Managed healthcare System: 2 pages

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Health Medical

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Assignment: Critical Thinking

Managed Care refers to the cost management of healthcare services by controlling who the consumer sees and how much the service costs.

Providers and consumers are concerned with the quality of care when the insurance companies are focused on cost control.

Explain the strengths and weaknesses of managed care system in the US healthcare system.

The book:

Niles,Nancy J., Basics of the US Health Care System,(2015)Second Edition, Jones and Bartlett Publisher

After watching “High Price of Health” and reading Chapter 9, “Impact of Managed Care on Healthcare Delivery”, both outline the strengths and weaknesses of this type of practice. Using examples from these sources (and/or any of your own sources of information) write if you believe that using an assembly line approach to providing healthcare is the best model.

Criteria

Points

Score

Introduction/ opening statement:

  • Healthcare is considered a business in the US, as part of our economy

2

Discussion/ description of issue

  • Identify strengths and weaknesses of managed care
  • What are the priorities of HMOs?
  • What are the priorities of providers?
  • What are the priorities of consumers?
  • Who is watching or regulating quality of care?
  • Cite evidence (facts and examples) to support your view

4

Concluding statement

  • How this is relevant to understanding healthcare and healthcare reform
  • Summarize your professional response and thoughts

2

Grammar/ Syntax/ Spelling

  • Well written and well organized

2

Total

10

link help you:

Frontline Price of Health:

