Healthcare quality book vision strategy and tools

Elizabeth R. Ransom, Maulik S. Joshi, David B. Nash, and Scott B. Ransom, Editors

HEALTHCARE QUALITY BOOK

THETHETHE

SECOND EDITION

“Some of the best minds in healthcare” Nancy M. Schlichting, President and CEO, Henry Ford Health System

VISION, STRATEGY, AND TOOLS Revis

ed

and

Upda ted

QUALITY BOOK

(from the foreword)

HEALTHCARE QUALITY BOOK

THE

SECOND EDITION

AUPHA HAP Editorial Board

Sandra Potthoff, Ph.D., Chair University of Minnesota

Simone Cummings, Ph.D. Washington University

Sherril B. Gelmon, Dr.P.H., FACHE Portland State University

Thomas E. Getzen, Ph.D. Temple University

Barry Greene, Ph.D. University of Iowa

Richard S. Kurz, Ph.D. Saint Louis University

Sarah B. Laditka, Ph.D. University of South Carolina

Tim McBride, Ph.D. St. Louis University

Stephen S. Mick, Ph.D. Virginia Commonwealth University

Michael A. Morrisey, Ph.D. University of Alabama—Birmingham

Dawn Oetjen, Ph.D. University of Central Florida

Peter C. Olden, Ph.D. University of Scranton

Lydia M. Reed AUPHA

Sharon B. Schweikhart, Ph.D. The Ohio State University

Nancy H. Shanks, Ph.D. Metropolitan State College of Denver

Health Administration Press, Chicago

AUPHA Press, Washington, DC

HEALTHCARE QUALITY BOOK

THE

SECOND EDITION VISION, STRATEGY, AND TOOLS

Elizabeth R. Ransom, Maulik S. Joshi, David B. Nash, and Scott B. Ransom, Editors

Your board, staff, or clients may also benefit from this book’s insight. For more information on quantity discounts, contact the Health Administration Press Marketing Manager at (312) 424- 9470.

This publication is intended to provide accurate and authoritative information in regard to the subject matter covered. It is sold, or otherwise provided, with the understanding that the pub- lisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought.

The statements and opinions contained in this book are strictly those of the author(s) and do not represent the official positions of the American College of Healthcare Executives, of the Foundation of the American College of Healthcare Executives, or of the Association of University Programs in Health Administration.

Copyright © 2008 by the Foundation of the American College of Healthcare Executives. Printed in the United States of America. All rights reserved. This book or parts thereof may not be reproduced in any form without written permission of the publisher.

12 11 10 09 08 5 4 3 2 1

Library of Congress Cataloging-in-Publication Data

The healthcare quality book : vision, strategy, and tools / [edited by] Elizabeth R. Ransom ... [et al.].—2nd ed.

p. ; cm. Includes bibliographical references and index. ISBN 978-1-56793-301-7 (alk. paper) 1. Medical care—United States—Quality control. 2. Health services administration—

United States—Quality control. 3. Total quality management—United States. I. Ransom, Elizabeth R. [DNLM: 1. Quality of Health Care—organization & administration—United States. 2. Health Services Administration—United States. 3. Total Quality Management—organization & admin- istration—United States. W 84 AA1 H443 2008]

RA399.A3H433 2008 362.11068—dc22

2008017268

The paper used in this publication meets the minimum requirements of American National Standard for Information Sciences-Permanence of Paper for Printed Library Materials, ANSI Z39.48-1984. ∞™

Project manager: Jennifer Seibert; Acquisitions editor: Audrey Kaufman; Book designer: Scott R. Miller.

Health Administration Press Association of University Programs A division of the Foundation in Health Administration of the American College of 2000 14th Street North Healthcare Executives Suite 780

One North Franklin Street Arlington, VA 22201 Suite 1700 (703) 894-0940 Chicago, IL 60606 (312) 424-2800

CONTENTS IN BRIEF

FOREWORD..............................................................................................xiii

PREFACE...................................................................................................xv

III Science and Knowledge Foundation

1 Healthcare Quality and the Patient, by Maulik S. Joshi and Donald Berwick............................................................................3

2 Basic Concepts of Healthcare Quality, by Leon Wyszewianski ...................................................................................................25

3 Variation in Medical Practice and Implications for Quality, by David J. Ballard, Robert S. Hopkins III, and David Nicewander ...................................................................................................43

4 Quality Improvement: The Foundation, Processes, Tools, and Knowledge Transfer Techniques, by Kevin Warren ....................63

III Organization and Microsystem

5 Milestones in the Quality Measurement Journey, by Robert C. Lloyd .........................................................................87

6 Data Collection, by John J. Byrnes ..........................................109

7 Statistical Tools for Quality Improvement, by Jerod M. Loeb, Stephen Schmaltz, Linda S. Hanold, and Richard G. Koss ......131

8 Physician and Provider Profiling, by David B. Nash, Adam Evans, and Richard Jacoby ..................................................................169

9 Measuring and Improving Patient Experiences of Care, by Susan Edgman-Levitan .............................................................187

10 Dashboards and Scorecards: Tools for Creating Alignment, by Michael D. Pugh ......................................................................217

v

11 Patient Safety and Medical Errors, by Frances A. Griffin and Carol Haraden..........................................................................243

12 Information Technology Applications for Improved Quality, by Richard E. Ward .......................................................................269

13 Leadership for Quality, by James L. Reinertsen .......................311

14 Organizational Quality Infrastructure: How Does an Organization Staff Quality?, by A. Al-Assaf..............................331

15 Implementing Quality as the Core Organizational Strategy, by Scott B. Ransom, Thomas J. Fairchild, and Elizabeth R. Ransom .................................................................................................349

16 Implementing Healthcare Quality Improvement: Changing Clinician Behavior, by Valerie Weber and John Bulger ............377

