Improving Quality

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Discussion: Improving Quality

Improving the quality of health care delivery and patient safety continues to be a political concern and has been at the heart of reform issues for many years. The American Nurses Association (ANA) and the Institute of Medicine (IOM) have increased awareness of health care quality and safety issues, as well as advocated for health care reform. The documents featured at the ANA and IOM websites listed in this week’s Learning Resources focus on many of the current issues surrounding quality and safety in the health care industry.

To prepare:

  • Review this week’s Learning Resources, focusing on the Six Aims for Improvement presented in the landmark report “Crossing the Quality Chasm: The IOM Health Care Quality Initiative.”
  • Consider these six aims with regard to your current organization, or one with which you are familiar. In what areas have you seen improvement? What areas still present challenges? As a nurse leader, how can you contribute to improving the organization’s achievement of these aims?
  • Select one specific quality or safety issue that is presenting a challenge in the organization. Consider at least one quality improvement strategy that could be used to address the issue, as well as which of the six aims for improvement would then be addressed.
  • Reflect on your professional practice and your experiences with inter-professional collaboration to improve quality and safety. How has inter-professional collaboration contributed to your organization’s efforts to realize the IOM’s six aims for improving health care? Where has inter-professional collaboration been lacking?

By Day 3

Post a description of the quality or safety issue you selected and a brief summary of the impact that this issue has on health care delivery. Describe at least one quality improvement strategy used to address this issue. Then explain which of the six “aims for improvement” are addressed by the strategy. Finally, explain how inter-professional collaboration helps improve quality in this area.


Six Aims for Improvement

Advances must begin with all health care constituencies--health professionals, federal and state policy makers, public and private purchasers of care, regulators, organization managers and governing boards, and consumers--committing to a 2

Advances must begin with all health care constituencies… committing to a national statement of purpose…

national statement of purpose for the health care system as a whole. In making this commitment, the parties would accept as their explicit purpose “to continually reduce the burden of illness, injury, and disability, and to improve the health and functioning of the people of the United States.” The parties also would adopt a shared vision of six specific aims for improvement. These aims are built around the core need for health care to be:

• Safe: avoiding injuries to patients from the care that is intended to help them.

• Effective: providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit.

• Patient-centered: providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.

• Timely: reducing waits and sometimes harmful delays for both those who receive and those who give care. • Efficient: avoiding waste, including waste of equipment, supplies, ideas, and energy.

• Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.

A health care system that achieves major gains in these six areas would be far better at meeting patient needs. Patients would experience care that is safer, more reliable, more responsive to their needs, more integrated, and more available, and they could count on receiving the full array of preventive, acute, and chronic services that are likely to prove beneficial. Clinicians and other health workers also would benefit through their increased satisfaction at being better able to do their jobs and thereby bring improved health, greater longevity, less pain and suffering, and increased personal productivity to those who receive their care.