http://www.pbs.org/wgbh/pages/frontline/shows/hmo/

High Price of Health Transcript Here is a transcript of this hard to find video

http://www.pbs.org/wgbh/pages/frontline/shows/hmo/etc/script.html

Ten Statistics and Trends about Physician Shortage

Never Events | AHRQ Patient Safety Network

AHRQ Patient Safety Information home page, link to Oregon

https://psnet.ahrq.gov/

Unformatted Attachment Preview

2010 P re lim in a ry Co m p a ra tive Re s u lts : Me d ic a l Offic e S u rve y o n P a tie n t S a fe ty Cu ltu re Prepared for: U.S. Department of Health and Human Services Agency for Healthcare Research and Quality 540 Gaither Road Rockville, MD 20850 http://www.ahrq.gov Contract No. HHSA 290200710037 Managed and prepared by: Westat, Rockville, MD AHRQ Publication No. 11-0015-EF November 2010 The authors of this report are responsible for its content. Statements in the report should not be construed as endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services. This document is in the public domain and may be used and reprinted without permission except those copyrighted materials noted for which further reproduction is prohibited without specific permission of copyright holders. Suggested Citation: 2010 Preliminary Comparative Results: Medical Office Survey on Patient Safety Culture. (Prepared by Westat, Rockville, MD, under Contract No. HHSA 290200710037). Rockville, MD: Agency for Healthcare Research and Quality; November 2010. AHRQ Publication No. 110015-EF. No investigators have any affiliations or financial involvement (e.g., employment, consultancies, honoraria, stock options, expert testimony, grants or patents received or pending, or royalties) that conflict with material presented in this report. ii Contents Purpose and Use of This Document Report Overview Survey Development Survey Administration Description of the 470 Medical Offices Description of Medical Office Respondents Composite-Level and Item-Level Comparative Results Calculating Item Percent Positive Scores Calculating Composite Percent Positive Scores Comparative Results Using Percentiles Composite-Level and Item-Level Results by Staff Position 1 1 1 2 3 6 7 7 8 18 25 Tables Table 1. Overall and Average Response Statistics for 470 Medical Offices Table 2. Distribution of Medical Offices by Number of Providers and Staff Table 3. Distribution of Medical Offices by Type of Specialty Table 4. Number of Medical Offices by Specialty Table 5. Distribution of Medical Offices by Number of Locations Table 6. Distribution of Medical Offices by Majority Ownership Table 7. Implementation Status of Electronic Tools Table 8. Number of Patient Visits and Providers at the Medical Office Table 9. Distribution of Respondents by Staff Category Table 10. Distribution of Respondents by Tenure Table 11. Distribution of Respondents by Hours Worked per Week Table 12. Example of How To Calculate Item and Composite Percent Positive Scores Table 13. Interpretation of Percentile Scores Table 14. Sample Percentile Statistics Table 15. Composite-Level Minimum, Maximum, and Percentile Results Table 16. Item-Level Minimum, Maximum, and Percentile Results Table 17. Overall Rating on Quality Minimum, Maximum, and Percentile Results Table 18. Overall Rating on Patient Safety Minimum, Maximum, and Percentile Results Table 19. Composite-Level Results by Staff Position Table 20. Item-Level Results by Staff Position Table 21. Overall Rating on Quality Results by Staff Position Table 22. Overall Rating on Patient Safety Results by Staff Position 3 3 4 4 5 5 5 6 6 7 7 8 18 19 19 20 24 25 25 26 30 31 Charts Chart 1. Composite-Level Comparative Results From 470 Medical Offices Chart 2. Item-Level Comparative Results From 470 Medical Offices Chart 3. Comparative Results for Overall Ratings on Quality From 470 Medical Offices Chart 4. Comparative Results for Overall Rating on Patient Safety From 470 Medical Offices iii 10 11 17 18 Purpose and Use of This Document Comparative results are provided for the items and patient safety culture dimensions on the AHRQ Medical Office Survey on Patient Safety Culture to allow medical offices to compare their survey results against the results from 470 medical offices. This number includes 292 Practice Based Research Network (PBRN) medical offices that administered the survey in 2009 and 182 medical offices that participated in a pilot test of the survey in the United States in late 2007. The results presented here are from limited numbers of staff and medical offices and will provide only a general indication of how your medical office compares with other medical offices in the United States. The data summarized here were not derived from a statistically selected sample of U.S. medical offices. At this time, there is no central repository for medical offices to submit data for comparative purposes. However, similar to the AHRQ Hospital Survey on Patient Safety Culture Comparative Database (www.ahrq.gov/qual/patientsafetyculture), AHRQ plans to support a U.S. comparative database for the medical office survey that will provide more extensive comparative data. More details will be forthcoming from AHRQ about when data submission will begin and when updated comparative results will be available. Report Overview • • • • Comparative results are provided for the survey items and patient safety culture dimensions based on data from 10,567 staff from 470 medical offices. The data were obtained from two survey administrations: 6,463 staff from 292 PBRN medical offices surveyed in 2009 and 4,174 staff from 182 pilot test medical offices surveyed in late 2007. Basic descriptive data are provided about the respondents and medical offices. A description of how composite scores on the Medical Office Survey on Patient Safety Culture were calculated is also provided. Survey Development The Medical Office Survey on Patient Safety Culture is an expansion of the Agency for Healthcare Research and Quality’s (AHRQ) Hospital Survey on Patient Safety Culture, which was pilot tested and made available to the public in November 2004 (http://www.ahrq.gov/qual/patientsafetyculture/hospsurvindex.htm). The Medical Office Survey on Patient Safety Culture was specifically designed to measure the culture of patient safety in medical offices from the perspectives of providers and staff. Safety culture can be defined as the set of values, beliefs, and norms about what is important, how to behave, and what attitudes are appropriate when it comes to patient safety in a workgroup or organization. The Medical Office Survey on Patient Safety Culture is intended to help a medical office assess the extent to which its organization’s culture emphasizes the importance of patient safety, facilitates teamwork and open discussion about mistakes, and creates an atmosphere of continuous learning and improvement. 1 The survey design team reviewed the literature on patient safety problems and issues in medical offices, interviewed more than two dozen experts and researchers on patient safety in medical offices, asked many medical office providers and staff to identify appropriate survey topics, and drafted sets of survey dimensions and items for review by experts. The draft survey was pretested with medical office providers and staff to ensure that the questions were easy to understand and answer and that the items were relevant. The pilot test survey was then administered in 2007 in a total of 182 medical offices, the data were analyzed to examine the survey’s psychometric properties (reliability and factor structure), and the length was shortened by dropping items. The final survey includes 52 survey items that measure the following 12 areas of organizational culture pertaining to patient safety: 1. Communication About Error 2. Communication Openness 3. Information Exchange With Other Settings 4. Office Processes and Standardization 5. Organizational Learning 6. Overall Perceptions of Patient Safety and Quality 7. Owner/Managing Partner/Leadership Support for Patient Safety 8. Patient Care Tracking/Followup 9. Patient Safety and Quality Issues 10. Staff Training 11. Teamwork 12. Work Pressure and Pace The survey uses 6-point frequency scales (“Daily” to “Not in the past 12 months”), 5-point frequency scales (“Never” to “Always”), or 5-point scales of agreement (“Strongly disagree” to “Strongly agree”). Most items include a “Does not apply or Don’t know” option. The survey also includes overall ratings questions that ask respondents to rate their medical office in five areas of health care quality (patient centered, effective, timely, efficient, equitable) and to provide an overall rating on patient safety. Survey Administration In 2007, a pilot administration was conducted with 182 medical offices and 4,174 staff across 21 States. The pilot survey was designed to contain a diverse sample of medical offices, although participation was voluntary and therefore may not statistically represent all medical offices in the United States. In 2009, 11 PBRNs collected data from 292 medical offices and 6,463 staff across 17 States. The data from the 182 pilot test medical offices were combined with the data from the 292 PBRN medical offices, yielding a total of 474 medical offices. Four medical offices were dropped because they had participated in both data collections, resulting in a final combined dataset of 470 medical offices. 2 Description of the 470 Medical Offices Completed responses from the 470 medical offices came from 33 States. However, the medical offices that voluntarily participated in these data collection efforts may not be representative of all medical offices in the United States. Overall response results for the participating medical offices are summarized in Table 1. In all tables, column percent totals may not add to exactly 100 percent because of rounding. Table 1. Overall and Average Response Statistics for 470 Medical Offices Overall Response Rate Information Statistic 10,567 14,558 Number of respondents Number of surveys administered Overall response rate Average Response Rate Information Average number of respondents per medical office (range: 5 to 192) Average number of surveys administered per medical office (range: 5 to 376) Overall average medical office response rate (range: 21% to 100%) 73% Statistic 22 31 78% Medical office characteristics were obtained from a designated point of contact in each medical office. Tables 2 through 4 show the distribution of medical offices by total number of providers and staff, type of specialty, and number of medical offices by specialty. The vast majority of medical offices (77%) had 40 or fewer providers and staff. Table 2. Distribution of Medical Offices by Number of Providers and Staff All Medical Offices Number Percent 84 140 90 47 Total Number of Providers and Staff 5–10 11–20 21–30 31–40 41–50 51–60 61–70 More than 70 Total 40 22 11 36 470 3 18% 30% 19% 10% 9% 5% 2% 8% 100% As shown in Table 3, more than half of medical offices (56%) were single specialty. Table 3. Distribution of Medical Offices by Type of Specialty All Medical Offices Number Percent 263 56% Type of Specialty Single specialty Multispecialty with primary care only (e.g., family medicine, internal medicine, pediatrics, OB/GYN, general practice) 114 24% Multispecialty with primary care and specialty care Multispecialty with specialty care only Total Missing 81 11 469 1 17% 2% 100% 0 The 470 medical offices represent a wide range of specialties, with most categorized as family practice/family medicine (291 offices)(Table 4). Table 4. Number of Medical Offices by Specialty Specialty Allergy/immunology Anesthesiology Cardiology Number of Medical Offices 15 2 22 Child and adolescent psychiatry Dermatology Diagnostic radiology Emergency medicine 6 11 8 7 Endocrinology/metabolism Family practice/family medicine 22 291 Forensic pathology Gastroenterology 1 11 General practice General preventive medicine 16 7 General surgery Geriatrics Hematology/oncology Internal medicine Medical genetics Nephrology 21 14 12 102 2 9 Specialty Neurology Nuclear medicine OB/GYN or GYN Number of Medical Offices 11 2 63 Ophthalmology Orthopedics Otolaryngology Pathology – anatomic/clinical Pediatrics Physical medicine and rehabilitation Psychiatry Public health and rehabilitation Pulmonary medicine Radiology 15 23 12 1 Rheumatology Surgery (all) Urology Vascular medicine Other specialty 11 11 12 3 47 95 9 26 2 9 6 Note: The total number of medical offices will not necessarily sum to 470 as some medical offices may categorize themselves as more than one type of specialty. 