IIII Environment

17 The Quality Improvement Landscape, by Jean Johnson, Ellen Dawson, and Kimberly Acquaviva ...................................407

18 Accreditation: Its Role in Driving Accountability in Healthcare, by Greg Pawlson and Paul Schyve............................................433

19 How Purchasers Select and Pay for Quality, by Francois de Brantes ..................................................................457

INDEX...................................................................................................475

ABOUT THE AUTHORS ...............................................................................491

C o n t e n t s i n B r i e fvi

DETAILED CONTENTS

FOREWORD..............................................................................................xiii

PREFACE ..................................................................................................xv

III Science and Knowledge Foundation

1 Healthcare Quality and the Patient, by Maulik S. Joshi and Donald Berwick............................................................................3 Important Reports........................................................................4 A Focus on the Patient .................................................................6 Lessons Learned in Quality Improvement....................................7 Case Study..................................................................................17 Conclusion .................................................................................21 Study Questions .........................................................................22 Notes ..........................................................................................22 References ..................................................................................23

2 Basic Concepts of Healthcare Quality, by Leon Wyszewianski...25 Definition-Related Concepts ......................................................25 Measurement-Related Concepts.................................................33 Implications................................................................................39 Study Questions .........................................................................39 Note ...........................................................................................40 References ..................................................................................40

3 Variation in Medical Practice and Implications for Quality, by David J. Ballard, Robert S. Hopkins III, and

David Nicewander ...............................................................43 Background and Terminology ....................................................45 Scope and Use of Variation in Healthcare..................................47 Clinical and Operational Issues ..................................................48 Keys to Successful Implementation and Lessons Learned from

Failures ................................................................................51 Case Study..................................................................................53 Conclusion .................................................................................56 Study Questions .........................................................................56 References ..................................................................................59

vii

4 Quality Improvement: The Foundation, Processes, Tools, and Knowledge Transfer Techniques, by Kevin Warren ....................63 The Quality Foundation.............................................................63 Quality Improvement Processes and Approaches .......................67 Quality Tools..............................................................................73 Knowledge Transfer and Spread Techniques ..............................76 Conclusion .................................................................................81 Study Questions .........................................................................81 Note ...........................................................................................82 References ..................................................................................82

III Organization and Microsystem

5 Milestones in the Quality Measurement Journey, by Robert C. Lloyd .........................................................................87 The Measurement Challenge......................................................88 Milestones Along the Quality Measurement Journey.................88 Conclusion ...............................................................................105 Study Questions .......................................................................105 Notes ........................................................................................105 References ................................................................................106

6 Data Collection, by John J. Byrnes ..........................................109 Categories of Data....................................................................109 Considerations in Data Collection ...........................................109 Sources of Data ........................................................................112 Case Study in Clinical Reporting .............................................123 Conclusion ...............................................................................127 Study Questions .......................................................................127 Acknowledgments ....................................................................127 Notes ........................................................................................128 References ................................................................................129 Suggested Reading ...................................................................129

7 Statistical Tools for Quality Improvement, by Jerod M. Loeb, Stephen Schmaltz, Linda S. Hanold, and Richard G. Koss ...........131 Fundamentals of Performance Measurement ...........................131 Control Chart Analysis .............................................................138 Comparison Chart Analysis ......................................................142 Using Data for Performance Improvement ..............................147 Conclusion ...............................................................................149 Study Questions .......................................................................150 Appendix 1: Control Chart Formulas ......................................150

D e t a i l e d C o n t e n t sviii

D e t a i l e d C o n t e n t s

Appendix 2: Comparison Chart Formulas................................154 Appendix 3: Case Studies .........................................................158 Notes ........................................................................................166 References ................................................................................166

8 Physician and Provider Profiling, by David B. Nash, Adam Evans, and Richard Jacoby ..................................................................169 Background and Terminology ..................................................169 Scope and Use of Profiling in Healthcare ................................171 Keys to Successful Implementation and Lessons Learned ........178 Case Study................................................................................179 Study Questions .......................................................................183 References ................................................................................184

9 Measuring and Improving Patient Experiences of Care, by Susan Edgman-Levitan .............................................................187 Regulatory and Federal Patient Survey Initiatives....................188 Using Patient Feedback for Quality Improvement...................190 Scope and Use of Patient Experiences in Healthcare ...............197 Keys to Successful Implementation .........................................204 Lessons Learned, or “The Roads Not to Take” .......................206 Case Study................................................................................210 Conclusion ...............................................................................212 Study Questions .......................................................................212 Notes ........................................................................................212 References ................................................................................213 Other Useful Resources............................................................214

10 Dashboards and Scorecards: Tools for Creating Alignment, by Michael D. Pugh ......................................................................217 Background and Terminology ..................................................217 Scope and Use of Dashboards and Scorecards in Healthcare ...219 Clinical and Operational Issues ................................................225 Keys to Successful Implementation and Lessons Learned ........230 Case Study: St. Joseph Hospital ...............................................236 Conclusion ...............................................................................238 Study Questions .......................................................................241 Notes ........................................................................................242 References ................................................................................242

11 Patient Safety and Medical Errors, by Frances A. Griffin and Carol Haraden..........................................................................243 Background and Terminology ..................................................243 Scope and Use in Healthcare Organizations ............................247

ix

Clinical and Operational Issues ................................................258 Case Study: OSF Healthcare System ........................................261 Conclusion ...............................................................................266 Study Questions .......................................................................267 References ................................................................................267

12 Information Technology Applications for Improved Quality, by Richard E. Ward .......................................................................269 Background and Terminology ..................................................269 Taking a Lesson from Other Industries....................................272 The Emerging Field of Medical Informatics ............................274 Two Tiers of Clinical Information Technologies......................274 Technologies for Different Types of Clinical Care

