The healthcare system in the United States is in disarray. Communication among providers is poor. Providers continue to function without adequate data, thus, preventing mid-course corrections when the service they provide is off the mark. A shared organisational vision is lacking among healthcare providers. The suffusion of information technology is slow compared to other industries. A strong performance improvement structure to facilitate improvement is minimal in most healthcare institutions. The use of evidence-based medicine versus anecdotal experience to guide the practice of medicine is not often distinguished. The coup de gras is that care is not centered on the patient but on the disease. As a result, awareness of the physical and emotional needs of the patient with a disease is not considered and a prevention focus is missing.
Is it hopeless or can these issues be dealt with more effectively and care coordinated around the patient’s needs? To begin to address the dysfunction in “modern” medical care, the Institute of Medicine (IOM) issued its now famous report—To Err is Human—in 2000 1 . They pointed out that the frequency and severity of accidental injury in the healthcare system is a serious problem. While the number of deaths attributed to this dysfunctional system has been debated, whatever is the number, it is too large. The report concluded that the problem is caused by faulty systems of care, not faulty providers. To address the issue, they emphasised that new systems of care must be developed.
In their follow-up document—Crossing the Quality Chasm, the IOM urged that each process of care should be safe, effective, efficient, equitable, timely and patient centered. 2 They developed 10 new rules for 21st century healthcare (see Table 1).
While most of the New Rules in Table 1 are actionable now, two will require special attention. The patient as the source of control will depend on developing the tools for creating a more informed patient —the responsibility being shared by the provider team and the patient. The other knotty issue is embracing transparency. To deal with transparency, the legal system will have to make some adjustments so this New Rule doesn’t result in a malpractice quagmire.
Where do we begin? We begin by measuring. Using the Donabedian construct—structure, process and outcome measures—we can begin3. First, we need to have a performance improvement group available in the healthcare institution—this would be a structural measure. The group should be knowledgeable and experienced in measuring processes and outcomes. Then, we can start with measures that have been vetted for a number of years and are evidence-based such as the measures for acute myocardial infarction (AMI)4, 5. The AMI process measures include the use of aspirin and a beta-blocker on admission and discharge, use of an ACE inhibitor or an ARB if heart failure is present, and door to balloon inflation time of less than 90 minutes. These are process measures based on studies in the medical literature that show a decrease in mortality when these processes are followed. In fact, they are more accurately called process- oriented outcome indicators. A more standard outcome indicator would be mortality in the hospital or within 30 days. Mortality assessment depends on risk-adjustment and is a more difficult measure to assess accurately.
If you adopt the Institute for Healthcare Improvement’s 100,000 lives campaign you will have access to bundles of performance measures for managing AMI, preventing ventilator-associated pneumonia, central venous line infections and surgical site infections, and reducing adverse drug events with medication reconciliation 6. All of these are evidence-based. Finally, ongoing studies are attempting to determine if rapid response teams can detect failing patients early and prevent their transfer to an intensive care unit or death.
It is of interest that compliance with process measures translates into better outcomes7. They showed that for every 10% increase in compliance with the measures a 10% reduction occurred in inpatient mortality. The CMS-Premier Hospital Quality Initiative Demonstration project showed that in one year for community-acquired pneumonia (CAP) and coronary artery bypass graft surgery among approximately 3,000 hospital deaths were avoided and US$1 billion was saved8.
How well are we doing with reaching compliance with these well-described, evidence-based measures? McGlynn and colleagues studied compliance with many measures in 12 communities and found that compliance reached only 55%9.
There is a downside or potential unintended consequences to performance measurement. Human nature may lead to gaming the system to achieve compliance10. For example, for CAP, antibiotics are occasionally given before the diagnosis of CAP is made, in order to comply with the four-hour window allowed for antibiotic administration from the time of entry to the emergency room to the time of antibiotic administration. Because the diagnosis of CAP is not always clear, making the four-hour window can be difficult. Therefore, it is best to lower the compliance goal from 100% to 95%, for example, to account for those unusual cases where the diagnosis is not clear on initial presentation to the healthcare system.
We have a lot of work to do to correct the poor performance demonstrated by McGlynn et al. What are some of the implementation tools that we can use to improve?11 Additional factors are support from senior leadership to help shape the organisational culture. Involvement of the Board of Trustees of the institution is important. Attention to financial aspects of quality improvement will make an impact on these leaders. Efforts to reduce waste, bring down length of stay, use resources more wisely and efficiently, and go lean by cutting 1%-3% from the budget annually will enhance support to any investments that have to be made in the improvement effort.
