The IOM Reports: Summaries, Recommendations, and Implications
Introduction
In 1997, President Clinton established a short-term commission called the Advisory Commission on Consumer Protection and Quality in the Healthcare Industry. The purpose of this commission was to advise President Clinton about healthcare delivery system changes related to quality, consumer protection, and the availability of needed services (Wakefield, 1997). The commission investigated many aspects of quality care and the changes needed to improve care, and published a report of its findings in 1999 (Quality First: Better Healthcare for All Americans); however, the commission had no idea that it was opening Pandora’s Box and that its work would lead to a comprehensive examination of U.S. health care. This initiative produced numerous healthcare quality recommendations, including the need for change in healthcare professions education. Appendix A lists the commission’s recommendations. The Institute of Medicine (IOM) was asked to further examine healthcare quality, respond to issues identified in the Presidential Commission’s report, and identify strategies to improve healthcare quality over the next 10 years. As a result of this, the IOM has produced numerous reports collectively referred to as the Quality Chasm series. Many of these earlier reports are described in the following sections, as are more current reports that focus on quality care, best practices for better health, leadership, diversity and disparity, research- and evidence-based practice, public health, nursing, healthcare education, and many other issues that are highly relevant to nursing education and practice.
Quality Care
Since 1999, the IOM has published many major reports that focus primarily on quality care. Each of these reports is summarized in this part. The Institute of Medicine is a nonprofit organization, based in Washington, D.C., that was established in 1970. It acts as an advisor to the nation to improve health by providing evidence-based advice to policy-makers, professionals, educators, and the public. The IOM cannot make law or regulations; rather, it makes recommendations. When it examines a problem area, it invites a panel of experts to work on the problem and then publishes the experts’ final report. The title “Institute of Medicine” does not imply that this group focuses only on medicine. Its focus is on health care, and because of this, it may be time to consider a name change to the Institute for Health Care or something similar. Regardless of the title, though, the work of the IOM is highly significant for nursing education and practice, as is demonstrated in the following information about some of its landmark reports on the quality of care and subsequent discussion on the implications of those reports.
To Err Is Human (1999)
To Err Is Human describes the national patient safety problem and has significantly influenced the public’s view of health care. Ensuring patient safety requires a comprehensive approach, and we cannot rely on a single solution. This report emphasizes that
the workplace must not focus on punishing individuals for errors. Instead, root cause analysis, a standardized method of analyzing errors, must be conducted to determine individual practice and system problems that result in errors. The expectation is that healthcare organizations will then use these data to eliminate or at least reduce the system problems that compromise patient safety. Safe care does not imply that the care is thereby of higher quality; however, safe care does increase the likelihood of quality care. It would be easy to say that a strong regulatory and enforcement approach is the strategy for solving this problem, but use of appropriate technology is another means to reduce errors. A national mandatory reporting system for errors will also provide useful information to improve safety. Finally, in any of the recommended strategies, leadership is critical.
the workplace must not focus on punishing individuals for errors. Instead, root cause analysis, a standardized method of analyzing errors, must be conducted to determine individual practice and system problems that result in errors. The expectation is that healthcare organizations will then use these data to eliminate or at least reduce the system problems that compromise patient safety. Safe care does not imply that the care is thereby of higher quality; however, safe care does increase the likelihood of quality care. It would be easy to say that a strong regulatory and enforcement approach is the strategy for solving this problem, but use of appropriate technology is another means to reduce errors. A national mandatory reporting system for errors will also provide useful information to improve safety. Finally, in any of the recommended strategies, leadership is critical.
Next to recognition of the high level of errors, the most important conclusion from the report is the need to change to a nonpunitive, blame-free environment. If a survey asked healthcare providers what is the most common type of error, the prevailing response would probably be that individual providers make errors. Providers would also point out that they are at risk if they report errors. This is a simplistic view of errors and avoids addressing the more significant effect of systems and processes on errors. “Building safety into processes of care is a more effective way to reduce errors than blaming individuals” (IOM, 1999, p. 4). It is much easier to blame an individual, and this punitive approach has been a tradition in healthcare organizations. It has left us with an environment of fear in which individual staff members are reluctant to report errors or near misses. It ignores the critical fact that errors also provide important information about how the system is working, and keeps practitioners from using this information to improve care. Latent or unnoticed errors are the most problematic errors, and they can later lead to more complex errors. It is, however, much easier to address active errors, which are more visible, and miss the latent errors or errors that are not under the control of the direct care staff, such as equipment problems, environmental issues, and management decisions.
