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Driving Forces for Quality and Safety: Changing Mindsets to Improve Health Care

Gwen Sherwood, PhD, RN, FAAN, ANEF

Julia stashed her umbrella and looked at the overflowing waiting room of the Emergency Department (ED) where she had worked weekends for the past five years. It was summer and staffing was short even for a Sunday evening in August; several staff were on vacation and one had called in sick. A storm had pounded the area, and there was a power outage. The hospital was on the emergency generators, and that meant the electronic chart was slow in response because of the overload. Staff were taking shortcuts due to time pressures. Julia thought about these breakdowns and remembered the workshop she had recently attended on quality improvement. The focus had been on identifying problems and applying quality improvement tools to collect data on the problem, analyze results, and design solutions to close the gap between actual and desired practice. She noted that Ms. Masraf was in the waiting area; she had diabetes, and wounds were difficult to heal. Infection was a constant threat so she had been to the ED on several occasions. Julia turned at the sound of a crash and saw that one of the nurse aides had fallen where water had collected from wet umbrellas. Falls were common in the ED as a result of the population served and, with social distancing precautions from the current global pandemic, there were fewer family members to help patients with mobility issues. She wondered if she could initiate a quality improvement study on any of these continuing problems she saw every time she came to work. Other staff seemed to think this was just a part of how the ED functioned and were exhausted from the additional burden of the pandemic.

• What evidence-based instructional strategies can inspire and prepare health professionals to lead redesign of increasingly complex systems?
• What are the continuing barriers to reliable reporting systems in transparent just cultures?
• How do we prevent making the same mistakes over and over?
• What is the impact of the COVID-19 pandemic on quality and safety issues?

Patient safety and quality are primary concerns in almost every country. It is now recognized that preventable patient harm is a leading cause of death worldwide. The 1999 release of a stark report on the quality of health care in the United States, To Err Is Human (Institute of Medicine [IOM], 2000) ignited a call to action. Following a series of reports referred to as the Quality Chasm, consumers, regulatory agencies, and professional and public organizations have demanded system improvements. In these 20 years since the IOM (now the National Academy of Medicine) released the initial report, countless safety initiatives have sought to prevent harm. Education is the primary intervention for reducing preventable harm by changing providers' knowledge, skills, and attitudes about quality and safety that guide how they deliver care.

Quality and safety are intertwined, complex concepts with multiple dimensions. Lack of a comprehensive understanding of the full scope of these terms to overcome historical views poses a barrier for implementing quality and safety strategies. It is difficult to reshape mental models held by health care workers to develop new mindsets and attitudes about the imperative of quality and safety. Patient safety comprises the collective actions that create cultures, processes, technologies, and environments that mitigate risk of preventable harm (World Health Organization [WHO], 2021; see Chapter 8). The goal of quality improvement is to implement best practices to achieve best outcomes, accomplished first by measuring the reality of care delivered compared with benchmarks or the ideal outcome (Allen-Duck et al., 2017; see Chapter 6). Continuous quality monitoring is the mechanism for transforming the health care system, but it requires the collaboration of health care professionals, patients and their families, researchers, payers, planners, and educators working toward better patient outcomes (health) and better system performance (care).

In 2005, the Robert Wood Johnson Foundation funded the Quality and Safety Education for Nurses Project (QSEN) with the aim of transforming nursing education and practice so that nurses include quality and safety in their daily work. Although quality and safety have always been assumed as foundational in nursing education, the intentional integration of specific quality and safety concepts into nursing and other health professions curricula has only primarily occurred since QSEN was launched. This chapter will present a brief historical perspective on patient safety and quality by examining the impact of the IOM Quality Chasm series of reports and subsequent national initiatives, describe the science of patient safety and quality, report driving forces that are pushing the boundaries of patient safety and quality, describe major themes of the newly released national action plan, and examine education as the bridge to improvements. We also introduce the work of the QSEN project in helping lead system changes that are the central theme of this book.

Twenty Years Advancing Quality and Safety

To Err Is Human (IOM, 2000) and the subsequent Quality Chasm series of landmark reports were a wake-up call for drastic changes in health care delivery (Textbox 1.1). The series title represents the deep divide between the health care delivered and the health care that is achievable. The commitment to quality and safety must be hardwired into the everyday work of organizations across all levels and in decision-making to ensure all workers ground their work in quality and safety. To change attitudes and mindsets, quality and safety can never be considered optional work.

The IOM, a think tank of health care experts in the United States, was renamed the National Academy of Medicine in 2015 and will be referred to as NAM for work after 2015.

The Call to Action: Institute of Medicine Quality Chasm Reports

The 2000 release of To Err Is Human instigated a series of IOM reports that provided eye-opening data on the profusion of defects in health care and heralded ways to improve the system of care. Perhaps most shocking was the estimate that 44,000-98,000 people died each year due to preventable health care harm. Before the 1999 report, preventable harm was cloaked in silence; mistakes were hidden without discussion, patients were informed only when absolutely necessary, and workers were blamed and punished for mistakes. Before the 1999 report, we lacked evidence to determine the scope or depth of system issues that contributed to poor quality and safety outcomes because we lacked local and national reporting systems. To Err Is Human sparked action that gradually brought pressure from regulators, health care purchasers, third-party payers, and consumers to improve quality and safety outcomes.

Textbox 1.1 Summary: The Institute of Medicine Quality Chasm Series

• To Err Is Human: Building a Safer Health System (2000)

  This first IOM report presented the first aggregate data on the depth and breadth of quality and safety issues in US hospitals. Analysis of outcomes from hospitals in Colorado and Utah reported that 44,000 people die each year because of medical errors, while in New York hospitals there are 98,000 deaths. More people die annually from medical error than from motor vehicle accidents, breast cancer, or AIDS. Medical errors are the leading cause of unexpected deaths in health care settings. Communication is the root cause of 65% of sentinel events. The report presents a strategy for reducing preventable medical errors with a goal of a 50% reduction over five years.

• Crossing the Quality Chasm: A New Health System for the 21st Century (2001)

  Recognizing health care organizations as complex systems, the report offers system recommendations to achieve sweeping reform of the American healthcare system: quality problems are pervasive and costly; problems are embedded in the systems themselves, not workers; and major system redesigns hold the most potential for improvement. A set of six health care performance expectations measure patient care outcomes in the STEEEP model (Figure 1.1). Measures of these six aims align incentives for payment and accountability based on quality outcomes.

• Health Professions Education: A Bridge to Quality (2003)

  Education is declared as the bridge to quality based on five competencies identified as essential for health professionals of the twenty-first century: patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement (and safety, later added as a sixth competency), and informatics. Recommendations include developing a common language to use across disciplines, integrating learning experiences, developing evidence-based curricula and teaching approaches, initiating faculty development to model the core competencies, and implementing plans to monitor continued proficiency in the competencies.

• Keeping Patients Safe: Transforming the Work Environment of Nurses (2004)

  The 2004 IOM report links nurses' work environment with patient care safety and quality. Key recommendations helped shaped nurses' roles in quality and safety, including the importance of creating a...