Management Initiatives .....................................................278 Requirements and Architecture Framework for Clinical

Information Technology....................................................279 Workflow Automation Technology Applied to

Clinical Processes...............................................................284 Other Clinical Information Technology Components .............286 Information Needed for Practice Improvement on a

National Level....................................................................289 Case Examples ..........................................................................291 Overall Return on Investment of Clinical

Information Systems..........................................................295 Key Strategy Debates................................................................301 The Challenge ..........................................................................306 Study Questions .......................................................................309 References ................................................................................309

13 Leadership for Quality, by James L. Reinertsen .......................311 Background ..............................................................................311 Scope and Use of Leadership Concepts in Healthcare .............315 Clinical and Operational Issues ................................................319 Keys to Successful Quality Leadership and Lessons Learned ...320 Case Study of Leadership: Interview with

William Rupp, MD ............................................................322 Conclusion ...............................................................................327 Study Questions .......................................................................327 Notes ........................................................................................327 References ................................................................................328

14 Organizational Quality Infrastructure: How Does an Organization Staff Quality?, by A. Al-Assaf..............................331 Quality Assurance, Quality Improvement, Quality Control, and

D e t a i l e d C o n t e n t sx

D e t a i l e d C o n t e n t s

Total Quality Management................................................331 Management Commitment ......................................................332 Allocation of Resources ............................................................335 Organizational Structure ..........................................................336 Increasing Awareness of Healthcare Quality ............................338 Mapping Quality Improvement Intervention...........................338 Challenges, Opportunities, and Lessons Learned for Sustaining

QA/QI ..............................................................................342 Case Example ...........................................................................345 Study Questions .......................................................................346 References ................................................................................346 Suggested Reading ...................................................................347

15 Implementing Quality as the Core Organizational Strategy, by Scott B. Ransom, Thomas J. Fairchild, and

Elizabeth R. Ransom .........................................................349 Implementing Quality in Healthcare Organizations ................352 Case Study: An Academic Medical Center’s

Quality Journey .................................................................363 Conclusion ...............................................................................373 Study Questions .......................................................................373 Notes ........................................................................................374 References ................................................................................374

16 Implementing Healthcare Quality Improvement: Changing Clinician Behavior, by Valerie Weber and John Bulger ............377 Understanding Change Management in Healthcare ................377 Active Implementation Strategies.............................................384 Addressing the Cost of Implementation...................................391 Keys to Successful Implementation and Lessons Learned ........393 Case Studies .............................................................................394 Conclusion ...............................................................................399 Study Questions .......................................................................399 Note .........................................................................................399 References ................................................................................400

III Environment

17 The Quality Improvement Landscape, by Jean Johnson, Ellen Dawson, and Kimberly Acquaviva ...................................407 Quality Improvement Organizations........................................407 Drivers of Quality.....................................................................408 Measurement Development Process.........................................413

xi

Trends in Quality Improvement...............................................415 Trends and Initiatives in Specific Healthcare Sectors ...............419 Case Studies .............................................................................425 Conclusion ...............................................................................428 Study Questions .......................................................................429 References ................................................................................429

18 Accreditation: Its Role in Driving Accountability in Healthcare, by Greg Pawlson and Paul Schyve............................................433 Background and Terminology ..................................................433 Scope and Use of Accreditation in Healthcare:

Successes and Failures........................................................436 The Future of Accreditation: Challenges and Changes ............443 Conclusion ...............................................................................452 Study Questions .......................................................................452 Notes ........................................................................................452 References ................................................................................453 Other Useful Resources............................................................454

19 How Purchasers Select and Pay for Quality, by Francois de Brantes ...............................................................457

Background and Terminology ..................................................458 Case Study: Bridges to Excellence: Building a Real Business

Case for Better Quality Care .............................................460 Defining the Program Specifications—Measures, Specific

Incentives, and Consumer-Focused Elements ...................464 Designing the Program’s Implementation ...............................470 Program Evolution ...................................................................471 Conclusion and Key Lessons ....................................................471 Study Questions .......................................................................472 Notes ........................................................................................472 References ................................................................................472

INDEX ..................................................................................................475

ABOUT THE AUTHORS ....................................................................................

D e t a i l e d C o n t e n t sxii

FOREWORD

Nancy M. Schlichting

There has never been a more important and exciting time in the journey to achieve excellence in healthcare quality. After more than eight years since the Institute of Medicine released its groundbreaking report, To Err Is Human: Building a Safer Health System, on the poor state of healthcare quality in the United States, there is significant momentum for fundamen- tal change to improve quality. The momentum is being felt in a number of important venues:

• In the government world, as legislators and administrators are working to increase the incentives for quality in governmental programs

• In the business world, as companies are redesigning health benefit plans to encourage more involvement of the employees in their choice of health- care providers based on performance

• In the insurance world, as health plans are evaluating providers based on quality indicators

• In the provider world, as hospitals and physicians are investing in new infor- mation technology to provide more consistent and safer quality of care for their patients

• In the consumer world, as individuals are seeking out information about quality before choosing a physician, a hospital, or a health plan

The importance of this momentum cannot be overstated. It will cre- ate enormous opportunities for learning that can be spread across the coun- try, more alignment of incentives among all stakeholders, more informed consumers, and greater availability of accurate and useful information for decision making.

The second edition of The Healthcare Quality Book is a resource for all learners and participants in this critical process of change. It is a guide for quality improvement that incorporates both theoretical models and practical approaches for implementation. The editors have brought together some of the best minds in healthcare to offer insights on leadership strat- egy, tools, organizational design, information technology, legal and reg- ulatory issues, and, most important, the patient experience. The Healthcare Quality Book will serve all who have a passion for changing the quality

xiii

paradigm and creating an ideal patient and family experience. Now is the time for action! The editors of The Healthcare Quality Book are providing the necessary resources. I am confident the readers will be part of the healthcare quality solution.

