Crossing the Quality Chasm in Health Care

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Crossing the Quality Chasmin Health Care

• Harvey V. Fineberg, M.D., Ph.D.
• Inaugural Jorge Paulo Lemann Lecture
• Faculdade de Medicina
• Universidade de São Paulo
• 20 August 2007

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Pathways to Progressin Health Care

• Develop better things to do for patients
• Scientific discovery
• Product development
• Clinical trials
• Devise better ways to do what we already know
  should be done for patients
• Access to services, equipment, and facilities
• Efficiencies of production
• Improved quality

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IOM Study of Medical Errors
2000
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Response To IOM Errors Report

• 51 of the American public closely followed the
  media coverage (Kaiser Family Foundation, 2000)
• Congress appropriated 50 million for AHRQ
  patient safety center
• President Clintons call to action (DHHS Quality
  Interagency Coordinating Committee)
• Leapfrog Group reinforced and energized
• National Academy for State Health Policy
• Many national associations taking action

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IOM Study of Health Care Quality
2001
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Dimensions of Quality of Care

• Health care should be
• Safe
• Effective
• Patient-centered
• Timely
• Efficient
• Equitable

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Studies of Quality and Safety

• More than 70 studies document poor quality of
  care (Schuster et al, 1998 2000)
• More than 30 studies document medication errors
  (IOM, 2000)
• Large gaps between the care people should receive
  and the care they do receive
• true for preventive, acute and chronic
• across all health care settings
• all age groups and geographic areas

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Quality of Health Care Delivered to Adults in the
United States

• Methods
• Study of gt6700 participants in 12 metropolitan
  areas
• 439 indicators of quality for 30 conditions
• Selected Findings
• 46 did not receive recommended care
• 11 received potentially harmful care
• Only 24 of diabetics received 3 or more
  glycosylated Hgb tests over two-year period
• 65 of hypertensives receive recommended care
• Only 45 of persons with MI receive beta-blockers

McGlynn et al, N Engl J Med 2003 3482635-45
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Frequency and Consequences of Medical Injury
During Hospitalization

• Methods
• 18 patient safety indicators (from AHRQ)
• 994 acute care hospitals in 28 states in year
  2000
• 7.45 million hospital discharge abstracts
• Selected Findings
• 2.4 million extra days of hospitalization
• 9.3 billion excess charges
• gt32,000 attributable deaths

Zhan and Miller, JAMA 2003 2901868-74
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Studies of Errors AmongHospitalized Patients

• New York State (1984 data)
• 3.7 experience injury due to medical care
• 13.6 of injuries are fatal
• 58 of injuries are preventable
• Colorado and Utah (1992 data)
• 2.9 experience injury due to medical care
• 6.6 of injuries are fatal
• 53 of injuries are preventable

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Studies of Errors AmongHospitalized Patients

• Australia (1992 data)
• 16.6 experience injury or longer stay due to
  medical care
• 4.9 of injuries are fatal
• 51 of injuries are preventable

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Alternative Models to Apprehend Problems of
Safety and Quality

• Technology

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Alternative Models to Apprehend Problems of
Safety and Quality

• Technology
• Morality

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Alternative Models to Apprehend Problems of
Safety and Quality

• Technology
• Morality
• Rationality

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Alternative Models to Apprehend Problems of
Safety and Quality

• Technology
• Morality
• Rationality
• Psychology

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Alternative Models to Apprehend Problems of
Safety and Quality

• Technology
• Morality
• Rationality
• Psychology
• Education

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Alternative Models to Apprehend Problems of
Safety and Quality

• Technology
• Morality
• Rationality
• Psychology
• Education
• Systems

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The Doctor (1891) Fildes, Sir Luke (1843-1927)
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Ohio State University heart surgeons (1999)
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Systems Changes to Improve Quality

• Patientprovider interactions
• Microsystems or healthcare teams
• Health care organizations, e.g., hospitals,
  clinics, nursing homes, group practices
• External environment e.g., regulators, payers,
  accreditation organizations, other oversight
  organizations

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Organizational Supports for Change

• Redesign care processes
• Make effective use of information technologies
• Manage clinical knowledge and skills
• Develop effective teams
• Coordinate care across patient conditions,
  services and settings over time
• Measure and improve performance and outcomes

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Organizational Supports for Change