4 Table 5 shows the distribution of medical offices by number of locations. Approximately twothirds of medical offices (67%) had a single location, while the rest (33%) had multiple locations. Medical offices with more than one location had an average of 9 locations (ranging from 2 to 40 locations). Of the 152 medical offices with multiple locations, 48 indicated they were the primary/parent location and 104 indicated they were a satellite location. Table 5. Distribution of Medical Offices by Number of Locations All Medical Offices Number of Locations Number One location Multiple locations Total Missing Percent 310 152 462 8 67% 33% 100% Table 6 shows that almost half of medical offices (47%) were owned by a hospital or health system. Table 6. Distribution of Medical Offices by Majority Ownership All Medical Offices Number Percent 134 29% Majority Ownership Providers and/or Physicians Managed care or health maintenance organization University or medical school or academic medical institution Hospital or health system Federal, State, or local government, community board, etc. Other Total 3 75 220 23 10 465 Missing 1% 16% 47% 5% 2% 100% 5 Table 7 presents the implementation status of five common electronic tools in the medical offices. The vast majority of medical offices (82%) had fully implemented electronic appointment scheduling, while only 37% of medical offices had fully implemented electronic ordering of tests, imaging, or procedures. Table 7. Implementation Status of Electronic Tools Implementation Status Electronic Tools Electronic appointment scheduling Electronic ordering of medications Electronic ordering of tests, imaging, or procedures Electronic access to your patients’ test or imaging results Electronic medical/health records (EMR/EHR) 5 Fully Implemented 82% 41% 37% In Progress 13% 30% 26% Not Implemented 5% 29% 37% 59% 51% 29% 21% 12% 28% Table 8 presents the average number of patient visits per week per provider across all medical offices. i On average, the total number of patient visits per total number of providers was 69 (ranging from 1 to 450). Table 8. Number of Patient Visits and Providers at the Medical Office Medical Office Statistics Number of Patient Visits and Providers at the Medical Office Total number of patient visits/total number of providers Average 69 Minimum 1 Maximum 450 Description of Medical Office Respondents Tables 9 through 11 display distributions of the 10,567 medical office respondents by: • • • Staff category, Tenure in the medical office, and Hours worked per week in the medical office. According to the data on respondent characteristics shown in these tables: • • • Twenty-eight percent of respondents were administrative or clerical staff, 21% were other clinical staff or clinical support staff, and 19% were physicians. About 60% of respondents had worked in their medical office for at least 3 years. About 78% of respondents worked in their medical office at least 33 hours per week. Table 9. Distribution of Respondents by Staff Category All Medical Offices Staff Category Administrative or clerical staff Other clinical staff or clinical support staff Physician (M.D. or D.O.) Nurse (RN), licensed vocational nurse (LVN), licensed practical nurse (LPN) Management Physician assistant, nurse practitioner, clinical nurse specialist, nurse midwife, advanced practice nurse, etc. Other position TOTAL Missing Overall total i Number 2,860 2,155 1,941 1,564 749 Percent 28% 21% 19% 15% 7% 486 5% 435 10,190 377 10,567 4% 100% The PBRN medical offices were asked to report two pieces of information: total number of patient visits in a typical week and total number of providers working in the medical office in a typical week. The pilot test medical offices were simply asked to report the average number of patient visits per week across all providers. 6 Table 10. Distribution of Respondents by Tenure All Medical Offices Number Percent 282 Tenure in Medical Office Less than 2 months 2 months to less than 1 year 1 year to less than 3 years 3 years to less than 6 years 6 years to less than 11 years 11 years or more Total Missing 1,268 2,461 2,085 2,082 2,108 10,286 281 Overall total 10,567 3% 12% 24% 20% 20% 20% 100% Table 11. Distribution of Respondents by Hours Worked per Week Hours Worked per Week in the Medical Office 1 to 4 hours 5 to 16 hours 17 to 24 hours 25 to 32 hours 33 to 40 hours 41 hours or more Total Missing Overall total All Medical Offices Number Percent 118 492 706 996 5,245 2,735 10,292 275 10,567 1% 5% 7% 10% 51% 27% 100% Composite-Level and Item-Level Comparative Results You can obtain a summary view of how your medical office compares to other medical offices by examining the composite-level and item-level percent positive scores displayed in Charts 1 through 4. Calculating Item Percent Positive Scores To compare your medical office results to the comparative results from the Medical Office Survey on Patient Safety Culture, it is helpful to understand how the medical office percent positive scores are calculated. For positively worded items, percent positive is the total percentage of respondents who answered positively. This total is the combined percentage of “Strongly agree” and “Agree” responses or “Always” and “Most of the time” responses, depending on the response categories used for the item. For Section B (Information Exchange With Other Settings), percent positive is based on the combined percentage of “Problems once or twice in the past 12 months” and “No problems in the past 12 months.” 7 For negatively worded items, percent positive is the total percentage of respondents who answered negatively. This total is the combined percentage of “Strongly disagree” and ”Disagree” responses or “Never” and “Rarely” responses, since a negative answer on these items indicates a positive response. For Section A (List of Patient Safety and Quality Issues), all items are negatively worded, so the combined percentage of “Once or twice in the past 12 months” and “Not in the past 12 months” represents positive responses. Calculating Composite Percent Positive Scores A composite score summarizes how respondents answered groups of items that all measure the same thing. Composite scores on the 12 patient safety culture survey dimensions tell you the average percentage of respondents who answered positively when looking at the survey items that measure each safety culture dimension. Composite scores allow a summary comparison because you compare against only 12 safety culture dimensions rather than 52 separate survey items. To calculate each medical office’s composite score on a particular safety culture dimension, calculate the average percent positive response of the items included in the composite. Table 12 shows an example of computing a composite score for Office Processes and Standardization. The composite has four items. Two are positively worded (items C9 and C15) and two are negatively worded (items C8 and C12). Keep in mind that DISAGREEING with a negatively worded item indicates a POSITIVE response. Table 12. Example of How To Calculate Item and Composite Percent Positive Scores Office Processes and Standardization Item C9-positively worded: “We have good procedures for checking that work in this office was done correctly” Item C15-positively worded: “Staff in this office follow standardized processes to get tasks done” Item C8-negatively worded: “This office is more disorganized than it should be” Item C12-negatively worded: “We have problems with workflow in this office” For positively worded items, the # of “Strongly agree” or “Agree” responses For negatively worded items, the # of “Strongly disagree” or “Disagree” responses Total # of responses to the item* Percent positive response on item 24 NA* 52 24/52=46% 26 NA* 50 26/50=52% NA* 22 48 22/48=46% NA* 28 50 28/50= 56% Average percent positive response across the 4 items = 50% * Excluding not applicable/don’t know and missing responses 8 In this example, there were four items, with percent positive response scores of 46, 52, 46, and 56. Averaging these item-level percent positive scores ([46 + 52 + 46 + 56]/4 = 50) results in a composite score of .50 or 50% on Office Processes and Standardization. That is, an average of 50% of the respondents responded positively to the survey items in this composite. The charts on the following pages display the composite-level and item-level comparative results from the 470 medical offices. Chart 1 shows the average percent positive response for each of the survey’s patient safety culture composites, in order from most positive to least positive. Chart 2 provides the average percent positive response for the survey items. Chart 3 shows the average distribution of responses for the Overall Ratings on Quality, and Chart 4 shows the average distribution of responses for the Overall Rating on Patient Safety. Use a difference of 5 percentage points as a rule when comparing medical office results to the results shown. Medical office percentages should be at least 5 points higher than the comparative results to be considered “better” (e.g., 75% vs. 70%) and should be at least 5 points lower to be considered “lower” than the comparative results (e.g., 60% vs. 65%). A 5 percentage point difference is likely to be statistically significant for most medical offices given the number of responses per medical office and is also a meaningful difference to consider. This information provides only relative comparisons. Although your medical office’s results may be better than the comparative results, you may still believe there is room for improvement in an absolute sense. 9 Chart 1. Composite-Level Comparative Results From 470 Medical Offices Patient Safety Culture Composites % Positive Response 1. Teamwork 82% 2. Patient Care Tracking/Followup 77% 3. Organizational Learning 74% 4. Overall Perceptions of Patient Safety and Quality 74% 5. Staff Training 72% 6. Owner/Managing Partner/Leadership Support for Patient Safety 67% 7. Communication About Error 67% 65% 8. Communication Openness 9. Patient Safety and Quality Issues 60% 10. Office Processes and Standardization 59% 54% 11. Information Exchange With Other Settings 46% 12. Work Pressure and Pace 1 0 10 20 40 60 80 100 Chart 2. Item-Level Comparative Results from 470 Medical Offices Item Survey Items By Patient Safety Culture Average % Positive Response 1. Teamwork C1 1. When someone in this office gets really busy, others help out. C2 2. In this office, there is a good working relationship between staff and providers. C5 3. In this office, we treat each other with respect. 80% C13 4. This office emphasizes teamwork in taking care of patients. 80% D3 83% 87% 2. Patient Care Tracking/Follow-up 1. This office reminds patients when they need to schedule an appointment for preventive or routine care. 78% D5 2. This office documents how well our chroniccare patients follow their treatment plans. D6 3. Our office follows up when we do not receive a report we are expecting from an outside provider. D9 4. This office follows up with patients who need monitoring. F1 F5 F7 65% 77% 86% 3. Organizational Learning 1. When there is a problem in our office, we see if we need to change the way we do things. 2. This office is good at changing office processes to make sure the same problems don’t happen again. 82% 75% 3. After this office makes changes to improve the patient care process, we check to see if the changes worked. 67% 0% Note: The item’s survey location is shown to the left. 11 20% 40% 60% 80% 100% Chart 2. Item-Level Comparative Results from 470 Medical Offices, continued Item Survey Items By Patient Safety Culture Average % Positive Response 4. Overall Perceptions of Patient Safety and Quality F2 1. Our office processes are good at preventing mistakes that could affect patients. F3R 2. Mistakes happen more than they should in this office. F4R 3. It is just by chance that we don’t make more mistakes that affect our patients. 74% F6R 4. In this office, getting more work done is more important than quality of care. 73% 79% 70% 5. Staff Training C4 1. This office trains staff when new processes are put into place. C7 2. This office makes sure staff get the on-thejob training they need. 71% C10R 3. Staff in this office are asked to do tasks they haven’t been trained to do. 69% 75% 6. Owner/Managing Partner/Leadership Support for Patient Safety E1R 1. They aren’t investing enough resources to improve the quality of care in this office. E2R 2. They overlook patient care mistakes that happen over and over. 79% E3 3. They place a high priority on improving patient care processes. 78% E4R 4. They make decisions too often based on what is best for the office rather than what is best for patients. 51% 61% 0% 20% 40% 60% 80% 100% Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item). 12 Chart 2. Item-Level Comparative Results from 470 Medical Offices, continued Item Survey Items By Patient Safety Culture Average % Positive Response 7. Communication About Error D7R 1. Staff feel like their mistakes are held against them. 57% D8 2. Providers and staff talk openly about office problems. 59% D11 3. In this office, we discuss ways to prevent errors from happening again. D12 4. Staff are willing to report mistakes they observe in this office. 78% 72% 8. Communication Openness D1 1. Providers in this office are open to staff ideas about how to improve office processes. 69% D2 2. Staff are encouraged to express alternative viewpoints in this office. 68% D4R 3. Staff are afraid to ask questions when something does not seem right. 70% D10R 4. It is difficult to voice disagreement in this office. 53% 0% 20% 40% 60% 80% 100% Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item). 13 Chart 2. Item-Level Comparative Results from 470 Medical Offices, continued Item Survey Items By Patient Safety Culture Average % Positive Response 9. Patient Safety and Quality Issues In your best estimate, how often did the following things happen in your medical office over the past 12 months? Access to Care A1 1. A patient was unable to get an appointment within 48 hours for an acute/serious problem. 69% Patient Identification A2 2. The wrong chart/medical record was used for a patient. 86% Charts/Medical Records A3 3. A patient's chart/medical record was not available when needed. A4 4. Medical information was filed, scanned, or entered into the wrong patient's chart/medical record. 63% 70% Medical Equipment A5 5. Medical equipment was not working properly or was in need of repair or replacement. 73% Medication A6 6. A pharmacy contacted our office to clarify or correct a prescription. A7 7. A patient's medication list was not updated during his or her visit. 22% 44% Diagnostics & Tests A8 8. The results from a lab or imaging test were not available when needed. A9 9. A critical abnormal result from a lab or imaging test was not followed up within 1 business day. 39% 79% 0% 20% 40% 60% 80% 100% Note: The percent positive response is based on those who answered “Not in the past 12 months” or “Once or twice in the past 12 months.” 14 Chart 2. Item-Level Comparative Results from 470 Medical Offices, continued Item Survey Items By Patient Safety Culture Area Average % Positive Response 10. Office Processes and Standardization C8R 1. This office is more disorganized than it should be. 58% C9 2. We have good procedures for checking that work in this office was done correctly. 