Running head: ANALYSIS

OF QUALITY: THE INSTITUTE OF MEDICINE

1

(IO

Analysis of Quality: The Institute of Medicine (IOM) Quality Chasm Report

Liya Sarkisyan University of California, Los Angeles School of Nursing October 18, 2013

ANALYSIS OF QUALITY: THE INSTITUTE OF MEDICINE (IO

Call for Action: The Purpose of the IOM Report The wealth and power of the United States compares poorly with the framework and quality of its healthcare system. As a result, its citizens must navigate through a broken system that fails to deliver continuous, scientific-based care to meet the patients needs.The IOM paper (2011) addresses the fact that these problems in healthcare quality are based on poor systems rather than bad healthcare workers and that change is imperative. The IOM paper (2011) specifically states that Americans should be receiving care based on up-to-date, evidence-based research in order to effectively manage the chronicity of the diseases they are facing. The IOM report (2011) describes four main factors that are contributing to problems with quality of care. The first is the fact that although there have been staggering advances in both medicine and techology, the healthcare system has fallen behind in correctly incorporating new knowledge into improving patient outcomes. If not properly addressed, this key factor will continue to translate into poor quality because the complexity of technology is only expected to increase in the upcoming years. A second key factor is that the current structure of the healthcare system does not enable the effective use of its resources. The cost associated with taking care of an aging population must be managed by a decrease in medical errors and the elimination of additional, unnecessary services. This will be even more crucial as the silver tsunami of 78 million baby boomers start to utilize a healthcare system that is severely unprepared to meet their demans (Barry, 2008). A third factor is the shift from acute conditions to more chronic diseases, including the presence of multiple chronic diseases in one patient. The increase in the patients

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need for coordinated and long-term care based on the chronicity of their condition is hindered by the lack of support from clinical programs and comprehensive service centers. This becomes even more difficult to manage for a patient who does not have insurance or cannot afford basic preventative care. The fourth factor is the dearth of any real action towards implementing a new healthcare structure with improved quality and cost measures. There has been deep concern and attempt by leaders of healthcare institutions to move forward but a poorly organized delivery infrastructure has led to futile results. The Necessity of Improving Healthcare The need for a better functioning healthcare system is a matter of morals, not politics. Americans from all backgrounds and financial brackets are entitled to recieve the latest advancements in quality driven care. Focus must shift from struggling to manage the burden of multiple chronic conditions to providing effective screening measures and preventative strategies in order to decrease emergency room visits. In addition, statistics show that 49.1 million people under the age of 65 are uninsured and government healthcare spending totaled 1.2 trillion in 2010 alone (Jones, 2012). Continuing to pour money into a fragmented system will not only eventually make America bankrupt, but it will also leave its citizens with even less alternatives to seek appropriate healthcare. Six Aims of Quality Healthcare Crossing the chasm in healthcare will require leadership, committment, and an openness to adopt a completely new delivery system. As stated by Solberg et al (2009), serious improvements and organizational changes require leadership and support from both healthcare managers and decision makers. The six necessary aims put forth by the IOM committee to improve fuctioning of the healthcare system are safety, effectiveness, patient-centeredness, timlieness, efficiency, and equity. Safety is a top priority and must be implimented to avoid

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patient injuries, infections, and preventable medical errors. An effective healthcare system is one that provides appropriate care based on evidence-based scientific knowledge to those who will benefit most from it. Patient-centeredness is focused on the patient as a whole, providing care that respects the patients needs, values, culture, and personal preferences. Timely healthcare referes to less wait times for both the patient and the provider. Efficency is based on reducing waste, including materials, equipment, and energy. Lastly, to be equitable means to provide quality care that is unbiased in order to close the ethnic, racial, and socioeconomica gaps in health statuses. Ideally, interweaving these six aims will reconstitute a system that is more dependable, cohesive, and safe. Utilizing the Six Aims of Quality Healthcare as a Clinical Nurse Leader As an advanced practice nurse generalist, a clinical nurse leader (CNL) is in a great position to use the six aims set forth by the IOM to provide high-quality yet cost effective patient care while navigating through the various complexities of todays healthcare system (Lammon et al., 2010). By synchronizing communication, delegating tasks, and aligning care, a CNL is in a position to make fundamental systemic changes and decisions that are driven by patient outcomes (AACN, 2007). Stanley et al. (2008) describe a case study in which a CNL was responsible for 14 immunocompromised patients on an oncology floor in Clearwater, Florida. The CNL was given the task of improving quality of patient care by emphasizing evidence-based practice, improving communication among the healthcare team, and assuring that patients had a smooth flow through the healthcare system. The first aim of safety was demonstrated by the absence of nosociomial pressure ulcer developmeents and a 100% compliance with pneumonia and flu vaccinations 2 years after the CNL came on board. If I were the CNL on the unit, I would also ensure that all patients had fall prevention measures in place, especially weak and nauseous patients after