• Redesign care processes
• Make effective use of information technologies
• Manage clinical knowledge and skills
• Develop effective teams
• Coordinate care across patient conditions,
  services and settings over time
• Measure and improve performance and outcomes

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Redesign Care Processes

• System design using the 80/20 principle
• Design for safety
• Mass customization
• Continuous flow
• Production planning

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Redesign Care Processes

• System design using the 80/20 principle
• Design for safety
• Mass customization
• Continuous flow
• Production planning

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Does good design matter?
From Donald A. Norman, The Design of Everyday
Things
Jacques Carelmans Coffeepot for Masochists
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Safe Design

• Complex, tightly coupled systems are prone to
  error (Perrow, 1984 Reason, 1990)
• User-centered design principles (Norman, 1988)
• Visibility
• Simplicity
• Affordances and natural mappings
• Forcing functions
• Reversibility
• Standardization

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Making Anesthesia Safer

• Deaths from anesthesia in the U.S. have
  declined dramatically in the last 25 years.
• Early 1980s 1 per 10,000
• Today 1 per 200,000

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Making Anesthesia Safer

• 1985 Anesthesia Patient Safety Foundation
• Forum for health professionals, device
  manufacturers, regulatory bodies, and others
• Patient safety newsletter
• Seed grants in safety research
• New technology
• Pulse oximeter and capnometer
• Redesigned machines, standardized practice
  guidelines, improved training programs, hospital
  safety committees

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A New Environment for Care

• Applying evidence to health care delivery

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Applying Evidence to Health Care Delivery

• Ongoing analysis and synthesis of medical
  evidence
• Delineation of specific practice guidelines
• Enhanced dissemination of evidence and guidelines
  to the public and professions
• Decision support tools for clinicians and
  patients
• Identification of best practices in processes of
  care
• Development of quality measures for priority
  conditions

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A New Environment for Care

• Applying evidence to health care delivery
• Using information technology

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Using Information Technology

• Consumer health
• Clinical care
• Administration and finance
• Public health
• Professional education
• Research

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Core Functionalities for an Electronic Health
Record System

• Health information and data
• Results management
• Order entry/management
• Decision support management
• Electronic communication and connectivity
• Patient support
• Administrative processes
• Reporting population health

Institute of Medicine, July 2003
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A New Environment for Care

• Applying evidence to health care delivery
• Using information technology
• Aligning payment policies with quality improvement

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Aligning Payment Policies

• Investment to improve quality may be hard to
  justify on economic grounds alone
• Difficult to measure the impact of quality
  improvement on the financial bottom line
• Infrastructure investment required up front
  savings delayed
• Those who gain may differ from those who pay
• Many U.S. experiments underway to test the effect
  of differential payment for higher quality
  pay-for-performance
• Special payment for priority conditions

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A New Environment for Care

• Applying evidence to health care delivery
• Using information technology
• Aligning payment policies with quality
  improvement
• Preparing the workforce

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Preparing the Workforce

• Restructuring clinical education at first-stage,
  graduate, and continuing education for medical,
  nursing and other professionals.
• Implications for credentialing, funding and
  sponsorship of educational programs.

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Health Care 2010 Vision

• Population and Ecological Perspective community
  as well as individual
• Prevention and Public Health more than medical
  care alone
• Universal, Accessible, and Affordable not
  piecemeal coverage or unequal
• Person-centered not institution-centered
• Scientific, Innovative, and Evidence-based not
  anecdotal
• Entrepreneurial and Well-managed not ineptly
  administered
• Quality- and Value-driven not price-driven

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Toward Improved Health Care
Opinion Personal experience
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Toward Improved Health Care
Evidence Clinical Research
Opinion Personal experience
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Toward Improved Health Care
Standards Guidelines
Evidence Clinical Research
Opinion Personal experience
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Toward Improved Health Care
Use and Non-Use Practice
Standards Guidelines
Evidence Clinical Research
Opinion Personal experience
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Toward Improved Health Care
Quality and Safety Performance
Use and Non-Use Practice
Standards Guidelines
Evidence Clinical Research
Opinion Personal experience
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Toward Improved Health Care
Outcome and Cost Value
Quality and Safety Performance
Use and Non-Use Practice
Standards Guidelines
Evidence Clinical Research
Opinion Personal experience
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Key Points

• Quality and Safety are major challenges for
  health care
• Systems are a key organizing principle, and
  process redesign is a key strategy
• A superior health care system for the 21st
  century is within reach