same problems and issues, health care epidemiologists and infection control professionals often use terminology unfamiliar to other stakeholders, patients, and purchasers. We continue to describe one of our major activities as “surveillance and response”; instead, we need to change to “performance measurement, performance improvement, or reporting and learned response.” We monitor “infections and adverse health events”; we need to adopt the terminology “quality indicators” and “medical errors.” “Nosocomial,” a term understood by few people outside of hospital infection control, should be replaced with “health care-associated.” We should not describe—nor be content with—activities of “quality assurance,” but rather practice “quality promotion.” Finally, the community of health care epidemiologists and infection control professionals needs to incorporate the concepts that the public and our patients are also active partners in our business. Both Drs Eisenberg and Gerberding encouraged the conference attendees to ensure that our programs in quality promotion, infection prevention, and patient safety are designed with patient involvement and address patient needs. In her closing address, Dr Gerberding posed a challenge for change by imploring all conference attendees to “Put the ‘caring' back in health care.” The Decennial Conference addressed where we have come in infection control during the past 30 years and where we need to move in the next 10. Many of the conference presenters mapped out for us how change can be achieved. Our challenge is to recognize the forces that present new opportunities and embrace change in the way we practice quality promotion through infection prevention.

Continuing education meets the learning organization: The challenge of a systems approach to patient safety

Since the release of the report of the Institute of Medicine on medical errors and patient safety in November 1999, health policy makers and health care leaders in several nations have sought solutions that will improve the safety of health care. This attention to patient safety has high-lighted the importance of a learning approach and a systems approach to quality measurement and improvement. Balanced with the need for public disclosure of performance, confidential reporting with feedback is one of the prime ways that nations such as the United States, Canada, the United Kingdom, and Australia have approached this challenge. In the United States, the Quality Interagency Coordination Task Force has convened federal agencies that are involved in health care quality improvement for a coordinated initiative. Based on an investment in a strong research foundation in health care quality measurement and improvement, there are eight key lessons for continuing education if it is to parlay the interest in patient safety into enhanced continuing education and quality improvement in learning health care systems. The themes for these lessons are (1) informatics for information, (2) guidelines as learning tools, (3) learning from opinion leaders, (4) learning from the patient, (5) decision support systems, (6) the team learning together, (7) learning organizations, and (8) just-in-time and point-of-care delivery.