What is IOM?

1. What is IOM? By Holly Brooks Elizabeth Klynstra Amy Noonan Bridgett Weldon Ferris State University Nursing 320 April 26, 2012

2. Institute of Medicine (IOM) • Established in 1970, the Institute of Medicine (IOM) is an independent, nonprofit organization that works outside of government to provide unbiased and authoritative advice to decision makers and the public. • The IOM asks and answers the nation’s most pressing questions about health and health care. • Each year, more than 2,000 individuals, members, and nonmembers volunteer their time, knowledge, and expertise to advance the nation’s health through the work of the IOM. • Many of the studies that the IOM undertakes begin as specific mandates from Congress; still others are requested by federal agencies and independent organizations. • IOM provides information to decision makers so that they can change regulation or policy and to other influential groups who can change behavior, all aimed eventually at improving health. • The Institute of Medicine advises Congress on important health questions, from the quality of medical care to conflicts of interest in medical research, from malaria treatment to environmental hazards, and from vaccine safety to childhood obesity. Institute of Medicine (2013). About IOM. Retrieved on 4/21/13 from http://iom.edu/About-IOM.aspx

3. IOM Study Process • Consensus studies are conducted by committees carefully composed to ensure the requisite expertise and to avoid conflicts of interest. • The committee’s task is developed in collaboration with the study’s sponsor. Once the statement of task and budget are finalized, the committee works independently to come to consensus on the questions raised. • Sponsors can be a government agency, a foundation, or an independent organization. • All IOM reports undergo an independent external review by a second, independent group of experts whose comments are provided anonymously to the committee members, this is done to ensure the objectivity and quality of the reports. Institute of Medicine (2013). About IOM. Retrieved on 4/23/13 from http://iom.edu/About-IOM.aspx

4. IOM Reports The IOM produces various types of reports: • Consensus Report: A consensus report reflects a committee’s agreement following deliberations. A consensus report may include findings, conclusions, and recommendations, based on available scientific evidence. • Letter Report: reflects a committee’s agreement following deliberations, but typically takes the form of a letter to the report’s sponsor or to a third party. A letter report may include findings, conclusions, and recommendations, based on available scientific evidence. • Workshop Report: A workshop report is a summary of the presentations and discussions at a workshop. Although authored by a committee, a workshop report contains only the opinions of those who attended and presented at the workshop and does not include consensus findings or recommendations. A workshop report does not reflect the views of the IOM. • Workshop Summary: A workshop summary is a summary of the presentations and discussions at a workshop. A workshop summary contains only the opinions of those who attended and presented at the workshop and does not include consensus findings or recommendations. A workshop summary does not reflect the views of the IOM. Institute of Medicine (2013). About IOM. Retrieved on 4/23/13 from http://iom.edu/About-IOM.aspx

5. Types of IOM Activities The IOM undertakes many different types of activities: • Consensus Study: A consensus study is the result of an IOM consensus committee’s deliberations in regard to a specific request from the study’s sponsor. After discussing the issue of concern, the committee addresses those issues in a consensus report. • Stand Alone Workshop: A stand alone workshop brings together stakeholders from a host of backgrounds to discuss important health issues in an open forum. Workshops may result in workshop summaries and reports, but these reports may not issue recommendations. • Standing Committee: A standing committee, composed of experts in their field, guides the IOM’s work on a relatively narrow subject area but does not issue reports. Standing committees may be established for unspecified terms, anticipating a sponsors' need for continuing advice. • Forums and Roundtables: Forums and roundtables provide both a mechanism and a venue for convening a diverse group of individuals to meet and discuss issues of mutual interest and concern in a neutral setting. Meetings held by forums and roundtables may result in workshop summaries. • Awards: The IOM grants numerous awards annually to recognize individuals in the fields of science, medicine, and health. Institute of Medicine (2013). About IOM. Retrieved on 4/21/13 from http://iom.edu/About-IOM.aspx

6. “First do no harm”-Hippocrates . Why do Errors Happen, Chapter 3, summarizes that some healthcare systems are more prone to accidents and there are many things that can be done to make these systems more reliable and safe. Human error is one of the largest contributors to accidents in health care. When systems fail, errors are made. These are called latent errors and they “pose the greatest threat to safety in a complex system because they lead to operator errors”(Kohn, Corrigan, & Donaldson, 2000). Kohn, L. T., Corrigan, J., & Donaldson, M. S. (2000). Why Do Errors Happen?. In To err is human: building a safer health system (pp. 49-68). Retrieved from http://www.nap.edu/openbook.php?record_id=9728