60% C12R 3. We have problems with workflow in this office. C15 47% 4. Staff in this office follow standardized processes to get tasks done. 74% 11. Information Exchange With Other Settings Over the past 12 months, how often has your medical office had problems exchanging accurate, complete, and timely information with: B1 1. Outside labs/imaging centers? B2 2. Other medical offices/Outside physicians? 50% B3 3. Pharmacies? 52% B4 4. Hospitals? B5 5. Other? (Specify) 55% 58% 70% 0% 20% 40% 60% 80% 100% Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item). The percent positive response for items B1 through B5 is based on those who answered “Not in the past 12 months” or “Once or twice in the past 12 months.” 15 Chart 2. Item-Level Comparative Results from 470 Medical Offices, continued Item Survey Items By Patient Safety Culture Average % Positive Response 12. Work Pressure and Pace C3R 1. In this office, we often feel rushed when taking care of patients. C6R 2. We have too many patients for the number of providers in this office. C11 3. We have enough staff to handle our patient load. C14R 4. This office has too many patients to be able to handle everything effectively. 28% 46% 49% 59% 0% 20% 40% 60% 80% 100% Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item). 16 Chart 3. Comparative Results for Overall Ratings on Quality From 470 Medical Offices Item Survey Items By Patient Safety Culture Area Overall, how would you rate your medical office on each of the following areas of health care quality? G1a. Patient Centered 100% Is responsive to individual patient preferences, needs, and values. 80% 60% 42% 40% 27% 25% 20% 5% 1% Fair Poor 4% 0% Fair Poor 0% Excellent G1b. Effective Very Good Good 100% 80% Is based on scientific knowledge. 60% 46% 40% 25% 25% 20% 0% Excellent G1c. Timely Minimizes waits and potentially harmful delays. Very Good Good 35% 32% 100% 80% 60% 40% 15% 20% 15% 4% 0% Excellent Very Good G1d. Efficient Ensures cost-effective care (avoids waste, overuse, and misuse of services). Good Fair Poor 100% 80% 60% 39% 40% 33% 16% 20% 10% 2% 0% Excellent Very Good G1e. Equitable Provides the same quality of care to all individuals regardless of gender, race, ethnicity, socioeconomic status, language, etc. Good Fair Poor 3% 1% Fair Poor 100% 80% 52% 60% 31% 40% 14% 20% 0% Excellent Very Good Good Note: Some percentages add to more than 100 due to rounding. 17 Chart 4. Comparative Results for Overall Rating on Patient Safety From 470 Medical Offices 100 Percent 80 60 44 40 27 20 20 8 1 0 Excellent Very Good Good Fair Poor Comparative Results Using Percentiles In addition to comparing percent positive scores from your medical office with the average percent positive scores from other medical offices, you may find it useful to examine additional comparative statistics: minimum and maximum scores and percentiles. The minimum and maximum percent positive scores are presented for each composite. These scores provide information about the range of percent positive scores from the pilot test medical offices and are actual scores from the lowest and highest scoring offices. When comparing against the minimum and maximum scores, keep in mind that these scores may represent offices that are extreme outliers. The 25th, 50th, and 75th percentile scores are displayed for the survey composites. Percentiles provide information about the distribution of the medical office scores. To calculate percentile scores, percent positive scores from the 470 medical offices were rank ordered from low to high. A specific percentile score shows the percentage of medical offices that scored at or below a particular score. For example, the 75th percentile is the percent positive score where 75 percent of the medical offices scored the same or lower, and 25 percent of the medical offices scored higher. Interpret the percentile scores as shown in Table 13. Table 13. Interpretation of Percentile Scores Percentile Score 25th percentile Lower scoring medical offices 50th percentile Middle-scoring medical offices 75th percentile Higher scoring medical offices Interpretation 25% of the medical offices scored the same or lower 75% of the medical offices scored higher 50% of the medical offices scored the same or lower 50% of the medical offices scored higher 75% of the medical offices scored the same or lower 25% of the medical offices scored higher 18 For example, for a survey composite in Table 14, the 25th percentile score is 49 percent positive, and the 50th percentile score is 62 percent positive. If your medical office’s score on the composite is 55 percent positive, it falls above the 25th percentile but below the 50th percentile, meaning that your medical office scored higher than at least 25 percent of the other medical offices. If your medical office’s score on the composite is 65 percent positive, it falls above the 50th percentile, meaning your medical office scored higher than at least 50 percent of the other medical offices. Table 14. Sample Percentile Statistics Survey Composite Composite 1 Minimum 8% Composite Percent Positive Response 25th 75th Percentile 50th Percentile Percentile 49% 62% 85% Maximum 96% If your medical office’s score is 55%, your score falls here. If your medical office’s score is 65%, your score falls here. For each patient safety culture composite, Table 15 shows the average percent positive scores, minimum score, 25th percentile, 50th percentile, 75th percentile, and maximum score for the 470 medical offices. Table 15. Composite-Level Minimum, Maximum, and Percentile Results % Positive Response Patient Safety Culture Composites 1 Teamwork 2 3 4 5 6 7 8 9 10 11 12 Patient Care Tracking/Followup Organizational Learning Overall Perceptions of Patient Safety and Quality Staff Training Owner/Managing Partner/Leadership Support for Patient Safety Communication About Error Communication Openness Patient Safety and Quality Issues Office Processes and Standardization Information Exchange With Other Settings Work Pressure and Pace Average % Positive 82% Min 25% 25th %ile 75% Median/ 50th %ile 84% 75th %ile 92% Max 100% 77% 74% 74% 31% 23% 18% 69% 67% 65% 78% 75% 75% 86% 84% 85% 100% 100% 100% 72% 67% 15% 15% 61% 56% 73% 68% 83% 79% 100% 100% 67% 65% 60% 59% 17% 21% 22% 13% 57% 54% 52% 47% 67% 64% 61% 60% 75% 77% 69% 71% 100% 100% 95% 100% 54% 8% 42% 54% 66% 100% 46% 0% 31% 46% 60% 95% 19 Table 16 shows the average percent positive scores, minimum score, 25th percentile, 50th percentile, 75th percentile, and maximum score for the 470 medical offices on each survey item sorted by patient safety culture composite. Tables 17 and 18 show the average percent positive scores, minimum score, 25th percentile, 50th percentile, 75th percentile, and maximum score for the overall ratings on quality and overall ratings on patient safety, respectively. Table 16. Item-Level Minimum, Maximum, and Percentile Results Survey Items by Composite Average % Positive Min % Positive Response Median/ 25th 50th 75th %ile %ile %ile Max 1. Teamwork C1 1. When someone in this office gets really busy, others help out. C2 2. In this office, there is a good working relationship between staff and providers. C5 3. In this office, we treat each other with respect. C13 4. This office emphasizes teamwork in taking care of patients. 2. Patient Care Tracking/Followup D3 1. This office reminds patients when they need to schedule an appointment for preventive or routine care. D5 2. This office documents how well our chronic-care patients follow their treatment plans. D6 3. Our office follows up when we do not receive a report we are expecting from an outside provider. D9 4. This office follows up with patients who need monitoring. 3. Organizational Learning F1 F5 F7 1. When there is a problem in our office, we see if we need to change the way we do things. 2. This office is good at changing office processes to make sure the same problems don’t happen again. 3. After this office makes changes to improve the patient care process, we check to see if the changes worked. 83% 25% 75% 85% 92% 100% 87% 20% 80% 90% 100% 100% 80% 0% 70% 82% 93% 100% 80% 17% 71% 82% 90% 100% 78% 18% 67% 80% 91% 100% 65% 17% 50% 67% 80% 100% 77% 18% 67% 80% 89% 100% 86% 40% 79% 88% 100% 100% 82% 20% 73% 82% 93% 100% 75% 8% 64% 75% 86% 100% 67% 11% 57% 68% 80% 100% 20 Table 16. Item-Level Minimum, Maximum, and Percentile Results, continued Average Survey Items by Composite % Positive 4. Overall Perceptions of Patient Safety and Quality F2 1. Our office processes are good at 79% preventing mistakes that could affect patients. F3R 2. Mistakes happen more than they 70% should in this office. F4R 3. It is just by chance that we don’t 74% make more mistakes that affect our patients. F6R 4. In this office, getting more work 73% done is more important than quality of care. Min % Positive Response Median/ 25th 50th 75th %ile %ile %ile Max 11% 69% 81% 90% 100% 11% 60% 71% 83% 100% 11% 64% 76% 88% 100% 17% 60% 75% 87% 100% 75% 13% 64% 78% 88% 100% 71% 17% 60% 72% 85% 100% 69% 14% 57% 70% 80% 100% 6. Owner/Managing Partner/Leadership Support for Patient Safety E1R 1. They aren’t investing enough 51% 0% resources to improve the quality of care in this office. 33% 50% 67% 100% E2R 2. They overlook patient care mistakes that happen over and over. 79% 0% 71% 80% 92% 100% E3 3. They place a high priority on improving patient care processes. 78% 0% 70% 80% 90% 100% 4. They make decisions too often based on what is best for the office rather than what is best for patients. 7. Communication About Error 61% 0% 47% 60% 75% 100% D7 R 1. Staff feel like their mistakes are held against them. 57% 0% 41% 57% 71% 100% D8 2. Providers and staff talk openly about office problems. 59% 0% 46% 57% 71% 100% D11 3. In this office, we discuss ways to prevent errors from happening again. 4. Staff are willing to report mistakes they observe in this office. 78% 17% 69% 80% 89% 100% 5. Staff Training C4 1. This office trains staff when new processes are put into place. C7 2. This office makes sure staff get the on-the-job training they need. C10 3. Staff in this office are asked to do R tasks they haven’t been trained to do. E4R D12 72% 21 17% 63% 72% 82% 100% Table 16. Item-Level Minimum, Maximum, and Percentile Results, continued Survey Items by Composite 8. Communication Openness D1 1. Providers in this office are open to staff ideas about how to improve office processes. D2 2. Staff are encouraged to express alternative viewpoints in this office. D4 3. Staff are afraid to ask questions R when something does not seem right. D10 4. It is difficult to voice disagreement R in this office. 9. Patient Safety and Quality Issues Access to Care A1 1. A patient was unable to get an appointment within 48 hours for an acute/serious problem. Patient Identification A2 2. The wrong chart/medical record was used for a patient. Charts/Medical Records A3 3. A patient's chart/medical record was not available when needed. A4 4. Medical information was filed, scanned, or entered into the wrong patient's chart/medical record. Medical Equipment A5 5. Medical equipment was not working properly or was in need of repair or replacement. Medication A6 6. A pharmacy contacted our office to clarify or correct a prescription. A7 7. A patient's medication list was not updated during his or her visit. Diagnostics and Tests A8 8. The results from a lab or imaging test were not available when needed. A9 9. A critical abnormal result from a lab or imaging test was not followed up within 1 business day. Average % Positive Min % Positive Response Median/ 25th 50th 75th %ile %ile %ile Max 69% 13% 57% 70% 82% 100% 68% 0% 55% 68% 80% 100% 70% 20% 59% 71% 83% 100% 53% 0% 40% 50% 67% 100% 69% 0% 53% 75% 88% 100% 86% 14% 78% 89% 100% 100% 63% 0% 43% 70% 87% 100% 70% 10% 55% 71% 86% 100% 73% 14% 60% 73% 88% 100% 22% 0% 9% 18% 30% 100% 44% 0% 27% 43% 60% 100% 39% 0% 25% 38% 51% 100% 79% 17% 67% 82% 96% 100% Note: For the A items (Patient Safety and Quality Issues), the percent positive response is based on those who answered “Not in the past 12 months” or “Once or twice in the past 12 months.” 22 Table 16. Item-level Minimum, Maximum and Percentile Results, continued % Positive Response Median/ 25th 50th 75th %ile %ile %ile Average Survey Items by Composite % Positive Min Max 10. Office Processes and Standardization C8 1. This office is more 58% 0% 43% 59% 72% 100% R disorganized than it should be. C9 2. We have good procedures for 60% 0% 45% 60% 72% 100% checking that work in this office was done correctly. C12 3. We have problems with 47% 0% 31% 44% 62% 100% R workflow in this office. C15 4. Staff in this office follow 74% 20% 63% 75% 86% 100% standardized processes to get tasks done. 11. Information Exchange With Other Settings Over the past 12 months, how often has your medical office had problems exchanging accurate, complete, and timely information with: B1 1. Outside labs/imaging centers? 55% 0% 40% 56% 67% 100% B2 2. Other medical offices/outside 50% 0% 38% 50% 63% 100% physicians? B3 3. Pharmacies? 52% 0% 39% 50% 69% 100% B4 4. Hospitals? 58% 0% 45% 59% 72% 100% B5 5. Other? (Specify) 70% 0% 50% 67% 100% 100% 12. Work Pressure and Pace C3 1. In this office, we often feel R rushed when taking care of patients. C6 R C11 C14 R 2. We have too many patients for the number of providers in this office. 3. We have enough staff to handle our patient load. 4. This office has too many patients to be able to handle everything effectively. 