To Err Is Human concludes by identifying five critical principles in the design of safe healthcare systems: (1) provide leadership, (2) respect human limits in process design, (3) promote effective team functioning, (4) anticipate the unexpected, and (5) create a learning environment. All of the report’s recommendations are described in Appendix B. One of the recommendations was to continue to examine healthcare quality, as the reported error rate was most likely a low estimate due to the variation in how hospitals defined and/or tracked errors. This recommendation led to the next IOM reports.
Crossing the Quality Chasm (2001)
Following the publication of To Err Is Human, the next three IOM reports considered a new health system for the 21st century. The first of the three, Crossing the Quality Chasm (IOM, 2001a), describes the nation’s healthcare system as requiring fundamental change. At the same time, it recognizes that the system has experienced rapid changes, such as new medical science, new technology, and near-immediate availability of information. Nevertheless, the healthcare system is fragmented and poorly organized and
does not use its resources efficiently. This report identifies quality as a system property with six important improvement aims: Health care should be (1) safe, (2) effective, (3) patient-centered, (4) timely, (5) efficient, and (6) equitable. All healthcare constituents or stakeholders, including policy-makers, purchasers, regulators, health professionals, healthcare trustees and management, and consumers, must commit to a national agenda emphasizing these six aims for improvement. The goal is to raise the quality of care to unprecedented levels. The recommendations from this report are included in Appendix C. In addition, the report states 10 rules to guide major stakeholders to reach positive outcomes through collaboration. These rules are drawn from the work of Donald Berwick, M.D. (2008), who also notes the fundamental differences between the new rules and the current system. These differences are discussed in Part 4.
does not use its resources efficiently. This report identifies quality as a system property with six important improvement aims: Health care should be (1) safe, (2) effective, (3) patient-centered, (4) timely, (5) efficient, and (6) equitable. All healthcare constituents or stakeholders, including policy-makers, purchasers, regulators, health professionals, healthcare trustees and management, and consumers, must commit to a national agenda emphasizing these six aims for improvement. The goal is to raise the quality of care to unprecedented levels. The recommendations from this report are included in Appendix C. In addition, the report states 10 rules to guide major stakeholders to reach positive outcomes through collaboration. These rules are drawn from the work of Donald Berwick, M.D. (2008), who also notes the fundamental differences between the new rules and the current system. These differences are discussed in Part 4.
Envisioning the National Healthcare Quality Report (2001)
After completing a more in-depth description of the healthcare problem, the IOM recommended that care be monitored routinely. After extensive exploration of the quality of health care in the United States, the IOM was then challenged regarding what to do with this information and how to monitor quality. This report takes the process a step further by proposing a system for annually collecting data to monitor the quality of the nation’s healthcare system. There was need for a framework to use for monitoring healthcare quality. Envisioning the National Healthcare Quality Report (IOM, 2001b) describes a model framework for data collection, and that framework is now used to monitor quality of care annually, though it has been modified since the original version was developed. This analysis is now compiled annually by the Agency for Healthcare Research and Quality (AHRQ).
“The National Healthcare Quality Report should serve as a yardstick or the barometer by which to gauge progress in improving the performance of the healthcare delivery system in consistently providing high-quality care” (IOM, 2001b, p. 2). The focus of the report is not public health, but instead how the healthcare system performs in providing personal health care (health care for the individual). In addition, the report discusses health care from a broader perspective than the performance of individual providers such as hospitals. The report should not duplicate systems that many individual healthcare organizations currently use to measure their own performance. The quality report should assist policy-makers and should also be accessible and relevant to consumers, purchasers, providers, educators, and researchers. The design of the annual quality report builds on the definition of quality used in the various IOM reports. Quality is “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (IOM, 1990, p. 21).