7. ‘To Err is Human: Building a Safer Health System’The First Report from IOM • A 1999 study that examined health care in the United States and focused on medical errors. • Medical errors can be defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. • The study identified the consequences of medical errors which include: • Loss of life • Physical and Psychological pain • Increased costs • The expense of additional care resulting from medical errors, loss of income, and decrease productivity. • Loss of morale by healthcare workers, and frustration due to the inability to provide the best care Institute of Medicine (1999). To err is human. Retrieved from http://wwwiom.edu/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%201999%20%20report%20brief.pdf

8. IOM Findings: To Err is Human • The Committee found a variety of factors that contribute to medical errors: • Decentralized and fragmented nature of the health care delivery system • patients see multiple providers in different settings, none of whom has access to complete information. • Accreditation procedures with limited focus on prevention of medical errors. • Third-party purchasers of health care provide little financial incentive for health care organizations and providers to improve safety and quality (Institute of Medicine, 1999). • The majority of medical are caused by faulty systems, processes, and conditions that lead people to make mistakes or prevent them from happening (Institute of Medicine, 1999). • Mistakes can best be prevented by designing the health system at all levels to make it safer--to make it harder for people to do something wrong and easier for them to do it right (Institute of Medicine, 1999). Institute of Medicine (1999). To err is human. Retrieved from http://wwwiom.edu/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%201999%20%20report%20brief.pdf

9. IOM’s To Err is Human: Improvement Strategies To achieve a better safety record, the report recommends a four-tiered approach: • Establish a national focus to create leadership, research, tools, and protocols to enhance the knowledge base about safety. • Identify and learn from errors by developing a nationwide public mandatory reporting system and by encouraging health care organizations and practitioners to develop and participate in voluntary reporting systems. • Raising performance standards and expectations for improvements in safety through the actions of oversight organizations, professional groups, and group purchasers of health care. • Implementing safety systems in health care organizations to ensure safe practices at the delivery level. Institute of Medicine (1999). To err is human. Retrieved from http://wwwiom.edu/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%201999%20%20report%20brief.pdf

10. How has IOM and To Err is Human affected my nursing Practice? Amy Noonan IOM strategy improvement recommended that “ Health care organization must develop a “culture of safety” such that their workforce and processes are focused on improving the reliability and safety of care for patients” (IOM, 1999). When I worked on a medical surgical unit at a large hospital they implemented a new process for preparing patients for surgery. When nurses performed the before surgery check list we were requited to have the patient mark their surgical site, with a marker, in front of two witnesses. The goal of this process was to cut down on surgeries performed on the wrong site. Another policy change that this facility made was requiring physicians and nursing staff to perform a “time out” with patients for bedside procedures. This meant that patients were identified by two identifiers, the procedure was said out loud, along with the site, and the patient agreed to the procedure. This cut down on procedures performed on wrong patients. ( I know it seems crazy but someone at that facility placed an NG tube in a patient, but it was supposed to be the patient in the next bed!).

11. IOM’s affect on Nurse Care Management: - Amy Noonan The IOM committee cited the decentralized and fragmented care experienced by patients contributed to the high number of medical errors in the United States (Institute of Medicine 1999). While working as a triage nurse at a primary care and internal medicine office, it became obvious that many patients had gaps in care causing serious health decline. It is common for patients to see various physicians and specialists for treatment of chronic conditions, unfortunately, communication between different physicians and specialists is not always optimal and proper care was not given. • The major gaps in care occurred: • Upon discharge from the hospital • Discharge from nursing home or rehab facility • Communication between primary care physician and specialists • Explanations from medical professionals not adequately explained to patient Institute of Medicine (1999). To err is human. Retrieved from http://wwwiom.edu/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%201999%20%20report%20brief.pdf

