by Anne Gunderson, PhD
In its 1999 report, To Err is Human: Building a Safer Health System, the Institute of Medicine (IOM) concluded that medical errors, particularly hospital-acquired conditions, may be responsible for as many as 98,000 deaths annually, at costs of up to $29 billion. Suddenly, quality healthcare and patient safety became central, public concerns in the United States. According to the Institute of Medicine (IOM; 2000), medical errors accounted for between 48,000 and 98,000 deaths annually in the U.S. At that time, medical errors were considered the eighth leading cause of death in the U.S.; more prevalent than deaths from breast cancer, AIDS, or motor vehicle accidents.
I started my practice in medical education in 2000 at Southern Illinois University College of Medicine. At that time we were creating a new and robust, medical curriculum. Similarly to other medical schools, however, we had just a few lectures in this content area. By 2003, quality and safety had become central concerns in the U.S. Communication failures were identified as the root cause of the majority of both malpractice claims and major patient safety violations, including errors resulting in patient death. The Joint Commission found that communication breakdowns were the root cause of 60% of medical errors, 75% of which resulted in death. 2,034 errors, which means 915 people died as a result of a communication error in 2003. Clearly it was time to get serious.
It was 2005 when I joined the University of Illinois Chicago College of Medicine faculty in the medical education department. I had the opportunity to engage with faculty members seriously interested in training learners in patient safety. For two years, I worked with this team to create and deliver lectures and simulations, co-lead a patient safety elective, and was invited to attend the Telluride Experience.
In early 2007, we were in the middle of creating a patient safety institute to deliver a formal curriculum on the subject. One of my goals was to create an online, degree-granting patient safety leadership program. 6 months later, the Master of Science in Patient Safety Leadership (PSL) proposal was created. Once it had been approved by the various required entities, the curriculum was created by our team of patient safety experts. In fall 2008, the first cohort of learners began; however, this was only the beginning. The PSL program was very successful and applications were rolling in. The learners couldn’t get enough learning and we were getting rave reviews. Despite the program’s success, however, I found a letter from the Senior Dean for Medical Education that said they no longer needed my services.
So the journey continued…Thankfully, I had received opportunities from other medical schools. As the Associate Dean for Medical Education at the University of Cincinnati College of Medicine (UC), I had the opportunity to work with an amazing faculty and a very talented Senior Dean for Medical Education, Andrew Filak. Within 20 months, we created a new, contemporary, four-year medical school curriculum, which was awarded full accreditation from the Liaison Committee on Medical Education. . During these very busy years, we created an Institute for Healthcare Improvement (IHI) Open school and embedded safety, quality, and leadership into the curriculum. With other deans from nursing and pharmacy we implemented interprofessional sessions for medicine, nursing, and pharmacy learners. Each year, I also attended the Telluride Experience as a faculty member and continued to bring learners from UC to the events. One day, I picked up the phone and everything changed again.
It’s 2013 and the original PSL team is back together again; this time in Baltimore, MD and the District of Columbia. Despite 14 years of experience in medical education, I was amazed by how little quality and safety training was provided in medical and nursing schools nationwide. Basic training is required by accreditation bodies, but it does not adequately prepare the physicians and nurses for the complexity of medicine in today’s world. While some positive changes have occurred, we are still battling the same issues.
A little over a decade later, medical errors are now the third leading cause of death and account for more than 400,000 deaths per year. Recent studies have reported that as many as one-third of hospitalized patients may experience harm or an adverse event, often from preventable errors. Unfortunately, competencies for optimal patient care outcomes in the clinical environment include knowledge, skills, and attitudes in critical disciplines not traditionally trained in medical or other health science programs. Frankly, it’s hard to imagine that one can provide ‘care of the entire person’ if attention to quality care and patient safety is missing.
The absence of such training leads to medical errors – a serious problem that affects not just patients but also the health care workers involved. Many good physicians, nurses, pharmacists and other health care professionals have left the field due to depression and lack of support from their colleagues. Even more unfortunate, a growing number of health care professionals take their own lives each year when involved in a preventable medical error.
It’s 2017 and we have created a solution to this pervasive crisis. I worked with Georgetown University and MedStar Health to create a new Executive Master’s Degree in Clinical Quality, Safety and Leadership (CQSL).
CQSL unleashes a systematic, evidence-based education that will achieve striking results in safety, quality, reliability, and healthcare value. With a learner-focused environment the CQSL program will equip learners to become leaders in the advancement of safety science and quality healthcare. The curriculum includes online asynchronous coursework, simulation, team training, and one onsite residency. The inaugural class begins in fall 2017.
Health-care practioners and leaders need new skills and attitudes to meet the changing needs of patients in a medical environment that has complex multilayered systems, informatics, assessment, outcomes, and quality indicators. Secondary to these changes, health care has become a high-risk industry. As Yukl (2002) noted, “A vision is seldom created in a single moment of revelation, but instead it takes shape during a lengthy process of exploration, discussion, and refinement of ideas”.
And so the Journey continues…