28% 0% 15% 25% 40% 100% 46% 0% 25% 44% 67% 100% 49% 0% 29% 47% 67% 100% 59% 0% 43% 59% 78% 100% 23 Table 17. Overall Rating on Quality Minimum, Maximum, and Percentile Results % Positive Response Median/ 25th 50th 75th %ile %ile %ile Survey Items by Composite Average % Min Max G1a. Patient Centered Is responsive to individual patient preferences, needs, and values. Excellent 25% 0% 13% 22% 33% 100% Very Good 42% 0% 33% 42% 50% 89% Good 27% 0% 17% 27% 38% 71% Fair 5% 0% 0% 2% 8% 38% Poor 1% 0% 0% 0% 0% 13% G1b. Effective Is based on scientific knowledge. Excellent 25% 0% 13% 22% 33% 100% Very Good 46% 0% 36% 45% 55% 100% Good 25% 0% 14% 25% 35% 86% Fair 4% 0% 0% 0% 6% 29% Poor 0% 0% 0% 0% 0% 29% G1c. Timely Minimizes waits and potentially harmful delays. Excellent 15% 0% 5% 11% 20% 86% Very Good 35% 0% 22% 33% 44% 83% Good 32% 0% 22% 33% 41% 75% Fair 15% 0% 5% 13% 22% 75% Poor 4% 0% 0% 0% 6% 80% G1d. Efficient Ensures cost-effective care (avoids waste, overuse, and misuse of services). Excellent 16% 0% 6% 14% 22% 100% Very Good 39% 0% 27% 38% 50% 100% Good 33% 0% 23% 33% 43% 83% Fair 10% 0% 0% 9% 15% 38% Poor 2% 0% 0% 0% 3% 32% G1e. Equitable Provides the same quality of care to all individuals regardless of gender, race, ethnicity, socioeconomic status, language, etc. Excellent 52% 0% 39% 50% 63% 100% Very Good 31% 0% 21% 31% 40% 80% Good 14% 0% 5% 13% 20% 50% Fair 3% 0% 0% 0% 6% 33% Poor 1% 0% 0% 0% 0% 20% 24 Table 18. Overall Rating on Patient Safety Minimum, Maximum, and Percentile Results G2a. Overall Rating on Patient Safety Excellent Very Good Good Fair Poor Average % 20% 44% 27% 8% 1% Min 0% 0% 0% 0% 0% % Positive Response Median/ 25th 50th 75th %ile %ile %ile 10% 17% 27% 33% 43% 54% 18% 27% 37% 0% 6% 13% 0% 0% 0% Max 80% 88% 88% 47% 40% Composite-Level and Item-Level Results by Staff Position Tables 19 through 22 show the average percent positive scores for the survey composites and items across medical offices, broken down by staff position. These tables allow comparison of the survey results of various staff positions in the medical office. In the following four tables, the precise number of medical offices and respondents corresponding to each data cell varies, due to omission of survey items by some medical offices, individual nonresponse, and missing data. Table 19. Composite-Level Results by Staff Position Staff Position Patient Safety Culture Composites # Medical Offices # Respondents 1. Teamwork 2. Patient Care Tracking/Followup 3. Organizational Learning 4. Overall Perceptions of Patient Safety and Quality 5. Staff Training 6. 7. 8. 9. 10. 11. 12. Owner/Managing Partner/ Leadership Support for Patient Safety Communication About Error Communication Openness Patient Safety and Quality Issues Office Processes and Standardization Information Exchange With Other Settings Work Pressure and Pace PA, NP, Admin Physician CNS, N, or (M.D. or Midwife, Clerical D.O.) APN Mgmt Staff 127 12 24 222 1,251 61 159 2,265 87% 82% 87% 75% 62% 78% 72% 80% 75% 54% 85% 70% 70% 57% 77% 67% RN/ LVN/ LPN 125 1,132 79% 74% 69% 70% Other Clinical Staff or Clinical Support Staff 157 1,557 78% 80% 72% 70% 77% 66% 77% 63% 67% 65% 66% 61% 68% 65% 61% 64% 71% 76% 54% 54% 60% 68% 55% 49% 67% 64% 55% 58% 57% 53% 58% 55% 62% 54% 58% 53% 61% 55% 60% 57% 43% 36% 36% 53% 56% 58% 45% 38% 40% 40% 33% 41% Note: Respondents who selected “Other” and missing are not shown; results are not calculated when a staff position has fewer than five respondents or an item in the composite has fewer than three respondents. 25 Table 20. Item-Level Results by Staff Position Staff Position Survey Items by Composite # Medical Offices # Respondents 1. Teamwork C1 1. When someone in this office gets really busy, others help out. C2 2. In this office, there is a good working relationship between staff and providers. C5 3. In this office, we treat each other with respect. C13 4. This office emphasizes teamwork in taking care of patients. 2. Patient Care Tracking/Followup D3 1. This office reminds patients when they need to schedule an appointment for preventive or routine care. D5 2. This office documents how well our chronic-care patients follow their treatment plans. D6 3. Our office follows up when we do not receive a report we are expecting from an outside provider. D9 4. This office follows up with patients who need monitoring. 3. Organizational Learning F1 1. When there is a problem in our office, we see if we need to change the way we do things. F5 2. This office is good at changing office processes to make sure the same problems don’t happen again. F7 3. After this office makes changes to improve the patient care process, we check to see if the changes worked. PA, NP, Physician CNS, N, Admin or (M.D. or Midwife, Clerical D.O.) APN Mgmt Staff 127 12 24 222 1,251 61 159 2,265 Other Clinical Staff or RN/ Clinical LVN/ Support LPN Staff 125 157 1,132 1,557 86% 81% 90% 77% 79% 77% 91% 87% 89% 80% 87% 85% 92% 85% 82% 70% 76% 73% 80% 76% 86% 75% 75% 76% 64% 71% 66% 81% 78% 83% 50% 68% 65% 75% 59% 73% 56% 76% 79% 81% 76% 81% 78% 94% 82% 85% 82% 85% 88% 65% 90% 73% 78% 76% 70% 52% 85% 69% 66% 73% 66% 47% 79% 66% 64% 67% Note: Respondents who selected “Other” and missing are not shown; R indicates a negatively worded item; and results are not calculated when a staff position has fewer than five respondents or an item has fewer than three respondents. 26 Table 20. Item-Level Results by Staff Position, continued Staff Position PA, NP, Physician CNS, N, Admin or (M.D. or Midwife, Clerical Survey Items by Composite D.O.) APN Mgmt Staff 4. Overall Perceptions of Patient Safety and Quality F2 1. Our office processes are good 73% 58% 78% 73% at preventing mistakes that could affect patients. F3R 2. Mistakes happen more than 63% 60% 74% 60% they should in this office. F4R 3. It is just by chance that we 73% 57% 74% 65% don’t make more mistakes that affect our patients. F6R 4. In this office, getting more work 68% 53% 82% 69% done is more important than quality of care. 5. Staff Training C4 1. This office trains staff when 83% 66% 80% 66% new processes are put into place. C7 2. This office makes sure staff get 75% 63% 77% 66% the on-the-job training they need. C10R 3. Staff in this office are asked to 73% 68% 74% 57% do tasks they haven’t been trained to do. 6. Owner/Managing Partner/Leadership Support for Patient Safety E1R 1. They aren’t investing enough 48% 47% 45% 49% resources to improve the quality of care in this office. E2R 2. They overlook patient care 82% 83% 76% 75% mistakes that happen over and over. E3 3. They place a high priority on 78% 73% 85% 79% improving patient care processes. E4R 4. They make decisions too often 59% 40% 63% 59% based on what is best for the office rather than what is best for patients. 7. Communication About Error D7R 1. Staff feel like their mistakes are 65% 42% 51% 45% held against them. D8 2. Providers and staff talk openly 69% 58% 61% 45% about office problems. D11 3. In this office, we discuss ways 77% 73% 87% 72% to prevent errors from happening again. D12 4. Staff are willing to report 71% 68% 68% 65% mistakes they observe in this office. 27 RN/ LVN/ LPN Other Clinical Staff or Clinical Support Staff 77% 77% 72% 68% 72% 70% 58% 64% 69% 70% 66% 65% 66% 62% 41% 47% 77% 73% 75% 79% 51% 56% 51% 47% 50% 50% 77% 78% 69% 68% Table 20. Item-Level Results by Staff Position, continued Staff Position Survey Items by Composite 8. Communication Openness D1 1. Providers in this office are open to staff ideas about how to improve office processes. D2 2. Staff are encouraged to express alternative viewpoints in this office. D4R 3. Staff are afraid to ask questions when something does not seem right. D10R 4. It is difficult to voice disagreement in this office. 9. Patient Safety and Quality Issues Access to Care A1 1. A patient was unable to get an appointment within 48 hours for an acute/serious problem. Patient Identification A2 2. The wrong chart/medical record was used for a patient. Charts/Medical Records A3 3. A patient's chart/medical record was not available when needed. A4 4. Medical information was filed, scanned, or entered into the wrong patient's chart/medical record. Medical Equipment A5 5. Medical equipment was not working properly or was in need of repair or replacement. Medication A6 6. A pharmacy contacted our office to clarify or correct a prescription. A7 7. A patient's medication list was not updated during his or her visit. Physician (M.D. or D.O.) PA, NP, CNS, N, Midwife, APN Mgmt Admin or Clerical Staff RN/ LVN/ LPN Other Clinical Staff or Clinical Support Staff 83% 80% 60% 53% 55% 58% 77% 73% 77% 56% 55% 56% 71% 64% 66% 62% 64% 65% 72% 50% 53% 41% 42% 41% 65% 42% 55% 65% 63% 67% 84% 83% 84% 82% 85% 85% 59% 50% 55% 59% 62% 61% 64% 58% 63% 69% 72% 76% 64% 66% 69% 71% 62% 67% 22% 29% 15% 14% 22% 19% 30% 34% 35% 45% 41% 47% Note: For the A items (Patient Safety and Quality Issues), the percent positive response is based on those who answered “Not in the past 12 months” or “Once or twice in the past 12 months.” 28 Table 20. Item-Level Results by Staff Position, continued Staff Position Physician (M.D. or D.O.) PA, NP, CNS, N, Midwife, APN Admin or Clerical Staff RN/ LVN/ LPN Survey Items by Composite Mgmt Diagnostics and Tests A8 8. The results from a lab or 32% 42% 42% 44% 37% imaging test were not available when needed. A9 9. A critical abnormal result from 71% 69% 81% 68% 80% a lab or imaging test was not followed up within 1 business day. 10. Office Processes and Standardization C8R 1. This office is more 54% 51% 60% 53% 52% disorganized than it should be. C9 2. We have good procedures for 56% 51% 60% 56% 51% checking that work in this office was done correctly. C12R 3. We have problems with 37% 35% 42% 44% 40% workflow in this office. C15 4. Staff in this office follow 71% 59% 71% 70% 70% standardized processes to get tasks done. 11. Information Exchange With Other Settings Over the past 12 months, how often has your medical office had problems exchanging accurate, complete, and timely information with: B1 1. Outside labs/imaging 43% 37% 41% 55% 57% centers? B2 2. Other medical offices/outside 34% 38% 35% 53% 52% physicians? B3 3. Pharmacies? 50% 46% 42% 42% 55% B4 4. Hospitals? 45% 36% 41% 59% 62% B5 5. Other? (Specify) 77% 73% 81% 12. Work Pressure and Pace C3R 1. In this office, we often feel 19% 11% 20% 26% 19% rushed when taking care of patients. C6R 2. We have too many patients 48% 37% 40% 38% 31% for the number of providers in this office. C11 3. We have enough staff to 52% 47% 44% 42% 36% handle our patient load. C14R 4. This office has too many 60% 56% 56% 52% 44% patients to be able to handle everything effectively. 29 Other Clinical Staff or Clinical Support Staff 45% 80% 55% 58% 43% 72% 60% 56% 56% 63% 74% 28% 38% 45% 53% Table 21. Overall Rating on Quality Results by Staff Position Staff Position Physician (M.D. or D.O.) 127 1,251 PA, NP, CNS, N, Midwife, APN 12 61 Admin or Clerical Mgmt Staff 24 222 159 2,265 Other Clinical Staff or RN/ Clinical LVN/ Support LPN Staff 125 157 1,132 1,557 Survey Items by Composite # Medical Offices # Respondents G1a. Patient Centered Is responsive to individual patient preferences, needs, and values. Excellent 23% 7% 18% 18% 18% 21% Very Good 43% 51% 48% 38% 43% 37% Good 25% 34% 28% 34% 32% 35% Fair 8% 8% 6% 9% 6% 6% Poor 1% 0% 0% 1% 1% 0% G1b. Effective Is based on scientific knowledge. Excellent 30% 12% 19% 18% 20% 20% Very Good 47% 52% 55% 41% 47% 43% Good 20% 30% 24% 35% 27% 32% Fair 2% 5% 2% 6% 5% 5% Poor 0% 2% 0% 1% 0% 0% G1c. Timely Minimizes waits and potentially harmful delays. Excellent 14% 5% 9% 10% 8% 10% Very Good 34% 33% 37% 29% 35% 33% Good 31% 35% 37% 35% 34% 34% Fair 17% 24% 14% 19% 18% 18% Poor 4% 2% 3% 7% 6% 5% G1d. Efficient Ensures cost-effective care (avoids waste, overuse, and misuse of services). Excellent 13% 12% 9% 13% 9% 13% Very Good 36% 29% 41% 33% 38% 34% Good 35% 40% 38% 38% 37% 37% Fair 13% 13% 10% 13% 13% 12% Poor 3% 6% 2% 3% 3% 4% G1e. Equitable Provides the same quality of care to all individuals regardless of gender, race, ethnicity, socioeconomic status, language, etc. Excellent 55% 48% 51% 41% 43% 46% Very Good 32% 34% 33% 33% 37% 30% Good 11% 15% 12% 20% 17% 19% Fair 2% 2% 3% 5% 3% 4% Poor 0% 2% 1% 2% 1% 2% Note: Respondents who selected “Other” and missing are not shown; results are not calculated when a staff position has fewer than five respondents or an item has fewer than three respondents. Percentages for each position may not add to 100 due to rounding. 30 Table 22. Overall Rating on Patient Safety Results by Staff Position Staff Position G2a. Overall Rating on Patient Safety # Medical Offices # Respondents Excellent Very Good Good Fair Poor Physician (M.D. or D.O.) 127 1,251 16% 42% 31% 9% 1% PA, NP, CNS, N, Midwife, APN 12 61 14% 34% 34% 10% 8% Mgmt 24 159 14% 52% 26% 7% 0% Admin or Clerical Staff 222 2,265 17% 41% 31% 10% 1% RN/ LVN/ LPN 125 1,132 16% 44% 30% 9% 1% Other Clinical Staff or Clinical Support Staff 157 1,557 19% 41% 31% 8% 1% Note: Respondents who selected “Other” and missing are not shown; results are not calculated when a staff position has fewer than five respondents or an item has fewer than three respondents. Percentages for each position may not add to 100 due to rounding. 