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Crossing health care's quality chasm.

The safety and quality of health care today are far below the level we can and should achieve.

The Institute of Medicine, part of the National Academies, is a private organization that offers advice and recommendations to policy makers, health care professionals, and the general public on matters related to health.

Five years ago we produced an important report called "To Err Is Human." The report concluded that every year, tens of thousands of patients lose their lives in U.S. hospitals because of medical errors.

To put these numbers in perspective, if we counted medical errors as a cause of death, they would rank as 1 of the top 10 of causes of death in the United States.

The following year we released a second report, "Crossing the Quality Chasm." That report laid out a blueprint for the steps we can take to achieve higher quality and increased safety in our health care system.

This report describes six requirements for high-quality care: It must be safe, effective, centered on the needs of patients, delivered in a timely way, efficient, and equitable.

Behind these two reports are literally scores of studies documenting problems in the quality and safety of care, in virtually every setting: acute care, medical care, surgical care, chronic care, and preventive care.

In all regions, in both outpatient and inpatient settings, we repeatedly find preventable medical errors and deficiencies in patient safety.

There are several ways to think about this problem. When we focus on each physician's duty to individual patients, we may think about improving the selection and training of physicians. The idea here is that if physicians have a stronger ethical commitment to their patients, they won't make these mistakes.

A second model suggests that to achieve quality care, you need to offer incentives that lead to better quality, such as pay for performance. Various forms of pay for performance are going forward in many health care settings, offering financial rewards, or in some cases imposing financial sanctions, to improve the quality of care.

A third model notes that physicians often make clinical decisions when they are exhausted, working under great time pressure, coping with their patients' intense emotions, and juggling several different tasks at once.

The solution could be to reduce the cognitive and psychological burdens that contribute to errors. For example, we could shorten shifts and add computerized information support.

A fourth model suggests that we need to fundamentally train physicians better and give them the kind of tools and clinical expert knowledge that would lead to better decisions.

In my opinion, each of these models is relevant and has something to contribute to the quality and safety of our health care system. But the analyses of those who have thought deeply about these issues suggest that all of these together will not be sufficient.

To really improve quality and safety, we must look at our situation from a systems perspective. This means that many errors aren't due to the failings of a single individual. In our current health care system, individuals, devices, and organizations all work together. Errors occur when necessary communications among all these components somehow fail.

We like to think of our health care system as fundamentally sound, although it produces an occasional error. In fact, we ought to think of this system as perfectly designed to produce the results it actually achieves.

When we learn that we have a 3% error rate, then we have to face the fact that our system is designed to produce three errors per 100 cases.

If we instead want three errors per 1 million cases, we have to redesign the system. We shouldn't focus on training clinicians who can do the right thing under all circumstances; instead, we should design systems that are incapable of doing the wrong thing.

Experts observe that any complex, tightly coupled system, such as an airplane or a hospital, is prone to error. All the parts are so closely related that one failure can cascade throughout the system, leading to a catastrophic failure.

When we approach medical safety from this perspective, we see that certain principles can help us design safer systems. For example, we could design equipment so that it can't be misused. We could design an oxygen valve so that it connects to the oxygen supply tube but won't connect to any other tubing.

Within health care, reasonless variation is the source of many errors. Perhaps we could learn from the airlines and other industries that have introduced standardized ways to carry out essential functions. Before an airplane takes off, the pilot goes through a standard checklist and does it the same way every time.

Why? Because consistency is the source of quality.

Anesthesiologists have standardized their practice patterns and dramatically reduced the risk of problems. During the 1980s, the risk of death due to general anesthesia was about 1 in 10,000; today it is closer to 1 in 200,000. To achieve this goal, they took a systematic look at safety issues and funded key research. They established a patient safety foundation where clinicians, device manufacturers, and regulatory bodies could freely discuss potential problems. Some important new technology, such as pulsoximetry, was developed. All these things together contributed to a much safer system of anesthesiology.

Today we could and should apply similar processes of communication, research, and standardization to other aspects of care.

Traditional concepts of medical ethics focus on a purely personal professional duty to one's patients. That is the foundation of our professional duty, and it is necessary so we can offer our patients the care they deserve, but it is not sufficient.

In addition, we need to develop practice guidelines that are based on evidence rather than opinions. In this way, we can develop standardized practice patterns that offer the best possible outcomes at an affordable cost for both our patients and for society.

DR. FINEBERG is president of the Institute of Medicine.

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Title Annotation:quality management
Author:Fineberg, Harvey V.
Publication:Clinical Psychiatry News
Geographic Code:1USA
Date:Apr 1, 2006
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