March 2001 I N S T I T U TE OF M E D I C I N E Shaping the Future for Health CROSSING THE Q UALITY CHASM: A NEW HEALTH SYSTEM FOR THE 21ST CENTURY T he U.S. health care delivery system does not provide consistent, highquality medical care to all people. Americans should be able to count on receiving care that meets their needs and is based on the best scien­ tific knowledge--yet there is strong evidence that this frequently is not the case. Health care harms patients too frequently and routinely fails to deliver its potential benefits. Indeed, between the health care that we now have and the health care that we could have lies not just a gap, but a chasm. A number of factors have combined to create this chasm. Medical sci­ ence and technology have advanced at an unprecedented rate during the past half-century. In tandem has come growing complexity of health care, which today is characterized by more to know, more to do, more to manage, more to watch, and more people involved than ever before. Faced with such rapid changes, the nation’s health care delivery system has fallen far short in its ability to translate knowledge into practice and to apply new technology safely and appropriately. And if the system cannot consistently deliver today’s science and technology, it is even less prepared to respond to the ex­ traordinary advances that surely will emerge during the coming decades. The public’s health care needs have changed as well. Americans are living longer, due at least in part to advances in medical science and techno l­ ogy, and with this aging population comes an increase in the incidence and prevalence of chronic conditions. Such conditions, including heart disease, diabetes, and asthma, are now the leading cause of illness, disability, and death. But today’s health system remains overly devoted to dealing with acute, episodic care needs. There is a dearth of clinical programs with the multidisciplinary infrastructure required to provide the full complement of services needed by people with common chronic conditions. The health care delivery system also is poorly organized to meet the challenges at hand. The delivery of care often is overly complex and uncoor­ dinated, requiring steps and patient “handoffs” that slow down care and decrease rather than improve safety. These cumbersome processes waste resources; leave unaccountable voids in coverage; lead to loss of information; Faced with such rapid changes, the nation’s health care delivery system has fallen far short in its ability to translate knowledge into practice and to ap­ ply new technology safely and appro­ priately. CARE SYSTEM Supportive payment and regulatory en­ vironment Organizations that facilitate the work of patientcentered teams High perform­ ing patientcentered teams Outcomes: • Safe • Effective • Efficient • Personalized • Timely • Equitable REDESIGN IMPERATIVES: SIX CHALLENGES • Reengineered care processes • Effective use of information technologies • Knowledge and skills management • Development of effective teams • Coordination of care across patientconditions, services, sites of care over time and fail to build on the strengths of all health professionals involved to ensure that care is appropriate, timely, and safe. Organizational problems are particularly apparent regarding chronic conditions. The fact that more than 40 percent of people with chronic conditions have more than one such condition argues strongly for more sophisticated mechanisms to coordinate care. Yet health care organizations, hospitals, and physician groups typically operate as separate “silos,” acting without the benefit of complete information about the patient’s condition, medical history, services provided in other settings, or medications provided by other clinicians. Making change possible. Strategy for Reinventing the System Advances must begin with all health care con­ stituencies… committing to a national statement of purpose… Bringing state-of-the-art care to all Americans in every community will require a fundamental, sweeping redesign of the entire health system, according to a report by the Institute of Medicine (IOM), an arm of the National Academy of Sciences. Crossing the Quality Chasm: A New Health System for the 21st Century, prepared by the IOM’s Committee on the Quality of Health Care in America and released in March 2001, concludes that merely making incremental improvements in current systems of care will not suffice. The committee already has spoken to one urgent care problem--patient safety--in a 1999 report titled To Err is Human: Building a Safer Health System. Concluding that tens of thousands of Americans die each year as a result of pre­ ventable mistakes in their care, the report lays out a comprehensive strategy by which government, health care providers, industry, and consumers can reduce medical errors. Crossing the Quality Chasm focuses more broadly on how the health sys­ tem can be reinvented to foster innovation and improve the delivery of care. Toward this goal, the committee presents a comprehensive strategy and action plan for the coming decade. Six Aims for Improvement Advances must begin with all health care constituencies--health professionals, federal and state policy makers, public and private purchasers of care, regulators, organization managers and governing boards, and consumers--committing to a 2 national statement of purpose for the health care system as a whole. In making this commitment, the parties would accept as their explicit purpose “to continually reduce the burden of illness, injury, and disability, and to improve the health and functioning of the people of the United States.” The parties also would adopt a shared vision of six specific aims for improvement. These aims are built around the core need