Nancy M. Schlichting President and CEO

Henry Ford Health System Detroit, Michigan

F o r e w o r dxiv

PREFACE

Change is constant, and no statement is more appropriate for the health- care industry. Since the first edition of this textbook, healthcare costs have increased beyond the rate of inflation, the number of uninsured individu- als has grown dramatically, employers and consumers are facing a greater share of healthcare expenses, and navigation of the complex and compli- cated healthcare system has become a burden on the public. Our health- care crisis permeates every aspect of the industry—the delivery of medical care, the financing of our system, and the quality of healthcare we receive.

In our fragmented, unsustainable, and uncertain healthcare system, one element remains steadfast—healthcare quality is paramount. Healthcare that is safe, effective, efficient, equitable, patient centered, and timely is fundamen- tal to all potential healthcare reform plans—big or small, national or regional.

This textbook provides a framework, a context, strategies, and prac- tical tactics for all stakeholders to understand, learn, teach, and lead health- care improvement. We have assembled an internationally prominent group of contributors for the best available current thinking and practices in each of their disciplines.

This edition has evolved from the first. New case studies have been added, up-to-date content has been included, new study questions have been posed, and a new chapter has been added. The framework of the book remains constant. Chapters 1 through 4 discuss foundational healthcare quality principles. Chapters 5 through 16 discuss critical quality issues at the organizational and microsystem levels. Chapters 17 through 19 detail the influence the environment has on the organizations, teams, and indi- viduals delivering healthcare services and products.

In Chapter 1, Maulik Joshi and Donald Berwick center on the patient and articulate key findings from national, sentinel reports of healthcare qual- ity over the last ten years. In Chapter 2, Leon Wyszewianski discusses the fundamental concepts of quality. In Chapter 3, David Ballard and colleagues discuss medical practice variation and provide an updated case study, and Kevin Warren has revised Chapter 4 to reflect the latest quality improvement tools and programs.

In Chapter 5, Robert Lloyd discusses measurement as a building block in quality assessment and improvement. John Byrnes focuses on data collection and its sources in Chapter 6, and Jerod Loeb and colleagues discuss analytic opportunities in quality data in Chapter 7. In Chapter 8, David Nash and col- leagues detail a physician profiling system. In Chapter 9, Susan Edgman-Levitan tackles an often discussed but less understood area of patient satisfaction—expe- riences and perspectives of care—and includes an update on the latest surveys. In Chapter 10, Michael Pugh aggregates data into a management tool called the Balanced Scorecard. Frances Griffin and Carol Haraden in Chapter 11 and

xv

Richard Ward in Chapter 12 dive deeper into two evolving subjects essential to driving performance improvement—patient safety and information technology, respectively. Chapters 13 through 15, by James Reinertsen, A. Al-Assaf, and Scott Ransom and colleagues, provide a triad of keys for change in organiza- tions seeking to become high performers. The triad represents leadership, infra- structure, and strategy for quality improvement. Chapter 16, by Valerie Weber and John Bulger, is a compilation of strategies and tactics necessary to change staff behavior.

Chapter 17, by Jean Johnson and colleagues, a new chapter, pro- vides examples of many of the recent national quality improvement initia- tives and an overview of the quality improvement landscape. In Chapter 18, Greg Pawlson and Paul Schyve collaborate to summarize the work of the two major accrediting bodies within healthcare—the National Committee for Quality Assurance and The Joint Commission—and cover the latest changes in the accreditation process. The book concludes with an impor- tant chapter by Francois de Brantes on the power of the purchaser to select and pay for quality services, which he has updated to provide the latest information on pay for performance.

Several of these chapters could stand independently. Each represents an important contribution to our understanding of the patient-centered organizations and environment in which healthcare services are delivered. The science and knowledge on which quality measurement is based are changing rapidly. This book provides a timely analysis of extant tools and techniques.

Who should read this book? The editors believe all current stakeholders would benefit from reading this text. The primary audiences for the book are undergraduate and graduate students in healthcare and business administration, public health programs, nursing programs, allied health programs, and programs in medicine. As leadership development and continuing education programs proliferate, this textbook is a resource for executives and practitioners at the front line. We hope this book will break down the educational silos that currently pre- vent stakeholders from sharing equally in their understanding of patient-cen- tered organizational systems and the environment of healthcare quality.

This textbook and the accompanying instructor manual are designed to facilitate discussion and learning. There are study questions at the end of each chapter in the textbook. The instructor manual contains answers to the study questions and a PowerPoint presentation for each chapter as a teaching aid. For access information, e-mail hap1@ache.org.

Please contact us at doctormaulikjoshi@yahoo.com. Your feedback, your teaching, your learning, and your leadership are essential to raising the bar in healthcare.

Elizabeth R. Ransom Maulik S. Joshi David B. Nash Scott B. Ransom

P r e f a c exvi

I PART

SCIENCE AND KNOWLEDGE FOUNDATION

HEALTHCARE QUALITY AND THE PATIENT Maulik S. Joshi and Donald Berwick

Quality in the U.S. healthcare system is not what it should be. Peoplewere aware of this issue for years from personal stories and anec-dotes. Around the end of the last century, three major reports revealed evidence of this quality deficiency:

• The Institute of Medicine’s (IOM) National Roundtable on Health Care Quality report, “The Urgent Need to Improve Health Care Quality” (Chassin and Galvin 1998)

• To Err Is Human (Kohn, Corrigan, and Donaldson 2000) • IOM’s Crossing the Quality Chasm (IOM 2001)

These three reports made a tremendous statement and called for action on the state of healthcare, its gaps, and the opportunity to improve its quality in the United States to unprecedented levels.

