As a nation, we have invested extensively in striving for quality and patient safety in healthcare. Many of us would agree that the two major reports of the Institute of Medicine (IOM) –To Err is Human: Building a Safer Health System, which was published in 1999, and the 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century – are historically significant for their role in galvanizing administrators and healthcare professionals to make patient safety a central priority.The sobering reality that as many as 98,000 people die annually in hospitals as a result of preventable errors was a huge wake up call. As a result of these findings, systems are now in place to detect errors before they can harm patients, mandatory reporting requirements are the norm and patient safety education is prevalent. Many of the quality and patient safety initiatives are codified in regulatory frameworks. The accreditation industry is a leader and champion for quality. Payers focus on quality improvement as central to their payment policies.Tragically, however, a recent study from the Journal of Patient Safety found that between 210,000-440,000 patients die annually from medical errors in the hospital. Despite our efforts, we continue to find gaps between our written protocols of care and the dynamic living world of healthcare that patients experience every day.Most of our efforts to improve quality and patient safety have focused on design and control and rely predominantly on a system engineering approach. The IOM’s most recent report, Best Care at Lower Cost: The Path to Continuously Learning Health Care in America, draws extensively from systems engineering to outline a compelling vision and corresponding pathways to create a learning healthcare system.
Strengthening Organizational Learning
I was very enthusiastic to see that the latest IOM report also urges leaders to strengthen organizational learning. This is much easier said than done, of course and, naturally, we are learning all the time. Yet, just because I learned something doesn’t mean that I won’t make the same mistake again. So, the Committee is right; we need to create continuous learning in healthcare.
The incredible dynamics and “doxas” in healthcare are simply not optimal for learning. Indeed, overcoming our barriers to learning may be one of our greatest challenges if we are to move from a “vision-in-the-mind” to a “practice-at-work.” Moving towards the next future will be both a learning process and, even more importantly, an unlearning process.
Hope for the Future
Living and working in our modern, global world where what we know today is obsolete tomorrow requires each of us to ask, “What new knowledge and skills do I need to develop to continue to add value to society in the way that I would like?”
We each have a preference about how we like to learn and for coping with new situations. For example, if we want to know what the element water is and what it does, we can learn about water in different ways. Some of us choose to learn about water by studying its molecular structure in laboratory, others of us like to sit on a beach and come to know the water through our senses. Some of us prefer to run wildly into the water. Although the approaches are distinct what they have in common is that they expose our brain to different situations.
The new imperative for working in healthcare today – or any vocation, for that matter – is to joyfully and fully embrace life-long learning.
1. Brown, J., & Isaacs, D. (2005). The World Café shaping our futures through conversations that matter. San Francisco, CA: Berrett-Koehler.
2. James, J., A New Evidence-based Estimate of Patient Harm Associated with Hospital Care, Journal of Patient Safety, September 2013, Volume 9, Issue 3, p 122-128.
3. Kohn, L. (2000). To err is human building a safer health system. Washington, D.C.: National Academy Press.
4. Richardson, William. (2001). Crossing the quality chasm a new health system for the 21st century. Washington, D.C.: National Academy Press.
5. Smith, M. (2013). Best care at lower cost: The path to continuously learning health care in America. Washington, D.C.: National Academies Press.
Originally Published by ADVANCE for Administrators of the Laboratory on August 10, 2015.