|To Err is Human: Building a Safer Health Care System
November marked the ten-year anniversary of the Institute of Medicine’s 1999 report, To Err is Human, which proposed a comprehensive strategy for government, health care providers, industry, and consumers to reduce preventable medical errors, which claim “perhaps as many as 98,000 lives” of hospital patients each year. The report states, "To err is human, but errors can be prevented. Safety is a critical first step in improving quality of care."
In recognition of the anniversary of this groundbreaking report, the Health Research & Educational Trust (HRET), an independent educational and research affiliate of the American Hospital Association (AHA), assembled a panel of experts and top innovators from around the country to discuss actions of the past ten years, ideas for charting a course for future improvement, and to share success stories. Maulik Joshi, DrPH, President of HRET, moderated the panels in a live webcast on November 16, 2009, in which more than 500 hospitals participated.
We were thrilled that Julie Moretz, Director of Special Projects for the Institute for Family-Centered Care, was asked to join these prestigious panelists.
The webcast began with presentations by the National Expert Panel, Dr. Carolyn Clancy, Director, Agency for Healthcare Research and Quality, Rich Umbdenstock, President & CEO, The American Hospital Association, and Julie Moretz, Director of Special Projects for the Institute for Family-Centered Care. The Hospital Panel included: Frank Sardone, President & CEO, Bronson Healthcare Group, Carol Wagner, RN, MBA, Vice President, Patient Safety, Washington State Hospital Association, Gene Burke, MD, Vice President and Executive Medical Director of Clinical Effectiveness, Sentara Healthcare. Listen to the webcast.
Today there are a myriad of patient safety programs in hospitals and ambulatory care settings throughout the nation. The Patient Safety and Quality Improvement Act of 2005 authorized the creation of Patient Safety Organizations. Agencies, such as the National Patient Safety Foundation, Partnership for Patient Safety, and Consumers Advancing Patient Safety, are ensuring that patients and their families are partners in safety with health care providers. The Joint Commission publishes the monthly Journal on Quality and Patient Safety that includes a regular article on patient and family involvement.
In September 2009, the Agency for Healthcare Research and Quality awarded a multi-year grant to a team of organizations led by the American Institutes for Research to develop, evaluate, and implement a Guide to Patient and Family Engagement to improve patient safety in hospitals. The Institute is honored to be a member of the team that also includes Carilion Health Clinic, Consumers Advancing Patient Safety, the Joint Commission, and the Health Research and Education Trust. Watch for more information about this exciting initiative in our next issue of Pinwheel Pages.
You may view the Institute's bibliography of articles and links to programs that are dedicated to patient safety. If you have a patient safety resource or link you would like included, please contact the Institute.
|Become a Pinwheel Sponsor in 2010
The Pinwheel Sponsors Program recognizes all who are committed to improving health care through patient- and family-centered practices. Pinwheel Sponsors enjoy recognition across the United States and internationally as role models in advancing the practice of patient- and family-centered care. The Institute is grateful for the support of all its Pinwheel Sponsors—your support enables the Institute to continue its mission to advance the practice of patient- and family-centered care. The Institute invites organizations that have not already done so to consider becoming a Pinwheel Sponsor.
Pinwheel Sponsorship supports the Institute's ongoing work developing and providing:
• Guidance and educational resources;
• In-depth training seminars;
• A website highlighting innovation and available resources;
• Information dissemination on promising practices;
• A national and international showcase for innovative health care programs committed to patient- and family-centered care and meaningful collaboration with patients and families;
• Policy and research initiatives;
• Scholarship opportunities; and
• Training and technical assistance for individual hospitals.
The Pinwheel Program offers levels of sponsorship to a variety of organizations that are committed to patient- and family-centered care. So, whether your organization is a hospital, health system, corporation, or association—please accept our invitation to join the program by becoming a Pinwheel Sponsor for 2010.
Read more about the Pinwheel Sponsors Program and its many benefits, including discounts on resources, webinars, and seminars, and recognition on the Institute's website and in Institute promotional materials. Call 301-652-0281 for more information.
2009 Pinwheel Sponsors look for your 2010 renewal notice this month!
|Minnesota Seminar a Great Success....On to Dallas in April 2010
Thanks to all who made the Institute's Hospitals and Communities Moving Forward with Patient- and Family-Centered Care Intensive Training Seminar in Minneapolis, Minnesota, October 26-29, 2009, a great success! Of the nearly 320 attendees, we are delighted that 35 patient and family leaders, 48 physicians, 126 nurses, 80 participants from the Minnesota Department of Health, and many social workers and other professionals joined us for this educational meeting. A special thanks to University of Minnesota Amplatz Children's Hospital, University of Minnesota Medical Center, and University of Minnesota for their leadership support! Here are some comments from participants:
"Life changing. Really helps us to remember the reason we went in to medicine—and gives hope that we can get that back despite the pressure to see more patients in less time, economic constraints."
"It was transformational. I had no idea I would be so inspired and motivated to make changes in how I do my work."
"The quality of knowledge and presentation skills of all of the presenters was truly top notch."
"This was hands-down the best seminar that I have ever attended! The small work groups with action plans gave a great place to start."
"Our small group sessions were probably the most valuable part of the seminar for me."
"Outstanding…I plan to make a presentation to our leadership and recommend the Dallas seminar."
