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Invite the Next Generation to Lead
Reflecting on lessons from 10 years of the IHI Open School, this article shares five practical ideas for how can health care organizations can engage the next generation of health professionals as powerful change agents and leaders.
Transforming Concepts in Patient Safety: A Progress Report
This article reviews progress to date to advance patient safety in the US in five essential areas of health care, as first identified in 2009 by the IHI/NPSF Lucian Leape Institute.
Human-Centered Design and Performance Improvement: Better Together
Kaiser Permanente, an IHI Strategic Partner, is fusing methods from human-centered design and performance improvement to systematically partner with patients, families, and customers to co-design better care, systems, and programs.
Leadership and Vision for a Culture of Safety
Leaders seeking to transform their health care organization’s culture would do well to commit focused attention on six key areas described in this article.
No Place Like Home: Advancing the Safety of Care in the Home
This report provides expert panel recommendations, strategies, and tools for realizing five guiding principles for advancing the safety of home care.
The Scottish Improvement Journey: A Nationwide Approach to Improvement
Learn about Scotland’s 10-year effort to apply quality improvement on a national scale to improve patient safety, including an in-depth review of the successful Scottish Patient Safety Programme, and further QI efforts that spread across Scotland into new social policy areas such as children’s services, education, and justice.
Using Quality Improvement Methods to Combat Poverty: Northeast Wisconsin's POINT Initiative
This case study provides an overview of the Poverty Outcomes and Improvement Network Team (POINT) initiative, a multiyear regional effort to reduce poverty in Northeast Wisconsin by teaching nonprofit organizations how to use quality improvement methods and tools to improve the services they provide to those in the community living in poverty.
Making Health Equity a Strategic Priority
This article describes lessons learned from health systems participating in the Pursuing Equity initiative that are testing changes to make health equity a strategic priority — the first pillar in the IHI Framework for Achieving Health Equity.
Building Improvement Capacity and Capability: A "Dosing" Approach
This article describes the Institute for Healthcare Improvement's "dosing" approach to building improvement capacity and capability by establishing and deploying targeted levels of improvement knowledge and skills throughout an organization.
Integrating Behavioral Health in the Emergency Department and Upstream
This IHI Innovation Report discusses barriers to integrating behavioral health in the ED, and presents five drivers (emerging from six key themes from existing approaches) that form the building blocks of a theory of change for making improvements in this area.
Why Focusing on Professional Burnout Is Not Enough
With professional burnout rates in health care at an all-time high, IHI suggests shifting the focus from “burnout” to “joy in work.” This article describes the role of leaders and four proven steps to create joy in work.
Transforming Health Care: A Compendium of Reports from the NPSF Lucian Leape Institute
A guide for health care leaders in assessing where their organizations stand in the journey to safer care and what steps they can take to make greater progress.
Shining a Light: Safer Health Care Through Transparency
This Lucian Leape Institute report offers sweeping recommendations to bring greater transparency in four domains: between clinicians and patients; among clinicians within an organization; between organizations; and between organizations and the public. It makes the case that true transparency will result in improved outcomes, fewer medical errors, more satisfied patients, and lowered costs of care.
Safety Is Personal: Partnering with Patients and Families for the Safest Care
This Lucian Leape Institute report is a call to action for health leaders, clinicians, and policy makers to take the necessary steps to ensure patient and family engagement at all levels of health care. It identifies specific action items for health leaders, clinicians, and policy makers to pursue in making patient and family engagement a core value in the provision of health care.
Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care
This Lucian Leape Institute report details how workplace safety is inextricably linked to patient safety. It highlights vulnerabilities common in health care organizations, discusses the costs of inaction, outlines what a healthy and safe workplace would look like, and offers seven recommendations for actions that organizations need to pursue to effect real change.
Order from Chaos: Accelerating Care Integration
Too often, care integration — the planned, thoughtful design of the care process for the benefit and protection of the patient — is lacking. This Lucian Leape Institute report addresses the issue of care integration with the aim of outlining the major barriers to effective integration and providing a framework for further consideration and action among stakeholders.
Unmet Needs: Teaching Physicians to Provide Safe Patient Care
Unmet Needs is the culmination of three Lucian Leape Institute roundtable discussions and makes key recommendations for reforming medical education in order to improve patient safety. The paper was the first in a series of such reports on issues identified as top priorities in ongoing efforts to improve patient safety.
Highly Adoptable Improvement: A Practical Model and Toolkit to Address Adoptability and Sustainability of Quality Improvement Initiatives
This article presents the Highly Adoptable Improvement Model, a practical model and supporting tools developed on the basis of existing theories to help quality improvement (QI) programs design more adoptable approaches that lead to more sustainable improvement.
Leading a Culture of Safety: A Blueprint for Success
Creating a culture of safety in health care settings has proven to be a challenging endeavor, and there is a lack of clear actions for organizational leaders to take in developing such a culture. This guide provides chief executive officers and other health care leaders with a useful tool for assessing and advancing their organization’s culture of safety, and can be used to help determine the current state, inform dialogue with the board and leadership team, and help leaders set priorities.
Is Your Organization Highly Reliable?
This article presents common high-reliability organization (HRO) characteristics that apply to all health care organizations seeking to improve patient safety, and cross-walks them with the IHI Framework for Safe, Reliable, and Effective Care to help leaders build a culture and learning system to support HRO characteristics and safer systems of care.
Moral Choices for Today’s Physician
In this essay, Don Berwick considers moral choices physicians face personally, organizationally, and globally and exhorts them to understand that the health of humanity depends on their speaking out against the social injustice of overpricing drugs and services, mass incarceration, and the lack of environmental responsibility.
Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human
This report assesses the state of patient safety in health care, advocating for a total systems approach across the continuum of care and establishment of a culture of safety, and calling for action by government, regulators, health professionals, and others to place higher priority on patient safety improvement and implementation science.
Measuring Patient Safety in Real Time: An Essential Method for Effectively Improving the Safety of Care
The continuing evidence of preventable deaths due to medical error has led to recent calls to improve measurement of safety in hospitals. This need can be adequately addressed by harnessing health information technology.
Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era
The recommendations outlined in this publication are designed to help standardize the ways in which primary care practitioners activate referrals to specialists, and then keep track of the information over time. It describes a nine-step, closed-loop process in which all relevant patient information is communicated to the correct person through the appropriate channels and in a timely manner.
Discharge to Assess: “Flipping” Discharge Assessment from Hospital to Home
Discharge to Assess (D2A) (also referred to as "flipped discharge") is a redesign of the care process at Sheffield Teaching Hospitals in the UK that involves assessing a patient’s needs after discharge in the patient’s own home rather than in the hospital. Activities that traditionally happen at the end of a hospital admission are instead performed successfully and safely at home, thus enabling patients who are medically ready to go home earlier and spend less time in the acute care setting.