31 To Err Is Human: Building a Safer Health System (Free Executive Summary) http://www.nap.edu/catalog/9728.html Free Executive Summary To Err Is Human: Building a Safer Health System Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, Editors; Committee on Quality of Health Care in America, Institute of Medicine ISBN: 978-0-309-06837-6, 312 pages, 6 x 9, hardback (2000) This free executive summary is provided by the National Academies as part of our mission to educate the world on issues of science, engineering, and health. If you are interested in reading the full book, please visit us online at http://www.nap.edu/catalog/9728.html . You may browse and search the full, authoritative version for free; you may also purchase a print or electronic version of the book. If you have questions or just want more information about the books published by the National Academies Press, please contact our customer service department toll-free at 888-624-8373. As many as 98,000 people die each year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer and AIDS--making medical errors the fifth leading cause of death in this country. The Institute of Medicine now spearheads an initiative to improve the quality of care in America by focusing on the facts and making wide-ranging recommendations. Central to the ideas proposed by the IOM is the notion that skilled and caring professionals can--and do--make mistakes because, after all, to err is human. This is why it is vital that we put this issue at the top of our national agenda and seek ways to reduce these errors through the design of a safer health system. This executive summary plus thousands more available at www.nap.edu. Copyright © National Academy of Sciences. All rights reserved. Unless otherwise indicated, all materials in this PDF file are copyrighted by the National Academy of Sciences. Distribution or copying is strictly prohibited without permission of the National Academies Press http://www.nap.edu/permissions/ Permission is granted for this material to be posted on a secure password-protected Web site. The content may not be posted on a public Web site. To Err Is Human: Building a Safer Health System http://books.nap.edu/catalog/9728.html Executive Summary T he knowledgeable health reporter for the Boston Globe, Betsy Lehman, died from an overdose during chemotherapy. Willie King had the wrong leg amputated. Ben Kolb was eight years old when he died during “minor” surgery due to a drug mix-up.1 These horrific cases that make the headlines are just the tip of the iceberg. Two large studies, one conducted in Colorado and Utah and the other in New York, found that adverse events occurred in 2.9 and 3.7 percent of hospitalizations, respectively.2 In Colorado and Utah hospitals, 6.6 percent of adverse events led to death, as compared with 13.6 percent in New York hospitals. In both of these studies, over half of these adverse events resulted from medical errors and could have been prevented. When extrapolated to the over 33.6 million admissions to U.S. hospitals in 1997, the results of the study in Colorado and Utah imply that at least 44,000 Americans die each year as a result of medical errors.3 The results of the New York Study suggest the number may be as high as 98,000.4 Even when using the lower estimate, deaths due to medical errors exceed the number attributable to the 8th-leading cause of death.5 More people die in a given year as a result of medical errors than from motor vehicle accidents (43,458), breast cancer (42,297), or AIDS (16,516).6 Total national costs (lost income, lost household production, disability and health care costs) of preventable adverse events (medical errors result1 Copyright National Academy of Sciences. All rights reserved. This executive summary plus thousands more available at http://www.nap.edu To Err Is Human: Building a Safer Health System http://books.nap.edu/catalog/9728.html 2 TO ERR IS HUMAN ing in injury) are estimated to be between $17 billion and $29 billion, of which health care costs represent over one-half.7 In terms of lives lost, patient safety is as important an issue as worker safety. Every year, over 6,000 Americans die from workplace injuries.8 Medication errors alone, occurring either in or out of the hospital, are estimated to account for over 7,000 deaths annually.9 Medication-related errors occur frequently in hospitals and although not all result in actual harm, those that do, are costly. One recent study conducted at two prestigious teaching hospitals, found that about two out of every 100 admissions experienced a preventable adverse drug event, resulting in average increased hospital costs of $4,700 per admission or about $2.8 million annually for a 700-bed teaching hospital.10 If these findings are generalizable, the increased hospital costs alone of preventable adverse drug events affecting inpatients are about $2 billion for the nation as a whole. These figures offer only a very modest estimate of the magnitude of the problem since hospital patients represent only a small proportion of the total population at risk, and direct hospital costs are only a fraction of total costs. More care and increasingly complex care is provided in ambulatory settings. Outpatient surgical centers, physician offices and clinics serve thousands of patients daily. Home care requires patients and their families to use complicated equipment and perform follow-up care. Retail pharmacies play a major role in filling prescriptions for patients and educating them about their use. Other institutional settings, such as nursing homes, provide a broad array of services to vulnerable populations. Although many of the available studies have focused on the hospital setting, medical errors present a problem in any setting, not just hospitals. Errors are also costly in terms of opportunity costs. Dollars spent on having to repeat diagnostic tests or counteract adverse drug events are dollars unavailable for other purposes. Purchasers and patients pay for errors when insurance costs and copayments are inflated by services that would not have been necessary had proper care been provided. It is impossible for the nation to achieve the greatest value possible from the billions of dollars spent on medical care if the care contains errors. But not all the costs can be directly measured. Errors are also costly in terms of loss of trust in the system by patients and diminished satisfaction by both patients and health professionals. Patients who experience a longer hospital stay or disability as a result of errors pay with physical and psychological discomfort. Health care professionals pay with loss of morale and frustration at not being able to provide the best care possible. Employers Copyright National Academy of Sciences. All rights reserved. This executive summary plus thousands more available at http://www.nap.edu To Err Is Human: Building a Safer Health System http://books.nap.edu/catalog/9728.html EXECUTIVE SUMMARY 3 and society, in general, pay in terms of lost worker productivity, reduced school attendance by children, and lower levels of population health status. Yet silence surrounds this issue. For the most part, consumers believe they are protected. Media coverage has been limited to reporting of anecdotal cases. Licensure and accreditation confer, in the eyes of the public, a “Good Housekeeping Seal of Approval.” Yet, licensing and accreditation processes have focused only limited attention on the issue, and even these minimal efforts have confronted some resistance from health care organizations and providers. Providers also perceive the medical liability system as a serious impediment to systematic efforts to uncover and learn from errors.11 The decentralized and fragmented nature of the health care delivery system (some would say “nonsystem”) also contributes to unsafe conditions for patients, and serves as an impediment to efforts to improve safety. Even within hospitals and large medical groups, there are rigidly-defined areas of specialization and influence. For example, when patients see multiple providers in different settings, none of whom have access to complete information, it is easier for something to go wrong than when care is better coordinated. At the same time, the provision of care to patients by a collection of loosely affiliated organizations and providers makes it difficult to implement improved clinical information systems capable of providing timely access to complete patient information. Unsafe care is one of the prices we pay for not having organized systems of care with clear lines of accountability. Lastly, the context in which health care is purchased further exacerbates these problems. Group purchasers have made few demands for improvements in safety.12 Most third party payment systems provide little incentive for a health care organization to improve safety, nor do they recognize and reward safety or quality. The goal of this report is to break this cycle of inaction. The status quo is not acceptable and cannot be tolerated any longer. Despite the cost pressures, liability constraints, resistance to change and other seemingly insurmountable barriers, it is simply not acceptable for patients to be harmed by the same health care system that is supposed to offer healing and comfort. “First do no harm” is an often quoted term from Hippocrates.13 Everyone working in health care is familiar with the term. At a very minimum, the health system needs to offer that assurance and security to the public. A comprehensive approach to improving patient safety is needed. This approach cannot focus on a single solution since there is no “magic bullet” that will solve this problem, and indeed, no single recommendation in this report should be considered as the answer. Rather, large, complex problems Copyright National Academy of Sciences. All rights reserved. This executive summary plus thousands more available at http://www.nap.edu To Err Is Human: Building a Safer Health System http://books.nap.edu/catalog/9728.html 4 TO ERR IS HUMAN require thoughtful, multifaceted responses. The combined goal of the recommendations is for the external environment to create sufficient pressure to make errors costly to health care organizations and providers, so they are compelled to take action to improve safety. At the same time, there is a need to enhance knowledge and tools to improve safety and break down legal and cultural barriers that impede safety improvement. Given current knowledge about the magnitude of the problem, the committee believes it would be irresponsible to expect anything less than a 50 percent reduction in errors over five years. In this report, safety is defined as freedom from accidental injury. This definition recognizes that this is the primary safety goal from the patient’s perspective. Error is defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. According to noted expert James Reason, errors depend on two kinds of failures: either the correct action does not proceed as intended (an error of execution) or the original intended action is not correct (an error of planning).14 Errors can happen in all stages in the process of care, from diagnosis, to treatment, to preventive care. Not all errors result in harm. Errors that do result in injury are sometimes called preventable adverse events. An adverse event is an injury resulting from a medical intervention, or in other words, it is not due to the underlying condition of the patient. While all adverse events result from medical management, not all are preventable (i.e., not all are attributable to errors). For example, if a patient has surgery and dies from pneumonia he or she got postoperatively, it is an adverse event. If analysis of the case reveals that the patient got pneumonia because of poor hand washing or instrument cleaning techniques by staff, the adverse event was preventable (attributable to an error of execution). But the analysis may conclude that no error occurred and the patient would be presumed to have had a difficult surgery and recovery (not a preventable adverse event). Much can be learned from the analysis of errors. All adverse events resulting in serious injury or death should be evaluated to assess whether improvements in the delivery system can be made to reduce the likelihood of similar events occurring in the future. Errors that do not result in harm also represent an important opportunity to identify system improvements having the potential to prevent adverse events. Preventing errors means designing the health care system at all levels to make it safer. Building safety into processes of care is a more effective way to reduce errors than blaming individuals (some experts, such as Deming, believe improving processes is Copyright National Academy of Sciences. All rights reserved. This executive summary plus thousands more available at http://www.nap.edu To Err Is Human: Building a Safer Health System http://books.nap.edu/catalog/9728.html EXECUTIVE SUMMARY 5 the only way to improve quality15 ). The focus must shift from blaming individuals for past errors to a focus on preventing future errors by designing safety into the system. This does not mean that individuals can be careless. People must still be vigilant and held responsible for their actions. But when an error occurs, blaming an individual does little to make the system safer and prevent someone else from committing the same error. Health care is a decade or more behind other high-risk industries in its attention to ensuring basic safety. Aviation has focused extensively on building safe systems and has been doing so since World War II. Between 1990 and 1994, the U.S. airline fatality rate was less than one-third the rate experienced in mid century.16 In 1998, there were no deaths in the United States in commercial aviation. In health care, preventable injuries from care have been estimated to affect between three to four percent of hospital patients.17 Although health care may never achieve aviation’s impressive record, there is clearly room for improvement. To err is human, but errors can be prevented. Safety is a critical first step in improving quality of care. The Harvard Medical Practice Study, a seminal research study on this issue, was published almost ten years ago; other studies have corroborated its findings. Yet few tangible actions to improve patient safety can be found. Must we wait another decade to be safe in our health system? RECOMMENDATIONS The IOM Quality of Health Care in America Committee was formed in June 1998 to develop a strategy that will result in a threshold improvement in quality over the next ten years. This report addresses issues related to patient safety, a subset of overall quality-related concerns, and lays out a national agenda for reducing errors in health care and improving patient safety. Although it is a national agenda, many activities are aimed at prompting responses at the state and local levels and within health care organizations and professional groups. The committee believes that although there is still much to learn about the types of errors committed in health care and why they occur, enough is known today to recognize that a serious concern exists for patients. Whether a person is sick or just trying to stay healthy, they should not have to worry