The New Focus on Quality and Outcomes Introduction In 1999, the Institute of Medicine (IOM) published a groundbreaking analysis of the impact of medical errors on the health care delivery system and the patients it serves. The analysis, published as "To Err is Human: Building a Safer Healthcare System," concluded that medical errors resulted in up to 98,000 patient deaths in American hospitals every year. This report hit the national press and participants in the health care system and the political system with the force of a large bomb. Since that time, hospitals and other health care entities have refocused their attention on quality, errors, and patient safety in an unprecedented way, urged on by public outcry and by federal and state efforts to compel improvements in the health care system. Such entities as the Institute for Healthcare Improvement (www.ihi.org) the National Quality Forum (www.qualityforum.org), and the Institute of Medicine (www.iom.edu) have all emerged as champions of quality and safety initiatives, offering training, resources, access to best practices, and data collection strategies to move the cause of quality and safety for patients forward. History The IOM report had a huge impact on the discussion of quality and safety in the health care field. Aspects of quality care have always been present in hospitals, typically focused around the quality assurance or quality management departments. They historically collected data on department indicators and monitored them as part of accreditation. However, departmental data was typically focused on operational performance in the departments in question, and not a great deal was collected on issues of medical errors and near-misses. The litigious legal climate caused most hospitals to fear collecting and sharing data that could potentially be used against them in a legal action. However, the IOM report caused a national demand to know what health care institutions were doing to protect their patients from injury caused by errors. A climate of increased transparency has begun to emerge, although it is still a very long way from the concept of full openness on standardized reporting of indicators. The Centers for Medicare and Medicaid Services (CMS) weighed in with publication of their never-events, as explored further below. Finally there has been an increased push for public reporting of data on individual hospital performance on selected indicators. While some progress has been made, there is a large range of indicators that is not yet publically reported, and medical errors are not publically reported at all at this point, although those with great potential to cause harm must be reported to their relevant state licensing agency. What Is Happening Now Out of all this push has come an increasing focus on patient safety as a critical aspect of health care quality. Hospitals and other health care institutions are experimenting with the creation of cultures of quality, wherein ...

1. The New Focus on Quality and Outcomes
Introduction
In 1999, the Institute of Medicine (IOM) published a
groundbreaking analysis of the impact of medical errors on the
health care delivery system and the patients it serves. The
analysis, published as "To Err is Human: Building a Safer
Healthcare System," concluded that medical errors resulted in
up to 98,000 patient deaths in American hospitals every year.
This report hit the national press and participants in the health
care system and the political system with the force of a large
bomb. Since that time, hospitals and other health care entities
have refocused their attention on quality, errors, and patient
safety in an unprecedented way, urged on by public outcry and
by federal and state efforts to compel improvements in the
health care system. Such entities as the Institute for Healthcare
Improvement (www.ihi.org) the National Quality Forum
(www.qualityforum.org), and the Institute of Medicine
(www.iom.edu) have all emerged as champions of quality and
safety initiatives, offering training, resources, access to best
practices, and data collection strategies to move the cause of
quality and safety for patients forward.
History
The IOM report had a huge impact on the discussion of quality
and safety in the health care field. Aspects of quality care have
always been present in hospitals, typically focused around the
quality assurance or quality management departments. They
historically collected data on department indicators and
monitored them as part of accreditation. However, departmental
data was typically focused on operational performance in the
departments in question, and not a great deal was collected on
issues of medical errors and near-misses. The litigious legal
climate caused most hospitals to fear collecting and sharing data
that could potentially be used against them in a legal action.
However, the IOM report caused a national demand to know