SAVE THE DATE!
The Institute's next Hospitals and Communities Moving Forward with Patient- and Family-Centered Care Intensive Training Seminar will be held in Dallas, Texas, April 19-22, 2010, with leadership support from Baylor Health Care System and Children's Medical Center. Registration opening soon.
U.S. Department of Health & Human Services Healthy People Initiative Strives for Collaboration and Partnership
Every 10 years, the U.S. Department of Health & Human Services (HHS) leverages scientific insights and lessons learned from the past decade, along with new knowledge of current data, trends, and innovations—in consultation with others—to set health objectives for the Nation for the next decade. The Healthy People initiative is based on a simple but powerful idea: provide health objectives in a format that enables diverse groups to combine their efforts and work as a team. HHS and other federal agencies work together with the Healthy People Consortium, state and local communities, other strategic partners, including businesses and various other organizations, to implement a variety of programs to improve the health of our nation. The goals and objectives set forth in Healthy People 2020 are prepared with the input of public health professionals, policy makers, health care professionals, patients, teachers, mothers, fathers, and members of our communities who believe that these objectives are critical for the future health and well-being of our country.
It is now time for public input on Healthy People 2020. The Healthy People process is inclusive and collaboration is part of its strength; it strives to maximize transparency, public input, and stakeholder dialogue to ensure relevance to diverse public health needs and the ability to seize opportunities to achieve its goals. HHS is seeking input from communities and stakeholders through public meetings across the country and public comment periods, to provide a framework to address risk factors and determinants of health and the diseases and disorders that affect our communities. Stating, "America needs strong leadership, diverse partnerships, and commitment to putting people at the center of public policy, and creating programs and services that meet their needs," HHS is seeking public comments. Comments will be accepted through December 31, 2009.
| PFACnetwork Provides Support and Resources
Occasionally, the Institute will feature an idea or program discussed on the PFACnetwork listserv—a listserv for anyone interested in the work of patient and family advisory councils. Family members, patients, and health care staff are welcome to join. Discussion topics include starting and sustaining patient and family advisory councils and promoting patient- and family-centered care. The Institute's website includes a special section for PFACnetwork members to post resources to share.
Recently, Laura Bedrossian, a family leader from The Children's Hospital of Philadelphia, posted a request on the listserv asking for examples of educational materials for families regarding safe medication use. Nick Masi, the Director of Family-Centered Care at Joe DiMaggio Children's Hospital in Hollywood, Florida, posted a sample of their Medication Administration Record (MAR). Families receive a daily printout of this MAR specifying medications, dosages, how the medication is given, and how often. After seeing the tool on the listserv, Michelle Ashland discussed the MAR with fellow family leaders at Lucile Packard Children's Hospital at Stanford in California. These leaders remarked on the usefulness of the tool, but suggested one addition—a description of what the medication looked like—to increase the MAR's power to improve medication safety. As Michelle added, “My two experiences with potential medication errors were thwarted when I noticed the med looked different than usual—and, of course, questioned the dosage before it was given.”
Join or learn more about the PFACnetwork listserv.
|Meet Katie O'Donnell
The Institute welcomes Katie O’Donnell, who is participating in her high school internship program that offers opportunities for students to gain “real world” experience in a variety of workplace settings. Katie’s interest in writing and health care led her to the Institute’s internship.
Katie is working on a variety of projects while at the Institute. Some of her responsibilities include triaging phone calls, filling publication orders, compiling results from seminar and conference evaluations, and providing support to the Institute's Information Specialists and the Special Projects team.
Katie lives with her parents, and has one older brother who is in college in Oregon. Katie’s dad is an attorney and her mom is a teacher. Katie and her family enjoy trips to Wisconsin, where often they sail and hike while visiting relatives.
Katie’s interests are varied and include photography and helping with equestrian shows. When she was younger, she played soccer, softball, and basketball. In high school, she has been on the cross-country team.
A senior, Katie is in the midst of the college application process. She is interested in studying English, journalism, and history. When not in class or working at the Institute, Katie loves to write short stories and hang out with her friends. The Institute is delighted to have Katie as a member of our team!
At the recent Conference of the International Society for Quality in Healthcare (ISQua), convened in Dublin, Ireland in October, three Picker Award winners discussed, How to Achieve Outstanding Patient- and Family-Centered Care: Methods and Tools.
Listen to what Bev Johnson, President and CEO of the Institute for Family-Centered Care, said on the topic of How Patients and Their Families Can Help Providers Achieve Better Patient- and Family-Centered Care.
With the arrival of H1N1 influenza, hospitals and clinics are working to prevent or limit disease transmission. At the Minnesota Seminar, the Institute established a working group to help pandemic planners incorporate the core concepts of patient- and family-centered care in their decision-making. Involving patients and their families with experts who understand the science of disease transmission reinforces that everyone is a steward of patient safety.
Once completed, suggested guidelines will be available on the Institute's website. Please check the homepage within the next several weeks and give us some feedback on this document. Do you find the guidelines useful? The Institute welcomes your review and comments! Let us know if you make changes in policy or practices, and, if so, please give us specific examples.
In the meantime check out the new brochure, Seasonal and 2009 H1N1 Flu: For Parents Who Have Children or Adolescents With High-Risk Medical Conditions, now available from the Centers for Disease Control and Prevention.