for health care to be: • Safe: avoiding injuries to patients from the care that is intended to help them. • Effective: providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit. • Patient-centered: providing care that is respectful of and responsive to in­ dividual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions. • Timely: reducing waits and sometimes harmful delays for both those who receive and those who give care. • Efficient: avoiding waste, including waste of equipment, supplies, ideas, and energy. • Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. A health care system that achieves major gains in these six areas would be far better at meeting patient needs. Patients would experience care that is safer, more reliable, more responsive to their needs, more integrated, and more available, and they could count on receiving the full array of preventive, acute, and chronic services that are likely to prove beneficial. Clinicians and other health workers also would benefit through their increased satisfaction at being better able to do their jobs and thereby bring improved health, greater longevity, less pain and suffering, and increased personal productivity to those who receive their care. A health care sys­ tem that achieves major gains in these six areas would be far better at meeting patient needs. Ten Rules for Redesign To help in achieving these improvement aims, the committee deemed that it would be neither useful nor possible to specify a blueprint for 21st-century health care delivery systems. Imagination abounds at all levels, and all promising routes for innovation should be encouraged. At the same time, the committee formu­ lated a set of ten simple rules, or general principles, to inform efforts to redesign the health system. These rules are: 1. Care is based on continuous healing relationships. Patients should re­ ceive care whenever they need it and in many forms, not just face-to-face visits. This implies that the health care system must be responsive at all times, and ac­ cess to care should be provided over the Internet, by telephone, and by other means in addition to in-person visits. 2. Care is customized according to patient needs and values. The system should be designed to meet the most common types of needs, but should have the capability to respond to individual patient choices and preferences. 3. The patient is the source of control. Patients should be given the nec3 …the health care system must be responsive at all times, and access to care should be provided over the Internet, by tele­ phone, and by other means in addition to inperson visits. Reducing risk and ensuring safety require greater a t­ tention to systems that help prevent and mitigate er­ rors. essary information and opportunity to exercise the degree of control they choose over health care decisions that affect them. The system should be able to accom­ modate differences in patient preferences and encourage shared decision making. 4. Knowledge is shared and information flows freely. Patients should have unfettered access to their own medical information and to clinical knowl­ edge. Clinicians and patients should communicate effectively and share informa­ tion. 5. Decision making is evidence-based. Patients should receive care based on the best available scientific knowledge. Care should not vary illogically from clinician to clinician or from place to place. 6. Safety is a system property. Patients should be safe from injury caused by the care system. Reducing risk and ensuring safety require greater attention to systems that help prevent and mitigate errors. 7. Transparency is necessary. The system should make available to pa­ tients and their families information that enables them to make informed decisions when selecting a health plan, hospital, or clinical practice, or when choosing among alternative treatments. This should include information describing the system’s performance on safety, evidence-based practice, and patient satisfaction. 8. Needs are anticipated. The system should anticipate patient needs, rather than simply react to events. 9. Waste is continuously decreased. The system should not waste resources or patient time. 10. Cooperation among clinicians is a priority. Clinicians and institutions should actively collaborate and communicate to ensure an appropriate exchange of information and coordination of care. Taking the First Steps To initiate the pro­ cess of change, Congress should establish a Health Care Quality Inno­ vation Fund To initiate the process of change, Congress should establish a Health Care Quality Innovation Fund--roughly $1 billion for use over three to five years to help pro­ duce a public-domain portfolio of programs, tools, and technologies of widespread applicability, and to help communicate the need for rapid and significant change throughout the health system. Some of the projects funded should be tar­ geted at achieving the six aims of improvement. The committee also calls for immediate attention on developing care proc­ esses for the common health conditions, most of them chronic, that afflict great numbers of people. The federal Agency for Healthcare Research and Quality (AHRQ) should identify 15 or more common priority conditions. (The agency has requested guidance from the IOM on selection of these conditions, and the Institute expects to issue its report in September 2002.) The AHRQ then should work with various stakeholders in the health community to develop strategies and action plans to improve care for each of these priority conditions over a five-year period. 