Before we begin discussion of these reports, however, let us begin by defining quality, its evolution, and its implications on our work as health- care professionals.

Avedis Donabedian, one of the pioneers in understanding approaches to quality, discussed in detail the various definitions of quality in relation to perspective. Among his conceptual constructs of quality, one view of Donabedian’s (1990) rang particularly true: “The balance of health bene- fits and harm is the essential core of a definition of quality.” The question of balance between benefit and harm is empirical and points to medicine’s essential chimerism: one part science and one part art (Mullan 2001).

The IOM Committee to Design a Strategy for Quality Review and Assurance in Medicare developed an often-cited definition of quality (Lohr 1990):

Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. . . . How care is provided should reflect appropriate use of the most current knowledge about scientific, clinical, technical, interpersonal, manual, cognitive, and organization and management elements of health care.

In 2001, Crossing the Quality Chasm stated powerfully and simply that healthcare should be safe, effective, efficient, timely, patient centered,

1 CHAPTER

3

and equitable. This six-dimensional aim, which will be discussed later in this chapter, provides the best-known and most goal-oriented definition, or at least conceptualization, of the components of quality today.

Important Reports

In 1998, the Journal of the American Medical Association’s National Roundtable report included two notable contributions to the industry. The first was its assessment of the state of quality. “Serious and widespread quality problems exist throughout American medicine. These problems . . . occur in small and large communities alike, in all parts of the country, and with approximately equal frequency in managed care and fee-for-service systems of care. Very large numbers of Americans are harmed.” The second contribution to the knowl- edge base of quality was a categorization of defects into three broad cate- gories: overuse, misuse, and underuse. The classification scheme of underuse, overuse, and misuse has become a common nosology for quality defects.

Underuse is evidenced by the fact that many scientifically sound prac- tices are not used as often as they should be. For example, biannual mam- mography screening in women ages 40 to 69 has been proven beneficial and yet is performed less than 75 percent of the time.

Overuse can be seen in areas such as imaging studies for diagnosis in acute asymptomatic low back pain or the prescription of antibiotics when not indicated for infections, such as viral upper respiratory infections.

Misuse is the term applied when the proper clinical care process is not executed appropriately, such as giving the wrong drug to a patient or incorrectly administering the correct drug.

Many reports have identified the gap between current and optimal healthcare practice. The studies range from evidence of specific processes falling short of the standard (e.g., children not receiving all their immu- nizations by age two) to overall performance gaps (e.g., risk-adjusted mor- tality rates in hospitals varying fivefold) (McGlynn et al. 2003).

Although the healthcare community knew of many of these quality- related challenges for years, the 2000 publication To Err Is Human exposed the severity of the problems in a way that captured the attention of all key stakeholders for the first time.

The executive summary of To Err Is Human began with these head- lines (Kohn, Corrigan, and Donaldson 2000):

• Betsy Lehman, a health reporter for the Boston Globe, died from an over- dose during chemotherapy.

• Ben Kolb, an eight-year-old receiving minor surgery, died due to a drug mix-up.

• As many as 98,000 people die every year in hospitals as a result of injuries from their care.

4 T h e H e a l t h c a r e Q u a l i t y B o o k

• Total national costs of preventable adverse events are estimated between $17 billion and $29 billion, of which health care costs are over one-half.

These data points focused on patient safety and medical errors as per- haps the most urgent forms of quality defect. Although many had spoken about improving healthcare, this report spoke about the negative—it framed the prob- lem in a way that everyone could understand and demonstrated that the situ- ation was unacceptable. One of the basic foundations for this report was a Harvard Medical Practice study done more than ten years earlier. For the first time, patient safety (i.e., ensuring safe care and preventing mistakes) became a solidifying force for policymakers, regulators, providers, and consumers.

In March 2001, soon after the release of To Err Is Human, IOM released Crossing the Quality Chasm, a more comprehensive report offer- ing a new framework for a redesigned U.S. healthcare system. Crossing the Quality Chasm provided a blueprint for the future that classified and uni- fied the components of quality through six aims for improvement, chain of effect, and simple rules for redesign of healthcare.

The six aims for improvement, viewed also as six dimensions of qual- ity, are as follows (Berwick 2002):

1. Safe: Care should be as safe for patients in healthcare facilities as in their homes.

2. Effective: The science and evidence behind healthcare should be applied and serve as the standard in the delivery of care.

3. Efficient: Care and service should be cost effective, and waste should be removed from the system.

4. Timely: Patients should experience no waits or delays in receiving care and service.

5. Patient centered: The system of care should revolve around the patient, respect patient preferences, and put the patient in control.

6. Equitable: Unequal treatment should be a fact of the past; disparities in care should be eradicated.

These six aims for improvement can be translated into respective outcome measures and goals. The following points are examples of the types of global measures that can be used to track IOM’s six aims.

• Safe care may be measured in terms of the percentage of overall mortal- ity rates or patients experiencing adverse events or harm.

• Effective care may be measured by how well evidenced-based practices are followed, such as the percentage of time diabetic patients receive all recommended care at each doctor visit, the percentage of hospital-acquired infections, or the percentage of patients who develop pressure ulcers (bed sores) while in the nursing home.

• Efficient care may be measured by analyzing the costs of care by patient, by organization, by provider, or by community.

C h a p t e r 1 : H e a l t h c a r e Q u a l i t y a n d t h e P a t i e n t 5

• Timely care may be measured by waits and delays in receiving needed care, service, and test results.

• Patient-centered measures may include patient or family satisfaction with care and service.

• Equitable care may be viewed by examining differences in quality meas- ures (such as measures of effectiveness and safety) by race, gender, income, or other population-based demographic and socioeconomic factors.