The quality report follows the most common approach to quality care assessment, derived from Donabedian’s (1996) three elements of quality: (1) structure, (2) process, and (3) outcomes. It is clear that health care quality does not mean that all desired outcomes will necessarily be reached; also, a patient who receives care below the quality standard may still reach the desired outcomes. In addition, the approach selected for
the report recognizes the influence of the patient: The patient’s desired outcome and preferences influence treatment and healthcare consumerism. The quality report matrix is discussed in Part 4.
the report recognizes the influence of the patient: The patient’s desired outcome and preferences influence treatment and healthcare consumerism. The quality report matrix is discussed in Part 4.
The first annual report was published online in 2003 by the Agency for Healthcare Research and Quality. It is a rich source of data, with current updates, but is typically one to two years behind the current year, as it takes time to analyze the data. The current annual national healthcare quality report can be accessed at the AHRQ site: www.ahrq.gov/qual/qrdr10.htm
Priority Areas for National Action: Transforming Healthcare Quality (2003)
Priority Areas (IOM, 2003f) adds another building block to the national initiative to improve the quality and safety of health care. This report begins by recognizing that not every aspect of care can be assessed annually—and that attempting to do so would not offer any advantage. The increase of chronic conditions in the United States has had a major impact on the system and is an important consideration in identifying the priority areas. More people are living longer and with chronic illnesses, mostly because of advances in medical science and technology. Many of these patients also have comorbid conditions that increase the complexity of their problems and require more collaborative health care. Three criteria are used to select the priority areas: (1) impact or extent of burden, (2) improvability or extent of the gap between current practice and evidence-based practice, and (3) inclusiveness or relevance of an area to a broad range of individuals.
Earlier reports identify serious quality and safety concerns in healthcare delivery; however, every part of care cannot be evaluated. The report initially specified 19 priority areas. Over time, the priority areas change as new needs arise and outcomes in priority areas improve; however, the annual report framework should not change greatly unless it proves to be inadequate. The priorities are discussed in more detail in Part 4.
Patient Safety: Achieving a New Standard of Care (2003)
Patient Safety (IOM, 2003e) discusses in more detail one recommended strategy for improving patient safety, defined as “freedom from accidental injury.” Patient safety improvement requires major changes in safety and quality of care. Multiple stakeholders must commit to these changes, which includes a revamping of patient information systems. This report continues the examination of safety issues and relates to the recommendations found in To Err Is Human (IOM, 1999). In the process of giving health care, providers need to: (1) access complete patient information; (2) understand the implications of environmental factors such as waiting time to receive care, bed availability, and so on; (3) use information about infectious diseases to decrease patient risk; and (4) appreciate the implications of chronic illness and how these may affect care needs. Each of these elements depends on accurate, timely, and accessible information in the form of a comprehensive electronic health record/electronic medical record (EHR/EMR). The EMR/EHR supports the implementation of best practices and evidence-based care
and facilitates standardization of care where appropriate. Additional discussion about informatics is found in Part 4.
and facilitates standardization of care where appropriate. Additional discussion about informatics is found in Part 4.
Preventing Medication Errors (2006)
The first report in the Quality Chasm series, To Err Is Human (IOM, 1999), sounded the alarm for healthcare providers and for consumers that there are too many errors in the healthcare system. Preventing Medication Errors takes the next step by proposing a methodology to prevent medication errors (IOM, 2006d). The report focuses on several aspects of medication errors. First is the drug development system, along with regulation and distribution issues. Second, the report reviews the literature on the incidence and costs of medication errors and prevention strategies.
Using all this information as background, the report then proposes a comprehensive approach for reducing medication errors. This plan requires changes in the healthcare practice of physicians, nurses, pharmacists, and other healthcare providers, as well as the Food and Drug Administration (FDA), hospitals and other healthcare organizations, and health-related government agencies. With an estimated minimum of 1.5 million preventable adverse drug events (ADEs) a year in hospitals and long-term care facilities, there is much to do to improve care. These errors are expensive, with an estimated average cost per ADE of $8,750 per hospital stay. Not all ADEs are preventable, but many are. Part 4 includes additional information on ADEs.
The plan for change begins with a greater emphasis on the patient-provider relationship—pushing patients to take a more active role in medical care with more education about their medications, and providing opportunities for them to ask questions and to question medication decisions. As will be noted later, this will lead to a greater emphasis on patient-centered care (PCC). Greater standardization of patient medication information is also needed.