12. IOM/ Nurse Care Management Cont.- Amy Noonan Due to so many instances of gaps in care, our office decided to have our triage nurses become certified in chronic care management. This is how we raised our performance standards and decreased oversight between professional groups; per IOM’s strategy for improvement suggestions (Institute of Medicine, 1999). As a chronic care manager it is my job to eliminate gaps in care and improve communication between physicians and facilities, physician offices to physician offices, and between physicians and patients. • Care Management Duties: • Calling patients 24-48 hours after hospital or nursing home discharge: this cuts down on errors by verifying that patients understand their discharge instructions and have proper follow up appointments scheduled. • Helping patients schedule and keep track of appointments and diagnostic tests: multiple appointments and tests provide more chance of missed appointments or duplicated testing; care managers help avoid this confusion. • Calling patients after specialist appointments to ensure patients understand the information they were given and know what follow up entails. • Organize home health care and medical equipment needs for home bound patients. • See patients face to face for chronic condition education. Institute of Medicine (1999). To err is human. Retrieved from http://wwwiom.edu/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%201999%20%20report%20brief.pdf

13. Prevention Safety and Quality within the Health Care Field • Being a new graduate nurse on the Progressive Care Unit, I find that safety and quality of my patients is a key implementation that needs to occur every day. Without such ideas we would find possibly more incidents such as medication errors, patient falls, and not maintaining sterile procedures. With the aid of the IOM or Institute of Medicine we as health care providers are able to learn from incidents and progress to developing more efficient and quality care. • One book, the Patient Safety and Quality: An Evidence-Based Handbook for Nurses provides such evidence by stating, “Institute of Medicine (IOM) reports clearly recommend that work be done on “studies and development of methods to better describe, both qualitatively and quantitatively, the work nurses perform in different care settings”(p. 325). Specifically, the recommendation is that research on patient safety needs to be addressed across care settings”(Loveland-Cherry, 2008). • Now from this the IOM isn’t limited to being used and applied in specific areas but it can be implemented throughout various health care settings as stated before. • Preventive services, primary care, and ambulatory care settings are areas in which there is a more limited body of work related to patient safety (Loveland-Cherry,2008). Bridgett’s Slide

14. Prevention Safety and Quality within the Health Care Field • What can we mainly focus on with patient safety and quality within different settings with the assistance of the IOM? They can be broken easily into the following categories: • Identification. • Classification of errors in primary care. • Harms of screening. • Harms of information technology. • Errors arising from language prevention in services. • Potential interventions to prevent errors and adverse events. Bridgett’s Slide Loveland-Cherry,C.(2008)Prevention-safety and quality.Patient safety and quality: An evidence-based handbook for nurses.Hughes RG, editor.Rockville (MD): Agency for Healthcare Research and Quality (US); Retrieved from http://www.ahrq.gov/professionals/clinicians-providers/resources/nursing/nurseshdbk/index.html

15. Err is Human in Primary Care • In relation to the view of the Err is Human with Errors in Preventative Services and Primary Care with the use of the IOM the following data was collected and published from 1965 to 2001. Informational data was provided by physicians, and related to such situations as malpractice suits, interviews with patients, and other observations data that was collected in relation to patient care and adverse events that have occurred. Here are some examples of data collected: • 344 incidents from 42 physicians over 20 weeks13 • 940 incidents over 2 weeks across 10 practices14 • 5,921 incidents from claims data for over a 15-year period12 • Again as health care providers we can learn from the IOM, and the Err that is Human theory and progress to prevent incidents and occurrences to provide adequate quality and safety to any patient in various health care settings. • Bridgett’s Slide Loveland-Cherry,C.(2008)Prevention-safety and quality.Patient safety and quality: An evidence-based handbook for nurses.HughesRG, editor.Rockville (MD): Agency for Healthcare Research and Quality (US); Retrieved from http://www.ahrq.gov/professionals/clinicians-providers/resources/nursing/nurseshdbk/index.html

16. Advancing The System As a nurse of 11years, I have seen how mistakes can be made.In my experience, I too have made a couple errors. Both have been medication related. Here are a few ways that my facility is advancing to help reduce our medication errors. A few years ago we transferred our medications into a Pyxis system. I see this as yet one more “check” before the medication even gets to the patient room. We have also started using the Electronic Medicine Administration Report(Emar). This now allows us to see exactly what times medications were given and if they are held, what was the reason. We are finally advancing to Computer Physician Order Entry(CPOE). This is coming up this month and will be placing responsibility of the ordering of medications back into the physicians hands. One thing we have not done yet is patient scanning. We do have the capability to do so, but we have had a lot of changes this past year. I think this will definitely be a goal after all the dust settles from the more recent changes. While referring to the article To Err is Human, I agree that as we look at how and where errors actually occur we can go back and fix them. One of these ways is by advancing our systems. I feel we are doing a great job at this at my facility. Institute of Medicine (2013). To Err is Human:Building a Stronger Health System. Retrieved from http://www.nap.edu/openbook.php?record_id=9728&page=r2 Holly’s Slide