2. what health care institutions were doing to protect their patients
from injury caused by errors. A climate of increased
transparency has begun to emerge, although it is still a very
long way from the concept of full openness on standardized
reporting of indicators. The Centers for Medicare and Medicaid
Services (CMS) weighed in with publication of their never-
events, as explored further below.
Finally there has been an increased push for public reporting of
data on individual hospital performance on selected indicators.
While some progress has been made, there is a large range of
indicators that is not yet publically reported, and medical errors
are not publically reported at all at this point, although those
with great potential to cause harm must be reported to their
relevant state licensing agency.
What Is Happening Now
Out of all this push has come an increasing focus on patient
safety as a critical aspect of health care quality. Hospitals and
other health care institutions are experimenting with the
creation of cultures of quality, wherein mistakes are not seen as
inevitable byproducts of human performance but as preventable
events in systems hardwired not to allow them. Others are
implementing a "just culture," whereby it is safe to report errors
and near-misses as a technique of analysis and prevention rather
than as a punitive, punishment-oriented approach. In many
facilities, staff who make an error are encouraged to share that
with other staff members, teaching and coaching on how to
avoid making the same mistake. Quality departments are
performing root cause analyses to identify system failures and
opportunities to improve safety.
Hospitals are also responding to multiple requirements by many
constituencies for reporting data. This highlights a problem with
the current health care system that drives up cost for
questionable benefit. Different regulatory agencies are requiring
the report of different indicators, forcing hospitals to access
their information systems for various different reports. The lack
of a standardized list of indicators for safety and quality

3. performance causes an increased workload on the part of health
care providers, who must scramble to achieve the reporting
requirements and commit expensive resources to access
databases that may not be user-friendly to produce the needed
reports. The lack of a national standard for quality indicators is
causing extra work in the system that could be focused
elsewhere if everyone was collecting the same data sets. CMS is
attempting to standardize its indicators and adding to them on
an ongoing basis, which could serve as the basis for a national
standard of validated outcomes and measures.
Two examples of this are the never-events and the perfect care
standards.
The never-events are 11 indicators for which CMS has
said it will not reimburse hospitals if the events occur during
the hospital stay. These events have been shown to be
preventable if care is rendered in certain, best-practice ways.
They include the following:
o Air embolism
o Administration of incompatible blood products
o Catheter-associated urinary tract infections
o Poor control of blood sugar levels
o Deep vein thrombosis or pulmonary embolus after surgery to
replace a hip or knee joint
o In-hospital patient falls with resultant trauma
o Retained foreign bodies in the surgical site after surgery
o Pressure ulcers
o Surgical site infections after certain orthopedic and bariatric
surgeries
o Surgical site infections after open heart surgery
o Vascular catheter-associated infections
The perfect care standards include outcomes and
activities for hospitals to follow for patients with acute
myocardial infarction, congestive heart failure, pneumonia,
surgical care improvements, and others. These data are
publically reported by CMS for the bulk of U.S. hospitals on the
Hospital Compare Web site (www.hospitalcompare.hhs.gov).

4. The data can be accessed by anyone who may be interested in
hospital performance.
What Is Still Needed
While efforts at measuring and reporting quality are significant
early steps, there are still aspects of the push for improvements
in quality that need to be addressed.
Data Transparency: Historically hospitals and other health
entities have been reluctant to expose their mistakes to outside
scrutiny, for fear of sparking legal action against them.
However, the need to be transparent in publishing quality
indicators and evidence of errors is becoming more and more
important. The public is slowly becoming aware that operational
and quality data are available to them, and there is increasing
interest in seeing how hospitals perform. In addition, hospitals
are becoming more open to reporting their errors and near-
misses, along with root-cause analyses that demonstrate how to
keep the error from reoccurring. CMS has been a leader in
compelling the release of information on how hospitals perform
on specific indicators, by tying the availability of such
information to payment for Medicare patients.
The Internet: A key element driving increased public awareness
of errors and quality indicators in health care has been the easy
availability of information on the Internet. With a few mouse
clicks, access to public comparison of hospital performance data
across hospitals is easy. Individuals considering surgery or
other procedures can identify several hospitals in their zip code
and compare those hospitals on key indicators. While this is
still very much an early emergence, it will become much more
common in the future. In the past, patients relied on their
physicians to tell them what hospital to use and that is still a
common practice today. However, the patients who bring reams
of printed information on a given disease to their physicians to
test the current state of their knowledge will also do extensive
research on the hospital that would provide their care.
Increasingly, physicians may advise the use of a specific
hospital, but the prospective patient will do his or her own