Most critical is the development of new systems of care delivery. The new systems will vary from one institution to the next. For example, in our medical centre, we found that inserting mid-level providers such as nurse practitioners, experts in a given medical condition such as heart failure, heart attack or stroke, was critical to monitoring the care patients received and vital to intervening with the physicians when performance measures were not being met12. The nurse practitioner was always backed up by the specialty and department chiefs. This approach inserted a redundancy into the system of care and assured compliance.
Another method for achieving compliance is to use the tools of reliability science13. To achieve 80%-90% compliance—i.e., 1-2 failures out of 10, use checklists and other standard order sheets, reminders, audit and feedback, avoid reliance on memory, and train in quality improvement. To move to the 95% level—i.e., 5 or less failures out of 100, institute computerised physician order entry with clinical decision support that provide decision aids and reminders to the provider, make the desired action the default action, simplify and standardise, and use redundancy as described above. Attention to human factors engineering is also helpful. Finally, to reach the 99% compliance level which is rare today—i.e., 5 or less failures out of 1,000, analyse each critical failure with the techniques of root cause analysis in retrospect and failure mode and effect analysis in prospect.
First, enlist the support of the innovators at your institution, then, the early adopters and early majority will follow14. Gradual adoption is critical and easier than attempting to accomplish all at once. Don’t worry about the traditionalists. They typically make up about 15% of the providers. They may not be worth the effort as you may never convince them to change.
Similar approaches can be applied to improving patient safety—the other side of the quality coin. These international patient safety goals also require instituting new systems mentioned in Table 315.
As you go about improving the quality and patient safety at your institution, keep in mind Kuebler-Ross’s stages of acceptance of impending change (actually, Kuebler-Ross described it in relation to acceptance of death).
Life is short , art is long. Good work takes a long time to accomplish.
1. Kohn LT, Corrigan JM, Donaldson MS (Eds). To Err is Human: Building a Safer Health System. National Academy Press, Washington, DC 2000
2. Committee on Quality of Health Care in America, Institute of Health. Crossing the Quality Chasm: A new healthy system for the 21st century. National Academy Press, Washington, DC 2001
3. Donabedian A. Quality assessment and monitoring. Retrospect and prospect. Eval Health Prof 1983;6(3):363-75
4. CMS Measures. www.hospitalcompare.hhs.gov, accessed 12/3/06
5. JCAHO Measures. www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement, accessed 12/3/06
6. Institute for Healthcare Improvement “100k lives Campaign”. www.ihi.org/IHI/Programs/Campaign, accessed 12/3/06
7. Patel MR, Chen AY, Peterson ED, et al. Prevalence, predictors and outcomes of patients with non-ST-segment evaluation myocardial infarction and insignificant coronary artery disease: Results from the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines (CRUSADE) initiative. Am Heart J 2006 Oct;152(4):607-10
8. CMS/Premier pay-for-performance project could save thousands of lives and reduce hospital costs, according to Premier analysis. www.premierinc.com/about/advocacy/issues/06/p4p/p4p-cms-0806.jsp, accessed 12/3/06
9. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003; 348(26):2635-45
10. Metersky NL, Sweeney TA, Getzow MB, et al. Antibiotic timing and diagnostic uncertainty in Medicare patients with pneumonia: Is it reasonable to expect all patients to receive antibiotics within 4 hours? Chest 2006;130(1):16-21
11. Gross PA, Greenfield S, Cretin S, Ferguson J, et al. Optimal methods for guidelines: Conclusions from Leeds Castle meeting. Med Care 2001;39 (8-Suppl 2):I185-92
12. Gross PA, Patriaco D, McGuire K, Skurnick J, Teichholz LE. A nurse practitioner intervention model to maximize efficient use of telemetry resources. Jt Comm J Qual Improv 2002;28(10):566-73
13. Reliability. www.ihi.org/IHI/Topics/Reliability, accessed 12/3/06
14. Gladwell M. The Tipping Point: How Little Things Can Make a Big Difference. Originally published in hardcover by Little, Brown & Company, March 2000; First Back Bay paperback edition, January 2002 www.amazon.com/Tipping-Point-Malcolm-Gladwell/
15. International Patient Safety Goals Created. Joint Commission International Center for Patient Safety, www.jcipatientsafety.org/show.asp?durki=11753, accessed 12/3/06
16. Sadler BL. To the Class of 2005: Will you be ready for the quality revolution? Jt. Comm J Qual Improv 2006;32(1):51-5
17. Hippocrates quoted from http://www/bart;eby.com/59/3/lifeisshorta.html Accessed 1/10/2007.