The underlying framework for achieving these aims for improvement depicts the healthcare system in four levels, all of which require changes. Level A is what happens with the patient. Level B reflects the microsystem where care is delivered by small provider teams. Level C is the organiza- tional level—the macrosystem or aggregation of the microsystems and sup- porting functions. Level D is the external environment where payment mechanisms, policy, and regulatory factors reside. Figure 1.1 provides a picture of these four cascading levels. The environment affects how organizations operate, which affects the microsystems housed in them, which in turn affect the patient. “True north” in the model lies at Level A, in the experience of patients, their loved ones, and the communities in which they live (Berwick 2002).

A Focus on the Patient

All healthcare professionals and organizations exist to serve their patients. Technically, medicine has never had more potential to help than it does today. The number of efficacious therapies and life-prolonging pharmaceu-

6

FIGURE 1.1 Four Levels of the Healthcare

System

Environment Level D

Organization Level C

Microsystem Level B

Patient Level A

SOURCE: Ferlie and Shortell (2001). Used with permission.

T h e H e a l t h c a r e Q u a l i t y B o o k

tical regimens has exploded. Yet, the system falls short of its technical poten- tial. Patients are dissatisfied and frustrated with the care they receive. Providers are overburdened and uninspired by a system that asks too much and makes their work more difficult. Society’s attempts to pay for and prop- erly regulate care add complexity and even chaos.

Demands for a fundamental redesign of the U.S. healthcare system are ever increasing. IOM proposed that a laser-like focus on the patient must sit at the center of efforts to improve and restructure healthcare. Patient-centered care is the proper future of medicine, and the current focus on quality and safety is a step on the path to excellence.

Today, patients’ perception of the quality of our healthcare system is not favorable. In healthcare, quality is a household word that evokes great emotion, including:

• frustration and despair, exhibited by patients who experience healthcare serv- ices firsthand or family members who observe the care of their loved ones;

• anxiety over the ever-increasing costs and complexities of care; • tension between individuals’ need for care and the difficulty and incon- venience in obtaining care; and

• alienation from a care system that seems to have little time for under- standing, much less meeting, patients’ needs.

To illustrate these issues, we will examine in depth the insights and experiences of a patient who has lived with chronic back pain for almost 50 years and use this case study to understand the inadequacies of the current delivery system and the potential for improvement. This case study is repre- sentative of the frustrations and challenges of the patients we are trying to serve and reflective of the opportunities that await us to radically improve the healthcare system. (See the section titled “Case Study” later in the chapter.)

Lessons Learned in Quality Improvement

We have noted the chasm in healthcare as it relates to quality. This chasm is wide, and the changes to the system are challenging. An important mes- sage is that changes are being made, patient care is improving, and the health of communities is beginning to demonstrate marked improvement. Let us take this opportunity to highlight examples of improvement proj- ects in various settings to provide insight into the progress.

Improvement Project: Improving ICU Care 1

One improvement project success story took place in 2002 in the inten- sive care unit (ICU) at Dominican Hospital in Santa Cruz County, California. Dominican, a 379-bed community hospital, is part of the 41- hospital Catholic Healthcare West system.

7C h a p t e r 1 : H e a l t h c a r e Q u a l i t y a n d t h e P a t i e n t

8

FIGURE 1.2 Improving

Critical Care Processes:

Mortality Rates and Average

Ventilator Days

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

1.8

2.0

Aug. 02

IC U

M or

ta li

ty R

at e:

A P

A CH

E II

IS co

re

Sep. 02 Oct. 02 Nov. 02 Dec. 02 Jan. 03 Feb. 03

•

•

•

•

•

•

Trendline

Goal = 0.76

0

1

2

3

4

5

6

7

Mar. 02

A ve

ra ge

M ec

ha ni

ca lV

en ti

la to

r D

ay s

Apr. 02

May 02

Jun. 02

Jul. 02

Aug. 02

Sep. 02

Oct. 02

Nov. 02

Dec. 02

Jan. 03

Feb. 03

Trendline

Goal = 4.0

SOURCE: Dominican Hospital, Santa Cruz, CA. Used with permission.

The staff in Dominican Hospital’s ICU learned an important lesson about the power of evidence over intuition. “We used to replace the venti- lator circuit for intubated patients daily because we thought this helped to prevent pneumonia,” explained Lee Vanderpool, vice president. “But the evidence shows that the more you interfere with that device, the more often you risk introducing infection. It turns out it is often better to leave it alone until it begins to become cloudy, or ‘gunky,’ as the nonclinicians say.”

The importance of using scientific evidence reliably in care was just the sort of lesson that healthcare professionals at Dominican had been learn- ing routinely for more than a decade as they pursued quality improvement throughout the hospital. Dominican’s leaders focused on improving criti- cal care processes, and their efforts improved mortality rates, average ven- tilator days, and other key measures (see Figure 1.2).

T h e H e a l t h c a r e Q u a l i t y B o o k

Ventilator Bundling and Glucose Control

After attending a conference in critical care, Dominican staff began to focus on a number of issues in the ICU. “The first thing we tackled was venti- lator bundling,” said Glenn Robbins, RPh, responsible for the day-to-day process and clinical support of Dominican’s critical care improvement team. Ventilator bundling refers to a group of five procedures that, performed together, improve outcomes for ventilator patients.2

“We were already doing four of the five elements,” said Robbins, “but not in a formalized, documented way that we could verify.” Ventilator bundling calls for ventilator patients to receive the following: the head of their bed elevated a minimum of 30 degrees; prophylactic care for peptic ulcer disease; prophylactic care for deep vein thrombosis; a “sedation vaca- tion” (a day or two without sedatives); and a formal assessment by a res- piratory therapist of readiness to be weaned from the ventilator.