The second component is the use of information technologies for prescribing and dispensing medications to reduce medication errors. The third area of concern is the need to improve labeling and packaging of medications. Finally, the plan covers policy issues such as funding for research about medication error prevention and greater efforts by regulatory agencies to guide and enforce standards to reduce medication errors.
Advancing Quality Improvement Research: Challenges and Opportunities (2007) and The State of QI and Implementation Research (2007)
Crossing the Quality Chasm (IOM, 2001a) discussed the need for improvement in healthcare quality. It was followed by Envisioning the National Healthcare Quality Report (IOM, 2001b), which describes the framework and process for a national healthcare quality report. We now have an active annual report that is accessible via the Internet. However, just recognizing that there is a problem in healthcare quality and collecting annual data on the status of that quality is not sufficient to improve care. Advancing Quality Improvement Research (IOM, 2007a) and The State of QI and Implementation Research (IOM, 2007h) explore examples of quality improvement (QI) focusing on the non-healthcare service sector (for example, Six Sigma and Lean Sigma); the integrated
healthcare delivery system (for example, Kaiser Permanente); the hospital perspective; and the nursing perspective.
healthcare delivery system (for example, Kaiser Permanente); the hospital perspective; and the nursing perspective.
Much remains to be understood about quality improvement and methods to analyze improvement. Some of these methods are case reports, systematic reviews, controlled trials, and hybrid quantitative and qualitative reports. This area of research differs from other types in what is considered the “gold standard.” Some experts claim that randomized controlled trials (RCTs) do not effectively assess complex social contexts; other experts do not agree. Part 4 explores this further. Numerous barriers may obstruct quality improvement and quality improvement research (Institute of Medicine, 2007h):
QI has many purposes. The purpose of research is very different from experiential learning, which is also an important part of QI.
The specific context is important when attempting to generalize across settings.
It is unclear where QI research belongs in academic settings. It should be interprofessional, but this is difficult to implement.
Most staff involved in QI projects do not have traditional research backgrounds.
Ethical oversight is critical for research, but it is not clear how this applies to QI. Is QI human subject research, and does it thus require institutional review boards (IRBs)?
There are methodological differences between the biological sciences and the social sciences. QI is not based on tightly controlled conditions of clinical interventions, so it is more difficult to generalize from QI studies.
Much of the published QI research has been poorly conducted.
There is a lack of common vocabulary for QI and implementation research terms.
Diversity and Disparity
The following IOM reports focus on the critical concern of equality in health care.
Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare (2003)
Unequal Treatment (IOM, 2003g) indicates that bias, prejudice, and stereotyping can lead to disparities in health care. We need greater education, standardized data collection to further understand the problem, and policies and procedures to eliminate inequities. This was the report that led to the recommendation of monitoring disparities. Healthcare organizations (HCOs) have increased staff training on this topic, and it is included in many curricula, but is this making a difference in practice? Disparities in health care are not caused only by a lack of education about culture, so one should not expect that education alone will make the difference. It is a multifaceted problem and requires multiple strategies—many of which will affect the delivery process.
Unequal Treatment focuses on disparities in health care and their impact on the nation’s public health, identifying major concerns about racial, ethnic, geographic, and
socioeconomic inequities. Healthcare disparities occur consistently across a variety of illnesses and delivery services. The findings of the Sullivan Commission (2004), though not one of the IOM reports, are relevant. That commission examined disparities in health care and concluded that a key contributor to this growing problem is disparity in the nation’s health professional workforce. This imbalance impedes minorities’ access to health care and undermines understanding of their needs. The Sullivan commission suggested that the solution is to increase the number of minority health professionals. This translates into increased admission into professional schools, something the United States has historically failed to accomplish. Today, with increased competition for positions in nursing, this problem can only grow. Many minority students do not have a strong basic education prior to entering college. If they are admitted, they often do not graduate. At-risk students should receive assistance to give them a greater chance of completing the program.
socioeconomic inequities. Healthcare disparities occur consistently across a variety of illnesses and delivery services. The findings of the Sullivan Commission (2004), though not one of the IOM reports, are relevant. That commission examined disparities in health care and concluded that a key contributor to this growing problem is disparity in the nation’s health professional workforce. This imbalance impedes minorities’ access to health care and undermines understanding of their needs. The Sullivan commission suggested that the solution is to increase the number of minority health professionals. This translates into increased admission into professional schools, something the United States has historically failed to accomplish. Today, with increased competition for positions in nursing, this problem can only grow. Many minority students do not have a strong basic education prior to entering college. If they are admitted, they often do not graduate. At-risk students should receive assistance to give them a greater chance of completing the program.