4 Changing the Environment Redesigning the health care delivery system also will require changing the struc­ tures and processes of the environment in which health professionals and organi­ zations function. Such changes need to occur in four main areas: • Applying evidence to health care delivery. Scientific knowledge about best care is not applied systematically or expeditiously to clinical practice. It now takes an average of 17 years for new knowledge generated by randomized controlled trails to be incorporated into practice, and even then application is highly uneven. The committee therefore recommends that the Department of Health and Human Services establish a comprehensive program aimed at making scientific evidence more useful and more accessible to clinicians and patients. It is critical that leadership from the private sector, both professional and other health care leaders and consumer representatives, be involved in all aspects of this effort to ensure its applicability and acceptability to clinicians and patients. The infrastructure developed through this public-private partnership should focus initially on priority conditions. Efforts should include analysis and synthesis of the medical evidence, delineation of specific practice guidelines, identification of best practices in the design of care processes, dissemination of the evidence and guidelines to the professional communities and the general public, development of support tools to help clinicians and patients in applying evidence and making decisions, establishment of goals for improvement in care processes and outcomes, and development of measures for assessing quality of care. • Using information technology. Information technology, including the Internet, holds enormous potential for transforming the health care delivery sys­ tem, which today remains relatively untouched by the revolution that has swept nearly every other aspect of society. Central to many information technology ap­ plications is the automation of patient-specific clinical information. Such infor­ mation typically is dispersed in a collection of paper records, which often are poorly organized, illegible, and not easy to retrieve, making it nearly impossible to manage various illnesses, especially chronic conditions, that require frequent monitoring and ongoing patient support. Many patients also could have their needs met more quickly and at a lower cost if they could communicate with health professionals through e-mail. In addition, the use of automated systems for or­ dering medications can reduce errors in prescribing and dosing drugs, and com­ puterized reminders can help both patients and clinicians identify needed services. The challenges of applying information technology should not be underestimated, however. Health care is undoubtedly one of the most, if not the most, complex sectors of the economy. Sizable capital investments and multiyear commitments to building systems will be needed. Widespread adoption of many information technology applications also will require behavioral adaptations on the part of large numbers of clinicians, organizations, and patients. Thus, the committee calls for a nationwide commitment of all stakeholders to building an information infrastructure to support health care delivery, consumer health, qua l­ ity measurement and improvement, public accountability, clinical and health services research, and clinical education. This commitment should lead to the elimination of most handwritten clinical data by the end of the decade. 5 It is critical that leadership from the private sector, both professional and other health care leaders and consumer repre­ sentatives, be in­ volved in all as­ pects of this ef­ fort… Information tech­ nology…holds enormous poten­ tial for transform­ ing the health care delivery system… Clinicians should be adequately compensated for taking good care of all types of pa­ tients… …the importance of adequately preparing the workforce to make a smooth transi­ tion into a thor­ oughly revamped health care sys­ tem cannot be un­ derestimated. Now is the right time to begin work on reinventing the nation’s health care delivery sys­ tem. • Aligning payment policies with quality improvement. Although pay­ ment is not the only factor that influences provider and patient behavior, it is an important one. The committee calls for all purchasers, both public and private, to carefully reexamine their payment policies to remove barriers that impede quality improvement and build in stronger incentives for quality enhancement. Clinicians should be adequately compensated for taking good care of all types of patients, neither gaining nor losing financially for caring for sicker patients or those with more complicated conditions. Payment methods also should provide an opportu­ nity for providers to share in the benefits of quality improvement, provide an op­ portunity for consumers and purchasers to recognize quality differences in health care and direct their decisions accordingly, align financial incentives with the im­ plementation of care processes based on best practices and the achievement of better patient outcomes, and enable providers to coordinate care for patients across settings and over time. To assist purchasers in their redesign of payment policies, the federal go v­ ernment, with input from the private sector, should develop a program to identify, pilot test, and evaluate various options for better aligning payment methods with quality improvement goals. Examples of possible means of achieving this end include blended methods of payment designed to counter the disadvantages of one payment method with the advantages of another, multiyear contracts, payment modifications to encourage use of electronic interaction among clinicians and between clinicians and patients, and bundled payments for priority conditions. • Preparing the workforce. Health care is not just another service in­ dustry. Its fundamental nature