History of Quality Improvement and Patient Safety: 1966 - Present

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From the course by Johns Hopkins University

Patient Safety and Quality Improvement: Developing a Systems View (Patient Safety I)

123 оценки

Johns Hopkins University

Patient Safety and Quality Improvement: Developing a Systems View (Patient Safety I)

123 оценки

Course 1 of 7 in the Specialization Patient Safety

In this course, you will be able develop a systems view for patient safety and quality improvement in healthcare. By then end of this course, you will be able to: 1) Describe a minimum of four key events in the history of patient safety and quality improvement, 2) define the key characteristics of high reliability organizations, and 3) explain the benefits of having strategies for both proactive and reactive systems thinking.

From the lesson

The History of Patient Safety and Quality Improvement

In this module, you will review the history of patient safety and quality improvement in healthcare. You will start with defining the scope of the problem of preventable harm in healthcare which leads into the history of the work that has been done to date that has helped to define, measure and improve preventable harm. You review three landmark reports to ensure you have a deep understanding of this work. At the end of this module, you will be able to: 1) identify a minimum of four key events in the history of patient safety an quality improvement, 2) describe the key characteristics of each of the three landmark patient safety publications and 3) summarize the impact of preventable harm on patients, communities and society.

The Scope of the Problem2:08

History of Quality Improvement and Patient Safety: 1854 - 19665:19

History of Quality Improvement and Patient Safety: 1966 - Present3:31

Mitigable or Preventable Harm: Crimean War, 1854-18564:19

"To Err is Human": Building a Safer Health System5:26

"Crossing the Quality Chasm": A New Health System for the 21st Century8:03

"Free From Harm": Accelerating Patient Safety Improvement Fifteen Years After "To Err is Human"7:07

Meet the Instructors

Melinda Sawyer
Director, Patient Safety
Armstrong Institute for Patient Safety

[MUSIC]

Hi, in this lesson, we're going to talk about the history of quality improvement

and patient safety from 1966 to the present.

In 1979, the Accreditation Association for Ambulatory Healthcare was formed.

This was important because it assisted ambulatory healthcare organizations

to improve the quality of care provided to patients in this setting.

In 1989, the Agency for Health Care Policy and

Research was created under the Omnibus Budget Reconciliation Act of 1989.

It was renamed the Agency for Healthcare Research and Quality,

what is now known as AHRQ,

as part of the Healthcare Research and Quality Act of 1999.

The purpose of AHRQ is to produce evidence to make health care safer,

higher quality, more accessible, equitable, and affordable, and

to ensure that the evidence is understood and used.

In 1990, the National Committee for

Quality Assurance, what is known as the NCQA,

was mandated to offer accreditation programs for health care plans.

They assumed responsibility for the health plan employer data and

information set, which is known as HEDIS.

HEDIS is a tool used by health plans to measure performance on important

dimensions of care and services provided to members of these plans.

And health plans that report HEDIS data to employers, and they use these results to

make improvements in the quality of care and service it provides to those plans.

In 1991, the Institute for Healthcare Improvement was founded, and it focused

on the identification and spread of best practices in quality and safety.

In 1994, Dr. Lucian Leape published Error in Medicine.

This was an early paper,

and it called for the application of systems theory to prevent medical errors.

We've included a copy of that as available for your reading.

In 1999, the Institute of Medicine published the landmark report called

To Err is Human, Building a Safer Health System.

We'll have an entire video dedicated to just this landmark paper.

In 2001, the Institute of Medicine published a follow up report to

To Err Is Human called Crossing the Quality Chasm, A New Health System for

the 21st Century.

We will also dedicate an entire lesson to this topic.

In 2001, Dr. Peter Pronovost published on a simple five-item

checklist that led to significant reductions in central line infections.

In 2003, he implemented this five-item checklist in

the Michigan Keystone Initiative which led to an estimated savings

of $100 million and 1500 lives saved across that state.

This summarizes the major events in quality improvement and

patient safety from 1966 to the present.

As you can see from these two videos, we've had a lot of important events that

contributed to where we are in quality and safety.

But what we're going to talk about later is how far we still have to go to really

eliminate preventable harm for our patients.

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