The problem of disparity in the nursing profession is slowly resolving. Data from the American Association of Colleges of Nursing (AACN) indicate that representation of students from minority backgrounds increased in all types of nursing programs in 2009, growing to 26.3% in entry-level baccalaureate programs, 25.6% in master’s programs, and 23.0% in research-focused doctoral programs (2010, p. 4). The percentage of men in nursing programs increased some, with the following representation: 10.8% of students in baccalaureate programs, 9.1% in master’s nursing programs, and 7.3% in doctoral research-focused programs and 8.1% in practicefocused programs. This does not mean that we do not have a diversity problem, as we still need to increase diversity more—but we are headed in the right direction.
Nursing education tends to stress content related to specific cultural groups as the primary method for improving knowledge of disparities, but this may actually lead to more stereotyping and oversimplification of culture (Betancourt, Green, Carrillo, & Park, 2005). Johnson (2005) states that you need both the generic and the specific approaches. Health Resources and Services Administration’s (HRSA) curriculum project on culture, Transforming the Face of Health Professions through Cultural and Linguistic Competence Education, is an excellent resource, accessible at www.hrsa.gov/culturalcompetence/cultcompedu.pdf (HRSA, 2008). This course and materials focus on patient-centered care and skills needed to understand the patient’s values, beliefs, and behaviors relevant to the healthcare delivery process for the patient, regardless of the setting, and to ensure effective, efficient, and timely care for all patients. Additional content on diversity is found in other parts of this book.
Guidance for the National Healthcare Disparities Report (2002)
Guidance for the National Healthcare Disparities Report outlines the annual National Healthcare Disparity Report, which is published by the AHRQ and is available on the Internet at www.ahrq.gov/qual/qrdr10.htm. It tracks four measurements: socioeconomic status, access to the healthcare system, healthcare services and quality, and geographic disparities in health care. The Guidance report is a companion to the National Healthcare Quality Report. It provides a comprehensive national overview of disparities in health care as they affect racial, ethnic, and socioeconomic groups and priority populations.
Similar to the National Healthcare Quality Report, the annual disparities report flows from the earlier IOM reports on diversity and disparity in health care. This report also correlates with the quality framework. The framework used to assess measures of healthcare disparities is described in Part 4.
Similar to the National Healthcare Quality Report, the annual disparities report flows from the earlier IOM reports on diversity and disparity in health care. This report also correlates with the quality framework. The framework used to assess measures of healthcare disparities is described in Part 4.
Health Literacy: A Prescription to End Confusion (2004)
Nearly half of all American adults—90 million people—have difficulty understanding and using health information, and there is a higher rate of hospitalization and use of emergency services among patients with limited health literacy, as reported in Health Literacy (IOM, 2004a). Limited health literacy may lead to billions of dollars in avoidable healthcare costs. Health literacy is much more than a measure of reading skills. It also includes writing, listening, speaking, arithmetic, and conceptual knowledge. Health literacy is defined as “the degree to which individuals have the capacity to obtain, process, and understand basic information and services needed to make appropriate decisions regarding their health” (IOM, 2004a, p. 2). Even well-educated people with strong reading and writing skills may have trouble understanding a medical form or healthcare provider instructions regarding a drug or procedure. Additional content is discussed in Part 4.
Promoting Health Literacy to Encourage Prevention and Wellness: Workshop Summary (2011)
Health literacy has an impact on the use of preventive services. This report emphasizes the need for public health professionals to do less telling people what they should do and more emphasizing the value of prevention to individuals and the community. Health literacy plays a critical role in a person’s ability to understand important prevention information. Health and well-being are addressed by primary prevention and secondary prevention, but they are also influenced by non-health issues such as residence location, work, family, economics, and so on. “People need simple instructions about what they need to do to stay healthy and avoid disease. They need ways to measure or score themselves on how well they are doing” (Institute of Medicine, 2011g, p. 8). Those who have an illness need information for self-management.