about being harmed by the health system itself. This report is a call to action to make health care safer for patients. The committee believes that a major force for improving patient safety Copyright National Academy of Sciences. All rights reserved. This executive summary plus thousands more available at http://www.nap.edu To Err Is Human: Building a Safer Health System http://books.nap.edu/catalog/9728.html 6 TO ERR IS HUMAN is the intrinsic motivation of health care providers, shaped by professional ethics, norms and expectations. But the interaction between factors in the external environment and factors inside health care organizations can also prompt the changes needed to improve patient safety. Factors in the external environment include availability of knowledge and tools to improve safety, strong and visible professional leadership, legislative and regulatory initiatives, and actions of purchasers and consumers to demand safety improvements. Factors inside health care organizations include strong leadership for safety, an organizational culture that encourages recognition and learning from errors, and an effective patient safety program. In developing its recommendations, the committee seeks to strike a balance between regulatory and market-based initiatives, and between the roles of professionals and organizations. No single action represents a complete answer, nor can any single group or sector offer a complete fix to the problem. However, different groups can, and should, make significant contributions to the solution. The committee recognizes that a number of groups are already working on improving patient safety, such as the National Patient Safety Foundation and the Anesthesia Patient Safety Foundation. The recommendations contained in this report lay out a four-tiered approach: • establishing a national focus to create leadership, research, tools and protocols to enhance the knowledge base about safety; • identifying and learning from errors through immediate and strong mandatory reporting efforts, as well as the encouragement of voluntary efforts, both with the aim of making sure the system continues to be made safer for patients; • raising standards and expectations for improvements in safety through the actions of oversight organizations, group purchasers, and professional groups; and • creating safety systems inside health care organizations through the implementation of safe practices at the delivery level. This level is the ultimate target of all the recommendations. Leadership and Knowledge Other industries that have been successful in improving safety, such as aviation and occupational health, have had the support of a designated agency that sets and communicates priorities, monitors progress in achiev- Copyright National Academy of Sciences. All rights reserved. This executive summary plus thousands more available at http://www.nap.edu To Err Is Human: Building a Safer Health System http://books.nap.edu/catalog/9728.html EXECUTIVE SUMMARY 7 ing goals, directs resources toward areas of need, and brings visibility to important issues. Although various agencies and organizations in health care may contribute to certain of these activities, there is no focal point for raising and sustaining attention to patient safety. Without it, health care is unlikely to match the safety improvements achieved in other industries. The growing awareness of the frequency and significance of errors in health care creates an imperative to improve our understanding of the problem and devise workable solutions. For some types of errors, the knowledge of how to prevent them exists today. In these areas, the need is for widespread dissemination of this information. For other areas, however, additional work is needed to develop and apply the knowledge that will make care safer for patients. Resources invested in building the knowledge base and diffusing the expertise throughout the industry can pay large dividends to both patients and the health professionals caring for them and produce savings for the health system. RECOMMENDATION 4.1 Congress should create a Center for Patient Safety within the Agency for Healthcare Research and Quality. This center should • set the national goals for patient safety, track progress in meeting these goals, and issue an annual report to the President and Congress on patient safety; and • develop knowledge and understanding of errors in health care by developing a research agenda, funding Centers of Excellence, evaluating methods for identifying and preventing errors, and funding dissemination and communication activities to improve patient safety. To make significant improvements in patient safety, a highly visible center is needed, with secure and adequate funding. The Center should establish goals for safety; develop a research agenda; define prototype safety systems; develop and disseminate tools for identifying and analyzing errors and evaluate approaches taken; develop tools and methods for educating consumers about patient safety; issue an annual report on the state of patient safety, and recommend additional improvements as needed. The committee recommends initial annual funding for the Center of $30 to $35 million. This initial funding would permit a center to conduct activities in goal setting, tracking, research and dissemination. Funding should grow over time to at least $100 million, or approximately 1% of the $8.8 billion in health care costs attributable to preventable adverse events.18 Copyright National Academy of Sciences. All rights reserved. This executive summary plus thousands more available at http://www.nap.edu To Err Is Human: Building a Safer Health System http://books.nap.edu/catalog/9728.html 8 TO ERR IS HUMAN This initial level of funding is modest relative to the resources devoted to other public health issues. The Center for Patient Safety should be created within the Agency for Healthcare Research and Quality because the agency is already involved in a broad range of quality and safety issues, and has established the infrastructure and experience to fund research, educational and coordinating activities. Identifying and Learning from Errors Another critical component of a comprehensive strategy to improve patient safety is to create an environment that encourages organizations to identify errors, evaluate causes and take appropriate actions to improve performance in the future. External reporting systems represent one mechanism to enhance our understanding of errors and the underlying factors that contribute to them. Reporting systems can be designed to meet two purposes. They can be designed as part of a public system for holding health care organizations accountable for performance. In this instance, reporting is often mandatory, usually focuses on specific cases that involve serious harm or death, may result in fines or penalties relative to the specific case, and information about the event may become known to the public. Such systems ensure a response to specific reports of serious injury, hold organizations and providers accountable for maintaining safety, respond to the public’s right to know, and provide incentives to health care organizations to implement internal safety systems that reduce the likelihood of such events occurring. Currently, at least twenty states have mandatory adverse event reporting systems. Voluntary, confidential reporting systems can also be part of an overall program for improving patient safety and can be designed to complement the mandatory reporting systems previously described. Voluntary reporting systems, which generally focus on a much broader set of errors and strive to detect system weaknesses before the occurrence of serious harm, can provide rich information to health care organizations in support of their quality improvement efforts. For either purpose, the goal of reporting systems is to analyze the information they gather and identify ways to prevent future errors from occurring. The goal is not data collection. Collecting reports and not doing anything with the information serves no useful purpose. Adequate resources and other support must be provided for analysis and response to critical issues. Copyright National Academy of Sciences. All rights reserved. This executive summary plus thousands more available at http://www.nap.edu To Err Is Human: Building a Safer Health System http://books.nap.edu/catalog/9728.html EXECUTIVE SUMMARY RECOMMENDATION 5.1 A nationwide mandatory reporting system should be established that provides for the collection of standardized information by state governments about adverse events that result in death or serious harm. Reporting should initially be required of hospitals and eventually be required of other institutional and ambulatory care delivery settings. Congress should • designate the National Forum for Health Care Quality Measurement and Reporting as the entity responsible for promulgating and maintaining a core set of reporting standards to be used by states, including a nomenclature and taxonomy for reporting; • require all health care organizations to report standardized information on a defined list of adverse events; • provide funds and technical expertise for state governments to establish or adapt their current error reporting systems to collect the standardized information, analyze it and conduct follow-up action as needed with health care organizations. Should a state choose not to implement the mandatory reporting system, the Department of Health and Human Services should be designated as the responsible entity; and • designate the Center for Patient Safety to: (1) convene states to share information and expertise, and to evaluate alternative approaches taken for implementing reporting programs, identify best practices for implementation, and assess the impact of state programs; and (2) receive and analyze aggregate reports from states to identify persistent safety issues that require more intensive analysis and/or a broader-based response (e.g., designing prototype systems or requesting a response by agencies, manufacturers or others). RECOMMENDATION 5.2 The development of voluntary reporting efforts should be encouraged. The Center for Patient Safety should • describe and disseminate information on external voluntary reporting programs to encourage greater participation in them and track the development of new reporting systems as they form; • convene sponsors and users of external reporting systems to evaluate what works and what does not work well in the programs, and ways to make them more effective; • periodically assess whether additional efforts are needed to address gaps in information to improve patient safety and to encourage Copyright National Academy of Sciences. All rights reserved. This executive summary plus thousands more available at http://www.nap.edu 9 To Err Is Human: Building a Safer Health System http://books.nap.edu/catalog/9728.html 10 TO ERR IS HUMAN health care organizations to participate in voluntary reporting programs; and • fund and evaluate pilot projects for reporting systems, both within individual health care organizations and collaborative efforts among health care organizations. The committee believes there is a role both for mandatory, public reporting systems and voluntary, confidential reporting systems. However, because of their distinct purposes, such systems should be operated and maintained separately. A nationwide mandatory reporting system should be established by building upon the current patchwork of state systems and by standardizing the types of adverse events and information to be reported. The newly established National Forum for Health Care Quality Measurement and Reporting, a public/private partnership, should be charged with the establishment of such standards. Voluntary reporting systems should also be promoted and the participation of health care organizations in them should be encouraged by accrediting bodies. RECOMMENDATION 6.1 Congress should pass legislation to extend peer review protections to data related to patient safety and quality improvement that are collected and analyzed by health care organizations for internal use or shared with others solely for purposes of improving safety and quality. The committee believes that information about the most serious adverse events which result in harm to patients and which are subsequently found to result from errors should not be protected from public disclosure. However, the committee also recognizes that for events not falling under this category, fears about the legal discoverability of information may undercut motivations to detect and analyze errors to improve safety. Unless such data are assured protection, information about errors will continue to be hidden and errors will be repeated. A more conducive environment is needed to encourage health care professionals and organizations to identify, analyze, and report errors without threat of litigation and without compromising patients’ legal rights. Setting Performance Standards and Expectations for Safety Setting and enforcing explicit standards for safety through regulatory and related mechanisms, such as licensing, certification, and accreditation, Copyright National Academy of Sciences. All rights reserved. This executive summary plus thousands more available at http://www.nap.edu To Err Is Human: Building a Safer Health System http://books.nap.edu/catalog/9728.html EXECUTIVE SUMMARY 11 can define minimum performance levels for health care organizations and professionals. Additionally, the process of developing and adopting standards helps to form expectations for safety among providers and consumers. However, standards and expectations are not only set through regulations. The actions of purchasers and consumers affect the behaviors of health care organizations, and the values and norms set by health professions influence standards of practice, training and education for providers. Standards for patient safety