The team tested ideas using Plan-Do-Study-Act (PDSA) cycles, ran various small tests, and then widened implementation of those that worked. Some fixes were complex, and some were simple. To ensure that nurses checked elevation at the head of the bed, for example, Camille Clark, RN, critical care manager, said, “We put a piece of red tape on the bed scales at 30 degrees as a reminder. We started with one nurse, then two, and then it spread. Now when we [perform rounds] in the ICU, we always check to see that the head of the bed is right. It has become an integrated part of the routine.”

Another important process change included the use of lists to iden- tify and track therapy goals for each patient. The form went through more than 20 PDSA cycles and 25 different versions before it was used 100 per- cent of the time for ICU patients. “We got some pushback from the nurses because it felt to them like double-charting,” said Clark. “So we kept work- ing on it, and incorporating their suggestions, until it became something that was useful to them rather than simply more paperwork.” Getting physi- cians on board regarding the daily goal list and other aspects of improve- ment was also a key factor in their project’s success.

Next, the team turned its attention to the intravenous insulin infusion protocol used in the ICU and intensified efforts to better control patients’ blood sugar. “The literature strongly suggests that controlling hyperglycemia helps reduce mortality in the ICU,” said Aaron Morse, MD, critical care medical director. “We initially trialed a more aggressive protocol on about 30 patients, and we’ve gone through seven or eight PDSA cycles on it. It is now standard protocol, and from the data we have so far, it has been extremely successful. We attribute our very low rate of ventilator-associated pneumo- nia to changes like the ventilator bundle and glucose control.”

Part of introducing a new protocol, or any new idea, involves edu- cation. “We worked to educate the staff on the importance of tight glucose

9C h a p t e r 1 : H e a l t h c a r e Q u a l i t y a n d t h e P a t i e n t

control in ICU patients,” said Robbins. Equally important is listening to the frontline staff who must implement the new procedures. “The nursing staff provides lots of feedback, which helps us refine our processes. We have vigorous dialogues with both nurses and physicians when we try things.”

At Dominican, the culture of improvement was pervasive for more than a decade, so all employees knew that performance improvement was part of their jobs. “We are in our 12th formal year of continuous performance improvement, and most of the people here have been a part of that from the inception,” said Vanderpool. As a result of the organi- zation’s long-term commitment to quality improvement, Vanderpool said progress was steady on many fronts. “Things that were once barri- ers to change are not today. People know they have the ability to make changes at the work level and show the trends associated with them. People feel empowered.”

“How Did You Get That to Happen?”

Vanderpool said other hospital leaders who were trying to achieve similar improvements as Dominican did in their own quality journeys often asked him the same question: “How did you get that to happen?” He empha- sized the value of creating a culture of improvement, which must start at the top of the organization. He demonstrated his commitment to quality by joining clinical staff on rounds in the ICU on a frequent, yet purpose- fully irregular, basis. “Some organizations overlook the importance of the culture change in performance improvement work,” said Sister Julie Hyer, OP, president of Dominican Hospital. “It is fundamental to create a cul- ture that supports and respects improvement efforts.”

Robbins cited physician buy-in as another key to successful improve- ment strategies. “We are lucky to have some very good physician champi- ons here,” he said. “They are active, creative, and knowledgeable, and their support makes a huge difference.”

Vanderpool, Hyer, and Robbins all acknowledged the value of the collaborative relationships they formed through the IMPACT Network sponsored by the Institute for Healthcare Improvement (IHI). “We are not working just within our institution, but with 40 others,” said Robbins. “In between learning sessions, we e-mail each other, talk on the phone, have site visits . . . we have adopted approaches others have used, and oth- ers have learned from us.”

Vanderpool said that working with outside experts over the past five years breathed new life into the hospital’s well-established improvement culture. “After the first four or five years of working doggedly and dili- gently on our own homegrown improvement projects, we found it got harder to be prophets in our own land. Bringing in expertise from the out- side has strengthened our approach and our commitment.”

10 T h e H e a l t h c a r e Q u a l i t y B o o k

Improvement Project: Redesigning the Clinical Office

The preceding improvement project case exemplified impressive gains in quality in one specific area, the ICU. The project in this section provided evidence of the power of complete redesign of healthcare by addressing multiple parts of the healthcare system and using the six IOM dimensions of quality as a measuring tool.

CareSouth Carolina, which serves 35,000 South Carolina patients in 11 locations, was determined to make significant improvements in office practice in all six of IOM’s aims, plus an additional category of equal impor- tance to the organization: vitality, measured by the degree to which stress was minimized in the workplace.

“This work is really a marriage between what we have learned about chronic care management and advanced practice concepts like advanced access,” said Ann Lewis, chief executive officer, in 2003. As one of the first participants in the Health Disparities Collaborative, run jointly by IHI and the federal Bureau of Primary Health Care (the Bureau of Primary Health Care provides significant funding for CareSouth and other similar clinics throughout the nation), CareSouth Carolina focused on improving access to quality care for patients with diabetes, asthma, and depression.

The results inspired Lewis to lead her organization into further improvement efforts. “When we started the diabetes collaborative, the aver- age HbA1c of the patients we were tracking was over 13,” Lewis recalled. “I didn’t even know what that meant. But I learned that every percentage drop in HbA1c represents a 13 percent drop in mortality, and that got my attention. And I would go to group visits where patients with diabetes were practically in tears with gratitude about how much our new approach to care was helping them.” Lewis realized that “it’s not about the business or economics of healthcare; it’s about the outcomes.”

The ambitious nature of CareSouth Carolina’s goals was testimony to Lewis’s success. For example, the clinic aimed to achieve a 7.0 average HbA1c for patients with diabetes, to meet 80 percent of patients’ self-management goals, to have 80 percent of each patient’s total visit time spent face to face with a provider of care, and to have the third next available appointment (a standard measure of access) be in zero days. “To be truly patient centered,” said Lewis, “it’s not enough to help patients set goals. It’s meeting the goals that puts the rubber to the road. We want the healthiest patients in America,” she said. “Why not? The knowledge is there—we know how to make peo- ple healthy and how to make care accessible. Let’s just do it.”