There is another viewpoint of health literacy that is very important today given the U.S. problem with healthcare disparities. “Health literacy is about health equity. Those who lack health literacy do not have the same opportunity to achieve health as those who are health literate, and therefore, improving health literacy can have a significant impact on health disparities” (2011g, p. 27). This report provides examples of strategies that have been used to promote health literacy and improve health promotion.
America’s Healthcare Safety Net: Intact but Endangered (2007)
The “safety net” is the “default system of care for more than 44 million low-income Americans with no or limited health insurance as well as many Medicaid beneficiaries and people who need services” (IOM, 2007b, p. 49). Since this statement was made, the U.S. healthcare system has expanded, and there is more advanced treatment for patients than ever before. Safety-net organizations provide care to the uninsured, Medicaid
patients, and vulnerable populations. Some provide the care because it is mandated by law or stated as part of an organization’s mission. In many cases the providers serve a mix of patients: some belong to these vulnerable populations and others do not. The IOM investigation into the healthcare system found it fragmented, consisting of a patchwork of service settings such as clinics, physician offices, and multiple healthcare organizations. It is also not financially secure. Several safety-net hospitals have closed over the last few years, while others are struggling to maintain services. Who, then, provides care in the safety-net system, and for how long? The most common providers are public hospitals, local health departments, community health centers, academic healthcare centers (not all but most), and specialty services such as AIDS clinics and school health clinics.
patients, and vulnerable populations. Some provide the care because it is mandated by law or stated as part of an organization’s mission. In many cases the providers serve a mix of patients: some belong to these vulnerable populations and others do not. The IOM investigation into the healthcare system found it fragmented, consisting of a patchwork of service settings such as clinics, physician offices, and multiple healthcare organizations. It is also not financially secure. Several safety-net hospitals have closed over the last few years, while others are struggling to maintain services. Who, then, provides care in the safety-net system, and for how long? The most common providers are public hospitals, local health departments, community health centers, academic healthcare centers (not all but most), and specialty services such as AIDS clinics and school health clinics.
The safety-net system varies from state to state, and it has managed to survive, although services and quality have been questioned. However, a number of factors may stress these organizations’ already weak financial support and have a major impact on the healthcare safety net (IOM, 2007h):
As the number of uninsured people increases, there is more need for safety-net services. Healthcare reform over time will reduce the number of uninsured, but not completely.
The direct and indirect subsidies that have helped to finance uncompensated care are eroding (for example, a decrease in federal Medicaid funds to states). Some providers are no longer able to provide “charity care” because it is harder to transfer these costs to paying patients. With the increase in unemployment, there are more people without coverage, only increasing the stress on the safety-net system.
Hospitals that care for a large number of Medicaid patients are unable to improve care as rapidly as hospitals that have better funding (Reinberg, 2008). With greater emphasis on performance, these safety-net hospitals experience a secondary impact when their lower performance means they get less funding. Less funding means less improvement—and the cycle continues.
The IOM report discusses policy issues, the healthcare safety-net system, forces affecting the system, and the future viability of the system. Additional discussion about the safety-net system is found in Part 4.
Leadership
The following IOM reports focus on the importance of leadership in health care.
Leadership By Example: Coordinating Government Roles in Improving Healthcare Quality (2003)
This report explores the characteristics of an infrastructure that will foster quality care (IOM, 2003d). Six government programs—Medicare, Medicaid, State Children’s Health Insurance Program (SCHIP), Department of Defense (DOD) TRICARE and TRICARE
for Life programs, Veterans Health Administration (VHA), and Indian Health Services (IHS) program—are examined for quality enhancement processes. These six programs serve about a third of all Americans. The difficulty with implementation of the recommendations in the IOM reports has been the lack of reliable, valid indicators of quality. This analysis stresses the need for the U.S. government to lead in establishing quality performance measures and improving safety and quality of care. The federal government serves in four healthcare delivery roles, which makes it uniquely suited to move the quality initiative forward.
for Life programs, Veterans Health Administration (VHA), and Indian Health Services (IHS) program—are examined for quality enhancement processes. These six programs serve about a third of all Americans. The difficulty with implementation of the recommendations in the IOM reports has been the lack of reliable, valid indicators of quality. This analysis stresses the need for the U.S. government to lead in establishing quality performance measures and improving safety and quality of care. The federal government serves in four healthcare delivery roles, which makes it uniquely suited to move the quality initiative forward.