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chemothearpy treatments. Improvements in effectivness were demonstrated by enhanced communication between telemetry technicians and nurses. By posting the technicans phone number in each telemetry room, the CNL allowed the nurses to have a faster method of contacting the technicians if they had any concerns with the patients heart rhythm. If I were the CNL on the unit, I would also search the literature for any new rhythm monitoring devices or techniques for oncology patients and report my findings to the other healthcare providers on the

unit. Timeliness was addressed in the case study by an 0.87 day decrease in the average length of stay for these patients. If I were the CNL on the unit, I would assess the IOMs aim of timeliness by ensuring that call bells were being answered in a reasonable amount of time as well. Efficency was shown by the CNL on the oncology unit by taking the time to guide three distressed, less experiened nurses on the floor to stay on the unit. This prevented additional time and energy to be spent replacing the nurses and hence, the hospital saved roughly $150,000. I, as the CNL, would have continued to check in with the nurses and provide any additional resources necessary to help them adjust and cope with stressors on the unit. Finally, although patient-centeredness and equity were not explicitly discussed in the case study, they are extremely important on an oncology unit. As a CNL, I would ensure that nonpharmacolgical treatments such as massage, guided imagery, and music are also being offered to cancer patients as a means of reducing their pain. I would allow for more frequent visiting hours for close family members as well. For any non-English speaking patients, I would check to see whether appropriate translators are being used for proper communication as well as gather brochures in the patients native language to help them understand their disease process. Resources, such as outpatient clinics and emergency care, would also be provided for underprivileged patient populations. Above all, I would remind the nursing staff about the

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importance of establishing interpersonal relationships with the patient and family in order to improve the quality and meaningfulness of the care being provided. Conclusion

Todays healthcare system is in immediate need for change and quality improvement. By implementing the six aims set forth by the IOM, progress can be made towards restructuring our system to improve patient outcomes and decrease healthcare costs. This must be done by comitting to hard work and leadership, assessing progress by continually meeting with policy makers, and above all, always keeping the patients needs in mind. Although the challenge may seem unfathomable, we must deem it our responsibility to fix this crisis so that the quality of life for future generations may only continue to improve.

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References American Association of Colleges of Nursing (AACN). (2007). White paper on the education and role of the clinical nurse leader, 23. Retrieved from www.aacn.nche.edu Barry, P. (2008). Silver surge: Who will take care of aging boomers?. American Association of Retired Persons. Retrieved from http://www.aarp.org/relationships/caregiving/info-042009/silver_surge__who.html Institute of Medicine. (2011). Crossing the quality chasm: A new health system for the 21st century. Retrieved from http://books.nap.edu/catalog.php?record_id=10027 Jones, N. (2012). Health care in america: Follow the money. National Public Radio. Retrieved from http://www.npr.org/blogs/health/2012/03/19/148932689/health-care-in-americafollow-the-money Lammon, C.A.B., Stanton, M.P., & Blakney, J.L. (2010). Innovative partnerships: the clinical nurse leader role in diverse clinical settings. Journal of Professional Nursing, 26(5), 258-263. doi: 10.1016/j.profnurs.2010.06.004 Solberg, L.I., Elward, K.S., Phillips, W.R., Gill, J.M., Swanson, G., Main, D.SPhillips Jr, R.L. (2009). How can primary care cross the quality chasm? Annals of Family Medicine, 7(2),

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164-169 Stanley, J.M., Gannon, J., Gabuat, J., Hartranft, S., Adams, N., Mayes, C., Shouse, G.M& Burch, D. (2008). The clinical nurse leader: a catalyst for improving quality and patient safety. Journal of Nursing Management, 16, 614-622. doi: 10.1111/j.13652834.2008.00899.x