The Institute of Medicine released two seminal reports in 1999 and 2001.The first report, To Err is Human: Building a Safer Health System released in 1999 received enormous publicity and focused attention on the issues of medical error and patient safety. However, the second report, Crossing the Quality Chasm: A New Health System for the 21st Century, released in 2001 received significantly less attention, but had more import regarding needed focus on specific quality issues and accompanying changes in the health care system that need to occur.
Specifically, the Crossing the Quality Chasm report indicated that all "health care organizations...should adopt 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."” While not identical, the AHA mission statement closely parallels the IOM definition:
The mission of the AHA is to advance the health of individuals and communities. AHA leads, represents, and serves health care organizations that are accountable to the community and committed to health improvement.
But are we achieving “quality” and fulfilling our mission in the health care that we provide today? Can we easily answer the questions that AHA President Dick Davidson poses:
Are we providing the right health care services to the right patients?
How well are we providing those services?
To close the “chasm,” the IOM report suggests that the health care system focus on six aims: patient safety, effectiveness, patient-centeredness, timeliness, efficiency, and equitability. The IOM report further notes that by focusing on these six aims a transformation will begin to occur in the health system. Current approaches will be discarded in favor of new, more beneficial approaches in providing care to patients:
|CURRENT APPROACH||NEW APPROACH|
|Care is primarily based on visits.||Care is based on continuous healing relationships.|
|Professional autonomy drives variability.||Care is customized according to patient needs and values.|
|Professionals control care.||The patient is the source of control.|
|Information is a record.||Knowledge is shared and information flows freely.|
|Decision-making is based on training and experience.||Decision-making is evidence-based.|
|Do no harm is an individual responsibility.||Safety is a system property.|
|Secrecy is necessary.||Transparency is necessary.|
|The system reacts to needs.||Needs are anticipated.|
|Cost reduction is sought.||Waste is continuously decreased.|
|Preference is given to professional roles over the system.||Cooperation among clinicians is a priority.|
For this transformation to occur and to successfully address the six quality aims, hospitals and health care leaders will have to undertake a serious effort that will require them to systematically re-design the present systems and processes of care. Without this re-design, improvement efforts will fall short and the progress that needs to be made will not occur, and if it does occur, will not be able to be sustained. It is these quality aims and the emphasis on system re-design within the healthcare system that constitutes the AHA Quality Agenda, which is an integral part of our policy and advocacy agenda and directly reflects the priorities articulated in our mission statement. Through working collaboratively with our individual members as well as metro, regional and state hospital associations, we hope to not only be a part of this change, but to provide the essential leadership needed to have this transformation occur. Steps that have been taken by the AHA Board of Trustees in beginning this transformation include the development of AHA Principles of Accountability, and the Final Report of the AHA Taskforce on Quality and Patient Safety.
Safety is the fundamental cornerstone of the health care system. If care is not provided in a safe manner in a safe environment, the chances of a good outcome occurring is lessened significantly. As noted in the IOM report, “Patients should not be harmed by the care that is intended to help them, nor should harm come to those who work in health care.”
While the goal is to have the health care be safe at all times, it is clearly recognized that humans provide care and that errors can and do occur. Thus, the goal must be to prevent harm from reaching patients and those involved in providing care to those patients. To do so, requires everyone to be involved in identifying opportunities where patient care can be made safer. It also requires that everyone be continuously involved in learning from medical errors and “near misses.”
The real business of health care is about preventing ill-health, caring for people who are sick, meeting the needs of people who must live their lives with disabilities or chronic disease, and making people in communities healthier. As defined by the IOM report, this specific aim focuses “on the patient’s experience of illness and health care and on the systems that work or fail to work to meet individual patients’ needs.”
In work done by the Picker Institute and utilized in the 1996 AHA Eye on Patients report, several characteristics of patient-centered care have been identified: (1) respect for patients’ values, preference, and expressed needs; (2) coordination and integration of care; (3) information, communication, and education; (4) physical comfort; (5) emotional support; (6) involvement of family and friends; and (7) access.
While patients vary in their desire to be involved in their health care, all to often, patients feel excluded from discussions and decisions that affect them and the health care that they receive. As a consequence, patients then find their health care to be not only impersonal, but are often left confused and unsure as to what they need to do in regard to their health care.
In health care, the term “efficiency” is often mistaken to mean the withholding of health care services. This is not the focus in the IOM report. Instead, the report notes that there are two primary methods to increase the efficiency of the health care system: (1) reduce quality waste, and (2) reduce administrative or production costs.
Reducing quality waste means that practitioners and those responsible for providing health care services need to eliminate (a) overuse of those services where a “health care service is provided when the potential risks outweigh the benefits” and (b) medical errors. Reduction in administrative costs can occur through the elimination of duplicative paper work, redundant testing, and multiple re-entries of various types of practitioner orders.
The IOM report defines effectiveness as “care that is based on the use of systematically acquired evidence to determine whether an intervention, such as a preventive service, diagnostic test, or therapy, produces better outcomes than alternatives – including the alternative of doing nothing”. This premise is the foundation upon which “evidence-based medicine” rests.
As noted in the IOM report and by those who have written extensively about this concept, evidence-based medicine is “the integration of best research evidence with clinical expertise and patient values”. This definition represents the melding of three critical factors: (1) best research evidence – refers to a broad base of evidence that is derived from laboratory experiments, clinical trials, epidemiological research, and outcomes research; (2) clinical expertise – refers to the ability of the clinician to utilize his/her clinical skills and experience to rapidly evaluate each patient’s unique health state, to make a diagnosis, and to recommend interventions based upon knowledge of the respective risks and benefits; and (3) patient values – refers to each patient’s unique preferences, concerns, and expectations that are part of each clinical encounter.
One of the most significant improvement needs concerning effectiveness of care is in the areas of palliative care and care at the end-of-life. Nowhere do AHA's quality goals -- namely, helping people manage their own health and health care and asking "what care is right?" and -- converge more poignantly to confirm the need for providers and patients to work together to make care better.
Simply stated by the IOM, the “purpose of the health system is 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 focus of this sixth aim of the IOM report is that these benefits of the health care system should be available to all.
Equity occurs at two levels: (1) population – where disparities in the provision of health care services are to be reduced and eliminated for all subgroups, whether it be on the basis of race, ethnicity, or gender, and (2) individual – where each individual is treated on the basis of their needs in regard to availability of care and quality of services rather than on the basis of personal characteristics that are unrelated to their illness.
Delays have become a frequently accepted norm within health care today. Delays may pertain to long waits for appointments as well as long waits in waiting rooms. Delays also can mean problems in readily accessing patient test results or inability to provide treatments in a timely manner. Regardless, all of those involved in health care should be focusing on ensuring that patient care processes flow smoothly.
The IOM report was blunt in its assessment about the present capability of today’s health care systems: “The current care systems cannot do the job... Health care has safety and quality problems because it relies on outmoded systems of work. Poor designs set the workforce up to fail, regardless of how hard they try. If we want safer, higher-quality care, we will need to have redesigned systems of care...
There are a multitude of management tools that can be used in helping hospital leaders redesign their systems and processes of care. However, as the IOM report noted, any system re-design must meet six challenges:
1. Redesign of care processes
2. Make effective use of information technologies
3. Manage clinical knowledge and skills
4. Develop effective teams
5. Coordinate care across patient conditions, services, settings over time
6. Incorporate performance and outcome measurements for improvement and accountability
Re-design efforts that address these challenges and strive to meet the IOM six quality aims will need to thoughtfully apply the quality improvement lessons learned from other industries.