AHRQ Summit--Improving Health Care Quality for All Americans (continued)

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AHRQ Summit—Improving Health Care Quality for All Americans

Turning the Corner on Quality

Donald M. Berwick, M.D., M.P.P.
President and Chief Executive Officer
Institute for Healthcare Improvement

The Institute for Healthcare Improvement looks at the issue of quality on a worldwide level, underscoring even more critically the huge gaps we face.

It Is Hard To Improve What We Cannot See

The quality and disparity reports are turning an essential public light on the status of health care in the United States, including huge gaps not only within our Nation but, even more strikingly, in comparison to other industrialized countries.

Many organizations and agencies are to be commended for drawing national attention to the issues of health care quality and disparities:

The Agency for Healthcare Research and Quality (AHRQ) for its seminal reports on health care quality and disparities, and Dr. Clancy for her leadership in the field.
The Commonwealth Fund for the way it has captured public information on health care performance.
The Centers for Medicare & Medicaid Services (CMS) for making comparisons available to the public on its Web site.
The Institute of Medicine (IOM) for its leadership in driving the discussion of quality gaps and medical errors.
The National Quality Forum for its new standards of quality performance.

International comparisons really drive the point home of embarrassing gaps in U.S. health care. A study by the Commonwealth Fund reveals that the United States ranks last on measures of safety, efficiency, effectiveness, and equity compared to the other industrialized, English-speaking countries of Australia, Canada, New Zealand, and the United Kingdom. We must admit this first if we are to make progress.

We Need New, More Robust Theories To Change Habits

Our Nation is at a turning point. Quality measures have advanced the battle toward quality improvement. However, this is only the first step in a long war. True improvement will require fundamental changes in the theories, practices, and behaviors that drive the way we provide health care in this country.

Some of the dominant theories that drive our health care system are either inaccurate or not powerful enough to drive the type of change needed to improve quality and reduce gaps. We must turn away from the theory that pushes the costs of efficiency and quality on to the consumer—a solution that is both unethical and unscientific.

To address health care quality and disparities requires a fundamental redistribution of wealth nationwide and should not be put on the backs of individual consumers or providers.

Similarly, we cannot rely on systems that offer providers more money to try harder. The vast majority of providers are dedicated and hard working; they need payment mechanisms designed to support their performance, not to promote it.

In order to improve quality, we must have:

Transparency.
Specific, clear goals for improvement.
Leadership from the top ranks of our health care sector dedicated to advancing those goals.
Greater technical assistance to share improved knowledge of how to improve quality.

We are not there yet but can look to the past for successful examples, such as the Clean Air Act.

The 1999 IOM report on medical errors set benchmarks and the challenge to reduce medical errors by 50 percent. To date, however, only the Department of Veterans Affairs has adopted this challenge.

We need greater involvement from leaders in the medical community, not just from doctors but from boards of trustees and stewards of health care organizations. These are the people who must adopt goals and place them up front and center. We must also set standards as a Nation with tighter consequences to drive improvement.

In addition, we need to promote more technical assistance. The improvement of knowledge must become a public good. We cannot afford to keep reinventing the wheel.

We must identify and share better knowledge and understanding of ways to improve quality. Once shared, that knowledge must be applied consistently and reliably. We cannot have variability across practices.

When We Value the Patient at the Center of Care, Things Get Better

When the patient is at the center of care, everything improves—quality, outcomes, and even costs. However, redesigning delivery systems to be truly patient-centered requires subversive change:

It requires radical shifts in the way health care professionals work.
It means we must cede the autonomy of individual health care specialties and professions.
It means we must place the value on cooperation between providers—a cooperation built around one primary concern, the patient.

This is a real challenge—to value cooperation without suboptimizing individual health care professions.

We Can Improve Health Care Quality and Outcomes Significantly

We can turn the corner. We have the science-based methods from AHRQ and models of successful projects.

Eight months ago, the Iowa Healthcare Collaborative (IHC) called together its staff, looked at successful methods and programs, and translated that information into a new health care improvement campaign. Called the 100K Lives Campaign, it was based on a list of goals to reduce avoidable deaths, pain, and waiting that the IHC referred to as the "no needless" list.

The goal of the 100K Lives Campaign is to avoid 100,000 needless deaths by June 14, 2006. It institutes a set of science-based standards that AHRQ-supported research has shown to reduce unnecessary deaths. These include:

Using rapid response teams in hospitals.
Making cardiac infarction care reliable with correct drug and procedure standards.
Reducing adverse drug events, especially when patients are transferred from one unit or facility to another.
Reducing hospital-based infections.
Raising the angle of hospital beds for patients to avoid ventilator-associated pneumonia.
Instituting measures for patients who are immobilized to avoid pressure ulcers.

Evidence indicates that if 200 hospitals use these methods, 100,000 deaths can be averted; thus, this was the goal of the campaign. However, the response to this campaign has been far greater than anticipated. To date, 1,700 hospitals have enrolled in the campaign; and by the end of April 2005, enrollment is expected to top 2,000.

The 100K Lives Campaign Shows Health Care Providers Are Open to Change

The huge response to the 100K Lives Campaign demonstrates the degree to which hospitals and health care staff are open to positive goals, help, achievement, trust, and learning. They are eager to adopt positive changes that they can implement and understand.

Along with the hospitals that have enrolled in the program, numerous national organizations have signed onto it, such as the American Medical Association, American Nurses Association, Department of Veterans Affairs, other Federal agencies, and several large hospital systems.

Questions and Discussion

Are there common themes from the 100K Lives Campaign that can help inform the debate as to whether or not we are at a turning point regarding health care quality in this country?

The huge response to the campaign is unusually promising and suggests we are at a turning point. In addition, three themes have emerged from the responses and inquiries we get regarding the campaign:

There is extraordinary curiosity and interest in the details of how to improve quality and institute standards and practices on a practical level.
There is a recognition that we must maintain focus on quality and on improvements.
The lights really are turning on among executive level leaders in hospitals and health care systems.

How do we implement successful theories of change?

It is a great challenge to get an industry of this size to learn and change. We need to spread the knowledge of how to implement standards and improvement. We need to find new ways to communicate within organizations. We must see learning as a fundamental asset.

How do we get the message of health care quality improvement into medical education and training?

Although academic health centers are often accused of being slow to change, this is an unfair assessment. There is good leadership within these institutions that is open to change. The key to change in education is the establishment of new competencies focused on practice-based learning and systems-based practice. However, it is important to note that changes in education will affect future practices; we need more immediate change now, too.

Should we be recording information on infections and how to prevent them?

The Institute for Healthcare Improvement is interested in looking at new areas for progress. Infection should be one. We have the science on hand. The Centers for Disease Control and Prevention have the answers, and the data definitions are available as a public good.

There are excellent examples of continuous improvement philosophies from other industries, such as the automotive industry. They address ways to increase process improvements by looking at who is responsible for the system.

In the health care sector, if you look at who is responsible for the system, one of the answers is the board of trustees. And if you look at who is on the boards of trustees of major hospitals and health institutions, many of them are also members of local chambers of commerce and the National Association for Manufacturers.

We need to reach out to these groups, invite them to meetings such as this one, and get their members informed and involved to apply pressure for change.

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