Online Marketplace

 

Advertise here

Quality of Care and Patient Safety

Bruce Balfe, Matthew Fitzgerald, MPH, DrPH

The science of quality improvement as applied to health care was introduced in the late 1980s. The approach is simple in its quasi-experimental design (typically lacking a control group) involving careful observation through performance measurement, the introduction of some tool, strategy or system expected to increase the quality of care, followed again by careful measurement to quantify the impact of the interventions. The principles of quality improvement have been more traditionally applied to manufacturing processes and their application to the highly complex world of healthcare delivery has been challenging. However over the past 20 years, health care quality improvement has evolved from an innovation for early adapters to an organizational imperative, almost universally practiced by hospitals. In the current environment of public reporting, pay-for-performance and increased accountability for quality and value, a rigorous application of quality improvement is increasingly becoming a standard component of hospital administration. Other delivery modalities are beginning to engage in quality improvement but have not yet reached the sophistication of acute care facilities. The ambulatory care environment is particularly challenged by the rigors of quality improvement, and hence have been the slowest to adopt it.

Defining and measuring the quality of medical care has been rapidly evolving over the past several decades. Initially the concept of defining and measuring quality was met with considerable resistance from health care providers but as measurement validity, precision and frequency increased so has acceptance. More recently, this concept has begun to transform continuing medical education programs, from a traditional didactic approach emphasizing credentialing and documenting attendance to programs where measuring actual performance and outcomes and the change therein are a key component.

In recent years, national attention has been focused on the quality delivered by our healthcare system. For example according to the Dartmouth Atlas “Tracking the Care of Patients with Severe Chronic Illnesses”, patients with chronic illnesses receive very different care, depending upon where patients live and which hospital or health care system the are loyal to. For example, the frequency of referrals to medical specialist per Medicare enrollee may vary by a factor more then five depending on your location. Spending on patients with serious chronic illness varies by a factor of nearly three.

Trends - Quality

• Increasingly, measuring actual performance and outcomes will be the goal of quality of care systems. A transition period will likely include a mix of input and process measures as well as outcome measures since outcome measures are harder to develop, get consensus on, and implement.

• Traditional measures based on education and training credentials and performance in continuing education will continue but will be a baseline rather than an end point in the quality of care arena. Increasingly, continuing medical education will be referred to as continuing professional development to encompass the broader context of quality of care.

• Performance measures are the building blocks of the quality of care effort and medical societies will continue to be the leaders in developing and maintaining them. In order to be sufficiently usable, performance measures will need to be specialty-specific and thus specialty societies will be leaders in this effort.

• However, in order to be useful in a system-wide approach there also needs to be general agreement across specialties on format and what constitutes a good performance measure. Umbrella organizations such as the AMA need to play a strong role in developing and maintaining the standards for performance measures.

• Implementing quality standards is easier in institutional settings. Hospitals and large group practices will find it easier to implement quality standards on a broad scale because they have the infrastructure and resources to implement them. However, in order to be fully effective, eventually all practices will have to be part of the system.

• The implementation of quality standards will be incremental in nature and will involve some false starts. An organized and coordinated effort is needed to learn from the mistakes that are made along the way.

• The implementation of quality of care standards and systems will increasingly be linked to payment systems. In many cases, the payment dimension will distort the real intent and effect of the quality measures and be transformed into cost reduction too ls. It will be up to the profession of medicine and their organizations to ensure that real quality of care is not hijacked by purely economic objectives

Patient Safety

The Institute of Medicine in its 2001 report, To Err is Human, shed light on the inadequacies of our health care system from a safety perspective. Although estimates of the injury, illness and death caused by healthcare itself vary greatly, it is generally accepted that safety is an area of great potential improvement in health care. Concurrent with this national focus on patient safety has been the realization that quality and safety deficiencies are mainly a systems problem which requires a systems approach to resolve. Patient safety is an important part of the overall quality movement because it is one of the easier dimensions of quality to measure and address. However it does involve a paradigm shift from personal competence and culpability towards team based care and a systems approach to care delivery.

It is generally accepted that a team approach is needed to achieve real progress in the quality and patient safety arena. However, before this effort can really mature in a system-wide fashion, some enabling steps are necessary. There must be a critical mass of generally agreed upon performance measures and information technology tools must be developed to support interoperable electronic medical records and usable quality of care data bases. This movement is happening incrementally and will be linked more and more with payment systems so that “value” becomes the operable concept that is discussed in healthcare policy development.

Trends:

• The medical profession has heretofore focused on personal competence and accountability in which the physician is always responsible for the patient’s safety. This paradigm is evolving towards a systems approach in which healthcare teams are responsible for care, and they are supported by systems that reinforce delivery of proper care.

• A systems approach to safety is being introduced to health care and success in the fields of aviation; nuclear energy and anesthesia are being applied more broadly to healthcare delivery.

• Failure Modes Effect Analysis, an engineering approach to examining possible failure modes and mitigating their impact is now being applied comprehensively in hospitals (a Joint Commission requirement).
  
  
• There is an increasing focus on human fatigue and the role that plays in jeopardizing patient safety. Increasingly stringent guidance for the hours health- care professionals may work, particularly for interns and fellows, is being published and implemented.

• Standardization of care is seen as a key to enhancing patient safety and this is pervading all aspects of care design including standardization of the hospital room where each room is an exact duplicate designed with the care processes in mind.