It serves as regulator when it sets minimum acceptable performance standards.
It is the largest purchaser of care through six major government health programs, and thus can have a major impact on other purchasers of care.
As a provider of care for veterans, military personnel and their dependents, and Native Americans, the federal government can implement model quality improvement programs and gather data about their outcomes—programs that could then be used by other providers.
Finally, it is a research sponsor, particularly in applied health services research.
The report’s recommendations are included in Appendix D.
Public Health
The IOM recognizes the importance of the U.S. public health system. An examination of the system is found in the following IOM reports.
The Future of the Public’s Health in the Twenty-first Century (2003) and Who Will Keep the Public Healthy? (2003)
The Future of the Public’s Health in the Twenty-first Century (IOM, 2003a) and Who Will Keep the Public Healthy? (IOM, 2003h) deal with public health. Reports discussed earlier, Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare (IOM, 2003g) and Guidance for the National Healthcare Disparities Report (IOM, 2002), also relate to public health. These four reports discuss the problems in the public health system and offer recommendations for improvement. Part of the current atmosphere of change is the need to instill a vision of public health, which has been identified as healthy people in healthy communities (HHS, 2012). This vision of the future of public health recognizes that “health is a primary good because many aspects of human potential such as employment, social relationships, and political participation are contingent on it” (IOM, 2003a, p. 2). Public health affects citizens, their lifestyle, income, work status, mortality and morbidity, education, and family life. But public health has frequently been overlooked in the broad view of the nation’s health. The key points of the action plan in The Future of the Public’s Health, found in Appendix E, include a population health approach, public health systems, infrastructure, partnerships, accountability, evidence, and communication.
Who Will Keep the Public Healthy? (IOM, 2003h) addresses public health needs in a world of globalization, rapid travel, scientific and technological advances, and demographic changes. Effective response to public health problems requires well-prepared professionals. “A public health professional is a person educated in public health or a related discipline who is employed to improve health through a population focus” (Orlando Business Journal, 2008, p. 4).
The Association of Schools of Public Health predicts that by 2020 the United States will need 250,000 additional public health workers; as a consequence, there is more interest in public health among all healthcare professionals (Orlando Business Journal, 2008). According to the IOM, the traditional core components of public health are still important: epidemiology, biostatistics, environmental health, health services administration, and social and behavioral science. Other areas are also important for current and future public health professions and should be included in nursing curricula. The report’s recommendations are found in Appendix F.
Leading Health Indicators for Healthy People 2020: Letter Report (2011)
The Department of Health and Human Services (HHS) requested that the IOM develop and recommend 12 leading health indicators and 24 objectives to assist HHS in its determination of leading indicators and objectives for Healthy People 2020 (2011g). This report is a good example of how the IOM quality reports are connected to other initiatives such as Healthy People. The mission of Healthy People 2020 (HHS, 2012) is to:
Identify nationwide health improvement priorities;
Increase public awareness and understanding of determinants of health, disease, disability, and opportunities for progress;
Provide measurable objectives and goals applicable at national, state, and local levels;
Engage multiple sectors to take actions to strengthen policies and improve practices that are driven by the best available evidence and knowledge; and
Identify critical research evaluation and data collection needs.
The IOM identified the leading indicators and objectives from the new Healthy People 2020′s 42 topic areas and nearly 600 objectives. The overarching goals for the 2020 version are:
Attain high-quality, longer lives free of preventable disease.
Achieve health equity; eliminate disparities.
Create social and physical environments that promote good health.
Promote quality of life, healthy development, and healthy behaviors across life stages.
From these many topics and objectives, the IOM identified the leading indicators and their related objectives, as described in Exhibit 1-1. The IOM used a conceptual
framework in identifying these elements: the life course perspective or life stage and the health determinants and health outcomes. The IOM report discusses each of the indicators in detail.
framework in identifying these elements: the life course perspective or life stage and the health determinants and health outcomes. The IOM report discusses each of the indicators in detail.
EXHIBIT 1-1 The IOM and Healthy People 2020: Topics, Indicators, and Objectives | ||||||||||||||||||||||||||||||||||||||||||
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