Improvement at CareSouth Carolina Through IOM’s Areas of Focus

CareSouth Carolina’s work in each of the seven areas of focus reflected cre- ativity, doggedness, and steadfast attention to the voice of the customer,

11C h a p t e r 1 : H e a l t h c a r e Q u a l i t y a n d t h e P a t i e n t

12

FIGURE 1.3 Improving

Effectiveness: Asthma

Symptom-Free Days and Average

HbAlc Levels

2

4

6

8

10

12

14

10 /2

2/ 02

11 /5

/0 2

12 /9

/0 2

1/ 10

/0 3

2/ 10

/0 3

3/ 10

/0 3

4/ 10

/0 3

5/ 10

/0 3

6/ 10

/0 3

7/ 10

/0 3

0

10 /2

2/ 02

A ve

ra ge

H bA

1c fo

r D

ia be

ti c

P at

ie nt

s

11 /5

/0 2

12 /9

/0 2

1/ 10

/0 3

2/ 10

/0 3

3/ 10

/0 3

4/ 10

/0 3

5/ 10

/0 3

6/ 10

/0 3

7/ 10

/0 3

7.0

7.5

8.0

8.5

9.0

9.5

10.0

A st

hm a

S ym

pt om

-F re

e D

ay s

(a ve

ra ge

ov er

pa st

14 da

ys )

SOURCE: CareSouth, Hartsville, SC. Used with permission.

its patients. “We ask the patients all the time what they want, what they think,” said Lewis. “They always tell us. But you have to ask.”

CareSouth Carolina worked diligently to improve in each of the IOM aim categories. Staff chose to add one more category, vitality, as a meas- ure of staff morale. Although progress toward achieving these ambitious goals varied, the organization remained determined.

Effectiveness

Goal: Asthma patients were to have an average of 10 or more symptom- free days out of 14. Diabetes patients were to have an average HbA1c of 7.0 or less. Figure 1.3 shows CareSouth Carolina’s results through July 2003 on these measures.

T h e H e a l t h c a r e Q u a l i t y B o o k

Action: The experience that CareSouth Carolina staff had already gained in chronic care management through the Health Disparities Collaborative gave them the tools they needed to improve effectiveness of care. “Once you know the model—self-management support, decision support, design of delivery system, clinical information system, community support—you can transfer it from one condition to another pretty smoothly,” Lewis said, referring to the Chronic Care Model developed by Ed Wagner, MD, and his colleagues, which is widely regarded as the standard for chronic care management. Wagner, a general internist/epidemiologist, is the director of Improving Chronic Illness Care at the Seattle-based MacColl Institute for Healthcare Innovation at the Center for Health Studies, Group Health Cooperative of Puget Sound.

Patient Safety

Goal: One hundred percent of all medication lists were to be updated at every visit (see Figure 1.4).

Action: “Patients have a hard time remembering what medications they are taking, especially when they take several,” said Lewis. “It’s best if they bring their medications to each appointment. Patients told us that it would help if they had something to bring them in, so we had very nice cloth medica- tion bags made for everyone on three meds or more. They have our logo on them, and a reminder to bring their medications to each visit. It’s a low- tech solution, but it has made a huge difference. We’ve had some early suc- cess in the work, as well as some recent setbacks, but I’m sure we’re on the right track.”

Patient Centeredness

Goal: Eighty percent of self-management goals set by patients were to be met (see Figure 1.5).

13

FIGURE 1.4 Improving Patient Safety: Percentage of Medication Lists on All Charts

12 /9

/0 2

P er

ce nt

ag e

1/ 10

/0 3

2/ 10

/0 3

3/ 10

/0 3

4/ 10

/0 3

5/ 10

/0 3

6/ 10

/0 3

7/ 10

/0 3

•

• • •

•

• •

60

70

80

90

100

•

SOURCE: CareSouth, Hartsville, SC. Used with permission.

C h a p t e r 1 : H e a l t h c a r e Q u a l i t y a n d t h e P a t i e n t

Action: “One of the biggest challenges the healthcare system faces is to help patients meet their own goals,” said Lewis. “We ask our patients in three ways how they want us to help them with self-management: through sur- veys, in one-on-one patient interviews, and in small focus groups.” Through these means, CareSouth Carolina staff members learned how to help patients tailor achievable goals. “Don’t tell me to lose 40 pounds,” Lewis said, explaining what patients often say. “Tell me how to do it in small steps.”

CareSouth Carolina also learned that patients are its best source of guidance regarding what system changes to make. Some of the feedback was surprising, according to Lewis. “Some of our elderly patients say they like it better when they can spend more time here, not less,” she said. “And we’ve learned that centralized appointment scheduling and medical records are not what our patients want. They want to talk with the same person each time they call, someone in their own doctor’s practice.” Little changes also mean a lot to patients, she said. “They told us to stop weighing them in the hallway where everyone can watch.”

Efficiency

Goal: The average amount of time spent with the clinician in an office visit was to be 12 minutes or more (see Figure 1.6).

Action: Working to increase patient time with clinicians and decrease non-value- added time was challenging for the CareSouth Carolina staff, but it made head- way. Again, the patients told the organization what they wanted. “They did- n’t care about the cycle time; they wanted a rich visit, more comprehensive, where they could get more done,” said Lewis. Patients liked group visits, time with the nurse as well as the doctor, and opportunities for health education, so the CareSouth Carolina staff worked to organize the delivery system accord- ingly. The average time patients spend with their doctors also increased.