is characterized by people taking care of other people in times of need and stress. Stable, trusting relationships between a patient and the people providing care can be critical to healing or managing an illness. Therefore, the importance of adequately preparing the workforce to make a smooth transition into a thoroughly revamped health care system cannot be un­ derestimated. Three approaches can be taken to support the workforce in this transition. One approach is to redesign the way health professionals are trained to emphasize the six aims for improvement, which will mean placing more stress on teaching evidence-based practice and providing more opportunities for interdisciplinary training. Second is to modify the ways in which health professionals are regu­ lated and accredited to facilitate needed changes in care delivery. Third is to use the liability system to support changes in care delivery while preserving its role in ensuring accountability among health professionals and organizations. All of these approaches likely will prove valuable, but key questions remain about each. The federal government and professional associations need to study these ap­ proaches to better ascertain how they can best contribute to ensuring the strong workforce that will be at the center of the health care system of the 21st century. No Better Time Now is the right time to begin work on reinventing the nation’s health care deliv­ ery system. Technological advances are making it possible to accomplish things today that were impossible only a few years ago. Health professionals and or6 ganizations, policy makers, and patients are becoming all too painfully aware of the shortcomings of the nation’s current system and of the importance of finding radically new and better approaches to meeting the health care needs of all Americans. Although Crossing the Quality Chasm does not offer a simple pre­ scription--there is none--it does provide a vision of what is possible and the path that can be taken. It will not be an easy road, but it will be most worthwhile. � � � For More Information… Copies of Crossing the Quality Chasm: A New Health System for the 21st Century are available for sale from the National Academy Press; call (800) 624-6242 or (202) 3343313 (in the Washington metropolitan area), or visit the NAP home page at www.nap.edu. The full text of this report is available at http://www.nap.edu/books/0309072808/html/ Support for this project was provided by: the Institute of Medicine; the National Research Council; The Robert Wood Johnson Foundation; the California Health Care Foundation; the Commonwealth Fund; and the Department of Health and Human Services’ Health Care Finance Administration, Public Health Service, and Agency for Healthcare Research and Quality. The views presented in this report are those of the Institute of Medi­ cine Committee on the Quality of Health Care in America and are not necessarily those of the funding agencies. The Institute of Medicine is a private, nonprofit organization that provides health policy advice under a congressional charter granted to the National Academy of Sciences. For more information about the Institute of Medicine, visit the IOM home page at www.iom.edu. Copyright ©2000 by the National Academy of Sciences. All rights reserved. Permission is granted to reproduce this document in its entirety, with no additions or al­ terations � � � COMMITTEE ON QUALITY OF HEALTH CARE IN AMERICA WILLIAM C. RICHARDSON (Chair), President and CEO, W.K. Kellogg Foundation, Battle Creek, MI DONALD M. BERWICK, President and CEO, Institute for Healthcare Improvement, Boston, MA J. CRIS BISGARD, Director, Health Services, Delta Air Lines, Inc., Atlanta, GA LONNIE R. BRISTOW, Former President, American Medical Association, Walnut Creek, CA CHARLES R. BUCK, Program Leader, Health Care Quality and Strategy Initiatives, General Electric Company, Fairfield, CT CHRISTINE K. CASSEL, Professor and Chairman, Department of Geriatrics and Adult Development, The Mount Sinai School of Medicine, New York, NY 7 MARK R. CHASSIN, Professor and Chairman, Department of Health Policy, The Mount Sinai School of Medicine, New York, NY MOLLY JOEL COYE, Senior Fellow, Institute for the Future, and President, Health Technology Center, San Francisco, CA DON E. DETMER, Dennis Gillings Professor of Health Management, University of Cambridge, UK JEROME H. GROSSMAN, Chairman and CEO, Lion Gate Management Corporation, Boston, MA BRENT JAMES, Executive Director, Intermountain Health Care Institute for Health Care Delivery Research, Salt Lake City, UT DAVID McK. LAWRENCE, Chairman and CEO, Kaiser Foundation Health Plan, Inc., Oakland, CA LUCIAN L. LEAPE, Adjunct Professor, Harvard School of Public Health, Boston, MA ARTHUR LEVIN, Director, Center for Medical Consumers, New York, NY RHONDA ROBINSON-BEALE, Executive Medical Director, Managed Care Manage­ ment and Clinical Programs, Blue Cross Blue Shield of Michigan, Southfield JOSEPH E. SCHERGER, Associate Dean for Primary Care, University of California, Irvine College of Medicine ARTHUR SOUTHAM, President and CEO, Health Systems Design, Oakland, CA MARY WAKEFIELD, Director, Center for Health Policy, Research, and Ethics, George Mason University, Fairfax, VA GAIL L. WARDEN, President and CEO, Henry Ford Health System, Detroit, MI Study Staff JANET M. CORRIGAN, Director, Quality of Health Care in America Project Director, Board on Health Care Services, MOLLA S. DONALDSON, Project Codirector LINDA T. KOHN, Project Codirector SHARI K. MAGUIRE, Research Assistant KELLY C. PIKE, Senior Project Assistant Auxiliary Staff MIKE EDINGTON, Managing Editor JENNIFER CANGCO, Financial Advisor Consultant RONA BRIER, Brier Associates, Inc. � � � 8

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