can be applied to health care professionals, the organizations in which they work, and the tools (drugs and devices) they use to care for patients. RECOMMENDATION 7.1 Performance standards and expectations for health care organizations should focus greater attention on patient safety. • Regulators and accreditors should require health care organizations to implement meaningful patient safety programs with defined executive responsibility. • Public and private purchasers should provide incentives to health care organizations to demonstrate continuous improvement in patient safety. Health care organizations are currently subject to compliance with licensing and accreditation standards. Although both devote some attention to issues related to patient safety, there is opportunity to strengthen such efforts. Regulators and accreditors have a role in encouraging and supporting actions in health care organizations by holding them accountable for ensuring a safe environment for patients. After a reasonable period of time for health care organizations to develop patient safety programs, regulators and accreditors should require them as a minimum standard. Purchaser and consumer demands also exert influence on health care organizations. Public and private purchasers should consider safety issues in their contracting decisions and reinforce the importance of patient safety by providing relevant information to their employees or beneficiaries. Purchasers should also communicate concerns about patient safety to accrediting bodies to support stronger oversight for patient safety. RECOMMENDATION 7.2 Performance standards and expectations for health professionals should focus greater attention on patient safety. Copyright National Academy of Sciences. All rights reserved. This executive summary plus thousands more available at http://www.nap.edu To Err Is Human: Building a Safer Health System http://books.nap.edu/catalog/9728.html 12 TO ERR IS HUMAN • Health professional licensing bodies should (1) implement periodic re-examinations and re-licensing of doctors, nurses, and other key providers, based on both competence and knowledge of safety practices; and (2) work with certifying and credentialing organizations to develop more effective methods to identify unsafe providers and take action. • Professional societies should make a visible commitment to patient safety by establishing a permanent committee dedicated to safety improvement. This committee should (1) develop a curriculum on patient safety and encourage its adoption into training and certification requirements; (2) disseminate information on patient safety to members through special sessions at annual conferences, journal articles and editorials, newsletters, publications and websites on a regular basis; (3) recognize patient safety considerations in practice guidelines and in standards related to the introduction and diffusion of new technologies, therapies and drugs; (4) work with the Center for Patient Safety to develop community-based, collaborative initiatives for error reporting and analysis and implementation of patient safety improvements; and (5) collaborate with other professional societies and disciplines in a national summit on the professional’s role in patient safety. Although unsafe practitioners are believed to be few in number, the rapid identification of such practitioners and corrective action are important to a comprehensive safety program. Responsibilities for documenting continuing skills are dispersed among licensing boards, specialty boards and professional groups, and health care organizations with little communication or coordination. In their ongoing assessments, existing licensing, certification and accreditation processes for health professionals should place greater attention on safety and performance skills. Additionally, professional societies and groups should become active leaders in encouraging and demanding improvements in patient safety. Setting standards, convening and communicating with members about safety, incorporating attention to patient safety into training programs and collabo- Copyright National Academy of Sciences. All rights reserved. This executive summary plus thousands more available at http://www.nap.edu To Err Is Human: Building a Safer Health System http://books.nap.edu/catalog/9728.html EXECUTIVE SUMMARY 13 rating across disciplines are all mechanisms that will contribute to creating a culture of safety. RECOMMENDATION 7.3 The Food and Drug Administration (FDA) should increase attention to the safe use of drugs in both preand post-marketing processes through the following actions: • develop and enforce standards for the design of drug packaging and labeling that will maximize safety in use; • require pharmaceutical companies to test (using FDA-approved methods) proposed drug names to identify and remedy potential sound-alike and look-alike confusion with existing drug names; and • work with physicians, pharmacists, consumers, and others to establish appropriate responses to problems identified through postmarketing surveillance, especially for concerns that are perceived to require immediate response to protect the safety of patients. The FDA’s role is to regulate manufacturers for the safety and effectiveness of their drugs and devices. However, even approved products can present safety problems in practice. For example, different drugs with similar sounding names can create confusion for both patients and providers. Attention to the safety of products in actual use should be increased during approval processes and in post-marketing monitoring systems. The FDA should also work with drug manufacturers, distributors, pharmacy benefit managers, health plans and other organizations to assist clinicians in identifying and preventing problems in the use of drugs. Implementing Safety Systems in Health Care Organizations Experience in other high-risk industries has provided well-understood illustrations that can be used to improve health care safety. However, health care management and professionals have rarely provided specific, clear, high-level, organization-wide incentives to apply what has been learned in other industries about ways to prevent error and reduce harm within their own organizations. Chief Executive Officers and Boards of Trustees should be held accountable for making a serious, visible and on-going commitment to creating safe systems of care. Copyright National Academy of Sciences. All rights reserved. This executive summary plus thousands more available at http://www.nap.edu To Err Is Human: Building a Safer Health System http://books.nap.edu/catalog/9728.html 14 TO ERR IS HUMAN RECOMMENDATION 8.1 Health care organizations and the professionals affiliated with them should make continually improved patient safety a declared and serious aim by establishing patient safety programs with defined executive responsibility. Patient safety programs should • provide strong, clear and visible attention to safety; • implement non-punitive systems for reporting and analyzing errors within their organizations; • incorporate well-understood safety principles, such as standardizing and simplifying equipment, supplies, and processes; and • establish interdisciplinary team training programs for providers that incorporate proven methods of team training, such as simulation. Health care organizations must develop a culture of safety such that an organization’s care processes and workforce are focused on improving the reliability and safety of care for patients. Safety should be an explicit organizational goal that is demonstrated by the strong direction and involvement of governance, management and clinical leadership. In addition, a meaningful patient safety program should include defined program objectives, personnel, and budget and should be monitored by regular progress reports to governance. RECOMMENDATION 8.2 Health care organizations should implement proven medication safety practices. A number of practices have been shown to reduce errors in the medication process. Several professional and collaborative organizations interested in patient safety have developed and published recommendations for safe medication practices, especially for hospitals. Although some of these recommendations have been implemented, none have been universally adopted and some are not yet implemented in a majority of hospitals. Safe medication practices should be implemented in all hospitals and health care organizations in which they are appropriate. SUMMARY This report lays out a comprehensive strategy for addressing a serious problem in health care to which we are all vulnerable. By laying out a concise list of recommendations, the committee does not underestimate the many barriers that must be overcome to accomplish this agenda. Significant Copyright National Academy of Sciences. All rights reserved. This executive summary plus thousands more available at http://www.nap.edu To Err Is Human: Building a Safer Health System http://books.nap.edu/catalog/9728.html EXECUTIVE SUMMARY 15 changes are required to improve awareness of the problem by the public and health professionals, to align payment systems and the liability system so they encourage safety improvements, to develop training and education programs that emphasize the importance of safety and for chief executive officers and trustees of health care organizations to create a culture of safety and demonstrate it in their daily decisions. Although no single activity can offer the solution, the combination of activities proposed offers a roadmap toward a safer health system. The proposed program should be evaluated after five years to assess progress in making the health system safer. With adequate leadership, attention and resources, improvements can be made. It may be part of human nature to err, but it is also part of human nature to create solutions, find better alternatives and meet the challenges ahead. REFERENCES 1. Cook, Richard; Woods, David; Miller, Charlotte, A Tale of Two Stories: Contrasting Views of Patient Safety. Chicago: National Patient Safety Foundation, 1998. 2. Brennan, Troyen A.; Leape, Lucian L.; Laird, Nan M., et al. Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard Medical Practice Study I. N Engl J Med. 324:370–376, 1991. See also: Leape, Lucian L.; Brennan, Troyen A.; Laird, Nan M., et al. The Nature of Adverse Events in Hospitalized Patients: Results of the Harvard Medical Practice Study II. N Engl J Med. 324(6):377–384, 1991. See also: Thomas, Eric J.; Studdert, David M.; Burstin, Helen R., et al. Incidence and Types of Adverse Events and Negligent Care in Utah and Colorado. Med Care forthcoming Spring 2000. 3. American Hospital Association. Hospital Statistics. Chicago. 1999. See also: Thomas, Eric J.; Studdert, David M.; Burstin, Helen R., et al. Incidence and Types of Adverse Events and Negligent Care in Utah and Colorado. Med Care forthcoming Spring 2000. See also: Thomas, Eric J.; Studdert, David M.; Newhouse, Joseph P., et al. Costs of Medical Injuries in Utah and Colorado. Inquiry. 36:255–264, 1999. 4. American Hospital Association. Hospital Statistics. Chicago. 1999. See also: Brennan, Troyen A.; Leape, Lucian L.; Laird, Nan M., et al. Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard Medical Practice Study I. N Engl J Med. 324:370–376, 1991. See also: Leape, Lucian L.; Brennan, Troyen A.; Laird, Nan M., et al. The Nature of Adverse Events in Hospitalized Patients: Results of the Harvard Medical Practice Study II. N Engl J Med. 324(6):377–384, 1991. 5. Centers for Disease Control and Prevention (National Center for Health Statistics). Deaths: Final Data for 1997. National Vital Statistics Reports. 47(19):27, 1999. 6. Centers for Disease Control and Prevention (National Center for Health Statistics). Births and Deaths: Preliminary Data for 1998. National Vital Statistics Reports. 47(25):6, 1999. 7. Thomas, Eric J.; Studdert, David M.; Newhouse, Joseph P., et al. Costs of Medical Injuries in Utah and Colorado. Inquiry. 36:255–264, 1999. See also: Johnson, W.G.; Copyright National Academy of Sciences. All rights reserved. This executive summary plus thousands more available at http://www.nap.edu To Err Is Human: Building a Safer Health System http://books.nap.edu/catalog/9728.html 16 TO ERR IS HUMAN Brennan, Troyen A.; Newhouse, Joseph P., et al. The Economic Consequences of Medical Injuries. JAMA. 267:2487–2492, 1992. 8. Occupational Safety and Health Administration. The New OSHA: Reinventing Worker Safety and Health [Web Page]. Dec. 16, 1998. Available at: www.osha.gov/ oshinfo/reinvent.html. 9. Phillips, David P.; Christenfeld, Nicholas; and Glynn, Laura M. Increase in US Medication-Error Deaths between 1983 and 1993. The Lancet. 351:643–644, 1998. 10. Bates, David W.; Spell, Nathan; Cullen, David J., et al. The Costs of Adverse Drug Events in Hospitalized Patients. JAMA. 277:307–311, 1997. 11. Leape, Lucian; Brennan, Troyen; Laird, Nan; et al., T...
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Running head: MANAGED HEALTHCARE SYSTEM.

MANAGED HEALTHCARE SYSTEM.

1

MANAGED HEALTHCARE SYSTEM.

2

Introduction.
Healthcare is considered a business in the US, as part of our economy, it accounts for about
one-sixth of the entire economy, more than any other industry. Healthcare expenditures total about
$2.5 trillion, 18% of America’s gross domestic product, a measure of the value of all goods and
services produced in the United States. That's up from 13% of GDP in around 2000 and 5% in the
year 1960, when health spending totaled just about $27.5 billion, barely 1 percent of today's level
(Johnson, 2009).
The strengths and weaknesses of managed care system in the US healthcare system.
Options for coverage are an essential benefit that accompanies this plan. People of the US
have a choice to select from three option plans under manager healthcare each with its desired
rates. These option...


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