17. Faulty Systems “Errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them” (Institute of Medicine, 2013). As a fairly new nurse we tend to be on the cautious side when it comes to our job, as we learn more and develop a level of comfort it is easy to get lost in the shuffle of work. No one intends on having errors, but we all do. One of my jobs on a rehab floor within a long term care facility, where they are not as technologically up to date as the hospitals. At this point doctors are hand writing their orders, for nurses to transcribe and implement them. I have found that this has caused an increased number of medication errors. Medications and lab orders are sometimes put in wrong, or missed which can be departmental to a patient’s health. Advancements in this system would directly have an impact on the number of medication errors that would occur. We would be able to fix the problem before it occurs, instead of finding a solution after the error has occurred. Institute of Medicine (2013). About IOM. Retrieved on 4/21/13 from http://iom.edu/About-IOM.aspx Institute of Medicine (2013). To Err is Human:Building a Stronger Health System. Retrieved from http://www.nap.edu/openbook.php?record_id=9728&page=r2 Elizabeth’s Slide

18. Overall effects of IOM on Nursing • “With more than 3 million members, the nursing profession is the largest segment of the nation’s health care workforce”(IOM 2010). • While trying to transform the nursing profession four key goals can be focused on • Nurses should be practicing at the full extent of their education and training • Higher levels of education and training should be obtained for optimal care • Nurses should be working along with physicians and other health care professionals to redesign health care • Effective workforce planning and policy making require better data collection and information infrastructure Institute of Medicine of the National Academics (2010). The future of Nursing: Leading Change, Advance Health retrieved from http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change- Advancing-Health.aspx

19. Overall effects of IOM on Nursing continued • There is a increased need for higher educated nurses based on the fact that the health care system was built on treating acute illness and injuries in the 20th century. • Chronic diseases such as diabetes, hypertension, arthritis, cardiovascular disease, and mental health conditions, due in part to the nation’s aging population and compounded by increasing obesity are the focus of the 21st century. • Patients needs have become more advanced, therefore nurses need the adequate training to provide care. • Some of these areas are leadership, health policy, system improvement, research and evidence-based practice, and teamwork and collaboration, as well as competency in specific content areas such as community and public health and geriatrics • Institute of Medicine of the National Academics (2010). The future of Nursing: Leading Change, Advance Health retrieved from http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change- Advancing-Health.aspx

20. Overall effects of IOM on Nursing Education • Currently nursing education focuses more on acute patient • The IOM Committee says “Nursing curricula need to be reexamined, updated, and adaptive enough to change with patients’ changing needs and improvements in science and technology” • Programs are having to change their curriculum to account for the changes in patient needs. • Higher education, such as obtaining your BSN is now becoming a requirement for hospitals. • Institute of Medicine of the National Academics (2010). The future of Nursing: Leading Change, Advance Health retrieved from http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change- Advancing-Health.aspx

21. Critical Thinking What did you enjoy or learn most from this PowerPoint? How does the IOM and Err to Human affect your own profession? Do you find yourself changing your own practice and learning from errors with others? Bridgett’s Slide

22. References • Institute of Medicine (1999). To err is human. Retrieved from http://wwwiom.edu/~/media/Files/Report%20Files/1999/To-Err-is- Human/To%20Err%201999%20%20report%20brief.pdf • Institute of Medicine (2013). To Err is Human:Building a Stronger Health System. Retrieved from http://www.nap.edu/openbook.php?record_id=9728&page=r2 • Institute of Medicine (2013). About IOM. Retrieved on 4/21/13 from http://iom.edu/About-IOM.aspx • Kohn, L. T., Corrigan, J., & Donaldson, M. S. (2000). Why Do Errors Happen?. In To err is human: building a safer health system (pp. 49-68). Retrieved from http://www.nap.edu/openbook.php?record_id=9728 • Loveland-Cherry,C.(2008)Prevention-safety and quality.Patient safety and quality: An evidence-based handbook for nurses.Hughes RG, editor.Rockville (MD): Agency for Healthcare Research and Quality (US); Retrieved from http://www.ahrq.gov/professionals/clinicians- providers/resources/nursing/nurseshdbk/index.html • Institute of Medicine of the National Academics (2010). The future of Nursing: Leading Change, Advance Health retrieved from http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change- Advancing-Health.aspx • Bridgett’s Slide