5. research on the publically reported performance of that hospital
prior to making the final choice. For instance, the Hospital
Compare Web site lists data for reporting hospitals on processes
of care, outcomes of care, the use of imaging services and
radiation exposure, the patients' experiences at the hospital, and
the hospital's Medicare payments and volume for selected
procedures.
A Validated, Standardized National Reporting System: As
previously noted, hospitals and health care entities are being
subjected to a barrage of requests for data from a wide variety
of sources, including government, state regulatory agencies, and
insurance companies, among others. All are focusing on
different data indicators, measured in different ways, to suit
their individual data needs. The entire health care system would
greatly benefit from a national standardized data set that all
entities, including providers and payors, agree to utilize as a
means of reporting and measuring the quality of their services
and outcomes. At this point, no real effort is being made to
create such a national data set, but as hospitals continue to
struggle with reporting multiple data sets to multiple outside
entities, national organizations such as the American Hospital
Association may be prompted to step in and attempt to negotiate
such an agreement. Alternatively, CMS could provide
leadership on what data sets are acceptable nationally,
particularly as it may begin to cover more Americans for their
health care.
Standardized Clinical Practices Based on Evidence: A number
of national studies have historically reported wide variation in
practice and outcomes for health services across the country.
For more than 20 years, the Dartmouth Atlas of Health Care
(www.dartmouthatlas.org) has studied how medical resources
are distributed and used in different areas across the United
States and has noted glaring variations. Of interest, the best
outcomes frequently do not correlate with the amount of money
spent on health care services. Data can be examined by region,
hospital, or topic of care. Hospitals and practitioners all exhibit

6. wide variations in the types and quality of care they render
across geographic areas. The Agency for Healthcare Research
and Quality (http://www.ahrq.gov) has received $300 million to
fund comparative effectiveness research. In this type of study,
different patterns of care are compared to determine how
effective they are and how they compare to other patterns for
care for the same disease. The results can provide a basis for
determining the health care services and interventions that work
to produce desired outcomes versus those that simply do not
work as anticipated or that do not work as well. The financial
implications of this research could be tremendous, as payors use
evidence to determine what services they will reimburse and
what services are not effective.
The Electronic Medical Record (EMR): The Holy Grail of
health care informatics is the pursuit of the ideal EMR. There
seems to be consensus that the electronic collection of data and
information on health care provided and patient outcomes,
which move across the continuum of care, could serve as a
jumping off point for measuring and adapting care to evidence-
based standards. It should also make public data reporting a
simpler process than it currently is. Ideas have been put forward
that include a patient's ability to carry his or her entire medical
history and information on a credit card-sized device. Such a
device could be screened by any provider to determine the
patient's essential medical information, without recourse to
paper records. The dilemma is that multiple EMR systems have
been developed by multiple vendors for hospital and provider
use. However, while they are all Health Level Seven
International interface-compliant, they do not exchange data
easily or at all. So a patient who has his or her information
coded by system X may find it useless if he or she goes to a
provider that uses system Y. EMRs also cost millions of dollars
to purchase, install, train, and implement, and many health care
entities are suffering from capital resource starvation. The
federal government has set up financial incentives to support
and subsidize a portion of the purchase and has instituted

7. financial penalties for entities that do not have significant
portions of an EMR in place by 2015. However, both the
financial and personnel resources required to design and
implement an EMR are a huge challenge for health care entities
at this point. Any choice that is made can have very expensive
negative outcomes if not done properly, and the risk to hospitals
and providers is significant.
Conclusion
There has never been more health care quality innovation
occurring in the delivery system than at the present time, and it
has never been more difficult or complex to determine what will
be successful and what will be an expensive mistake. The stakes
are great for many health providers and in some cases will
determine organizational survival. The management of quality
outcomes, the need to standardize care delivery, the importance
of controlling high cost utilization, and the demand for better
outcomes all combine to make it a very risky time for health
care providers. However, the demand for all of these is
unrelenting by a public that insists that Americans have the best
health care system in the world.
References
Institute of Medicine. (1999). To err is human: Building a safer
health system. Washington, D.C.: National Academy Press.
Copyright 2011. Grand Canyon University. All Rights Reserved.
150 words minimum for each question. Reference must be in
APA format. Must be searchable. Correct English grammar and
punctuation.
1.Describe how the endocrine system responds when it is under
stress. Describe how the endocrine system responds when it is
at rest. What are some similarities in both of the responses?

8. 2. Discuss the importance of lymphocytes and describe where
they are found in the body. What are some issues or diseases
that affect lymphocytes?
3. What are the roles of the various components of the digestive
system. How are ingested materials moved through the digestive
tract?
4. Based on studies what constitutes a balanced diet, and why
this is important. Provide a small example pf a vegetarian lunch
menu that includes all the amino acids necessary for a
vegetarian diet.