Overview
Donald M. Steinwachs, Ph.D.
It was a great pleasure to chair this committee and, as I will indicate in a moment, this was certainly a group effort that was very exciting. It was driven by a set of charges given to us by the funding agency, the Agency for Health Care Quality and Research, that asked this committee to identify the key aspects of the work environment of nurses that have an impact on patient safety and then to identify those areas where potential improvements could be made that would likely increase patient safety. As you know, an Institute of Medicine report is an evidence-based report, and so the recommendations you will be hearing, which came out of this work, are a synthesis of that evidence, an effort to try to pull it together in order to lay out a blueprint for health-care organizations in this country.
The committee’s expertise—and you have met some of the committee members here—is unusual in the sense that it reaches outside of health care. We recognized there was a lot to be learned from organizations that have high reliability: those that have low rates of error. Industries that handle transportation, nuclear power, and chemicals have spent years trying to figure out how to avoid accidents. These are industries that are concerned with how to reduce rates of error by understanding human factors and engineering, the man–environment, and the man–machine interface. They recognize the limits of humans: that humans are fallible, that we all make mistakes, and that we need systems behind us to deal with these realities.
There is expertise here. On behalf of the committee, I especially need to acknowledge and thank Ann Page, who served as the study director.
She was the one who made this come alive and come together, and so some of us refer to her as Mother Ann, with proper respect.
And Janet Corrigan certainly gave a guiding hand to our work and helped shape the composition of the committee; at some difficult points she also helped guide the direction that we took.
Keeping Patients Safe builds on two prior reports. Harvey indicated Crossing the Quality Chasm and To Err Is Human, and very briefly to put it into context, To Err Is Human documented the fact that we have substantial errors that occur in health care. It focused on hospitals and in-patient settings, and errors that lead to the death of an estimated 44,000 to 98,000 patients a year. I think for most people it was rather shocking to think that so many people would die because of errors or accidents, despite the work of committed institutions and dedicated health professionals.
It addressed some regulatory policy issues that needed to be addressed. Crossing the Quality Chasm took a next step and focused very much on what the system needs to do to relate to the patient and to the actual delivery of health care, sort of the micro part of the system: what happens on the unit, what happens between the nurse, the physician, the patient, and other health professionals.
This report reaches out somewhat differently. It really focuses on the health-care organization and what hospitals and nursing homes need to do in order to address patient safety. It focuses on nurses, who are the majority of the health-care work force, who are the ones whom the patients see the most, and who are in the position to provide the kind of surveillance and monitoring as well as interventions, that are critical to patient safety.
Also, part of the To Err Is Human report was a clear message that humans always commit errors but that fundamentally if you want to reduce errors it is a system problem. You have to change the system. You have to build a system. In some cases, this requires redundancy to get reliability. In other cases it requires other structures to assure that when errors occur they are stopped immediately or they don’t have a chance to occur at all. Most of the focus of this report is on the 90 percent of errors that are tied to failures in the system that are not really the blame of individuals.
As you know, nursing plays a preeminent role in health-care delivery. Fifty-four percent of health-care providers are nurses, and these nurses are frequently responsible for critical functions such as surveillance for rescue of patients and the coordination and integration of care. While all health-care providers contribute to errors, nurses often have the opportunity to intervene and to prevent that error from adversely affecting the patient.
The nursing work force, as many of you are well aware, is predominantly female. The average age of registered nurses (RNs) in this country
is older than the average age of the entire work force, and so in relative terms it is a work force that is growing older.
Many of the nursing assistants, and we rely on them very heavily in nursing homes, are earning incomes that put them below the poverty level, and so this work force includes individuals who are working on the margins.
Some of the most disturbing statistics are those that relate to turnover. When 21 percent of hospital RNs leave their jobs during a year and have to be replaced, 56 percent of nursing home RNs leave their jobs and have to be replaced, and the same for 78 percent of nursing home nursing assistants, there are tremendous implications for patient safety and quality, which we will talk about.
We also recognize that part of nursing in this country is the use of temporary workers, and this report addresses their role and the related concerns that arise around patient safety.
When you talk about nursing today, many times the first issue is the shortage, and we will be talking about recommendations that deal with staffing and the relationship to safety and patient outcomes. In these recommendations, I think we have a positive message about addressing safety and improving patient safety. Many of the things that we will be proposing to you are those things that you would also propose to reduce nurse turnover and effectively reduce the nursing shortage.
Very briefly, there have been big changes in the eighties and nineties to health care and hospitals. We know that hospitals have gone through changes in payment, shorter length of stay, more acute patients. Nursing homes are seeing the same thing.
During the late eighties and nineties, there was redesign and restructuring, which affected the role of nursing in many hospitals and institutions and redefined that role in problematic ways.
At the same time, rapid increases in knowledge and technology have demanded that all health-care workers be able to master new technologies more often and use them effectively in order to prevent errors and problems for patients.
What you will hear about next in Ada Sue Hinshaw’s presentation are the recommendations themselves and then the implications of those recommendations as seen by a CEO and hospital manager.
