The publication of two Institute of Medicine (IOM) reports-To Err is Human: Building A Safer Health System in 1999 and Crossing the Quality Chasm: A New Health System for the 21st Century in 2001-served as a catalyst to increase awareness among health care professionals that the American health care system is beset by serious problems related to patient safety and medical errors.
Since then, knowledge and opinion leaders in the health care industry, such as Kenneth I. Shine, MD, who was President of the IOM when these studies were done, have strived to improve this situation so that America’s health care system is safe, effective, patient-centered, timely, efficient, and equitable.
They envision a system that uses the best knowledge, is focused intensely on patients, and works across health care providers and settings. Achieving this ideal will require crossing a large chasm between today’s system and the possibilities of tomorrow.
I am pleased that the president of the American Head and Neck Society chose ‘quality’ as the overall theme for the 2007 COSM in San Diego, said Dr. Shine, who is now Executive Vice Chancellor in the Office of Health Affairs of the University of Texas System in Austin. This speaks well for this organization and its commitment to improve quality and safety.
Bridging the Quality Gap
During his John J. Conley Lectureship presentation at COSM, Dr. Shine listed 10 rules that are necessary to redesign care, in order to bridge the quality chasm:
- Care based on continuous healing relationships between health care professionals and patients.
- Customization based on patient needs and cultural values.
- Patient as source of control.
- Shared knowledge and free flow of information.
- Evidence-based decision-making.
- Safety as a systems property.
- Transparency (health care facilities need to make outcome data public).
- Anticipation of needs.
- Continuous decrease in waste.
- Cooperation among clinicians.
Many of these rules are in the process of being implemented, but not all of them at the same time, said Dr. Shine.
For example, safety as a systems property is already under way in some institutions that are using computerized physician order entry (CPOE) systems. CPOE can be remarkably effective in reducing the rate of serious medication errors. A study led by David Bates, MD, Chief of General Medicine at Boston’s Brigham and Women’s Hospital, demonstrated that CPOE reduced error rates by 55%-from 10.7 to 4.9 per 1000 patient days. Rates of serious medication errors fell by 88% in a subsequent study by the same group.1
Entering the Electronic Age
In his 2004 State of the Union address, President Bush outlined a plan to ensure that most Americans have electronic health records within the next 10 years, which will make shared knowledge and the free flow of information much easier. Electronic medical records (EMRs) that include reminder systems and computer-assisted diagnosis and management have shown to improve compliance with practice guidelines.2 A 2001 study conducted by the Boston Consulting Group found that 92% of EMRs users reported that EMRs have improved their overall efficiency, whereas 88% said they have improved the quality of the care they deliver to patients. About half the users in both cases described the impact as major. This means that EMRs are indeed liberating doctors from the hassle of documentation so they can concentrate on providing better care.3
Utilizing software programs, such as the Patient Safety Indicators prepared by the Agency for Healthcare Research and Quality (AHRQ) (www.qualityindicators.ahrq.gov ), can help hospitals identify potential adverse drug events (ADEs) occurring during hospitalization. This tool uses readily available hospital inpatient administrative data and is free from AHRQ.
Transparency is improving, as health care professionals are more willing to voluntarily report errors to national and proprietary error reporting systems without fear of legal retribution. The Medication Errors Reporting Program, operated by the US Pharmacopoeia-Institute for Safe Medication Practices, and MEDMARX® (www.usp.org ) are two examples of nonpunitive, anonymous, voluntary reporting programs. The Food and Drug Administration’s (FDA) safety information and adverse event reporting program, MedWatch (www.fda.gov/medwatch/how.htm ), is another resource.
If this sounds like a lot of work, it is-but it can and must be done, and there are success stories to prove it, said Dr. Shine during his presentation. The Iowa Health System in Des Moines reduced ADEs across its entire system of 10 hospitals by 75 percent in just one year. St. Joseph Medical Center in Bloomington, Illinois, reduced ADEs per 1000 doses by more than 50 percent in less than one year.
A Culture of Safety
These institutions encouraged a culture of safety by instituting such things as (1) patient safety leadership WalkRounds, during which senior leaders encourage frontline staff to identify opportunities for improvement and make suggestions, (2) safety briefings, during which good ideas for change are exchanged, and (3) reconciling medications so patients know the medications they are taking while hospitalized.
The FDA has also stepped in and now requires bar coding on certain drug and biological product labels and that reports on actual and potential medication errors be submitted to the agency within 15 calendar days, said Dr. Shine. It has also created a Safety Center-although I think it can do more, especially in the area of drug names and packaging.
Increasingly, disease management programs are playing a role in terms of improved quality because they emphasize a team approach, continued Dr. Shine. We do know that some of these programs can improve outcomes and possibly decrease costs. However, I am worried that the increasing commercialization of some disease management programs, and their methods and motivation for cost reduction, will affect overall quality. Additionally, some of these programs are attempting to care for patients without informing their physicians and this is a serious mistake.
Overcoming Obstacles
Obviously, there are going to be obstacles to crossing the quality chasm, such as physician disbelief, resistance to change, technology skepticism, and cost, said Dr. Shine. Fortunately, there are ways to overcome these challenges in order to achieve success, but they do require a change in mindset within our profession.
Characteristics of our profession in the 20th century included autonomy, solo practice, continuous learning, blame and shame, and knowledge, said Dr. Shine. We were annoyed by managed care, as it took away much or our autonomy. We placed a great deal of emphasis on continuous learning by requiring CMEs, only to find that this increased knowledge didn’t really translate into a change of physician behavior. We believed that this body of knowledge was sacred to our profession, but now anyone with access to the Internet can instantly obtain the same information as us.
Training the Next Generation
Medical students, residents, and young physicians of the 21st century must be trained to think differently. Teamwork is now and will continue to be required in all aspects of care. Fewer physicians work in solo practice; they must now interact within quality-improvement teams (like rapid response), unit-based committees, hospital-wide teams, task forces, and academic departments to solve problems. Some schools are beginning to bring together medical, nursing, pharmacy, and allied health students to learn together around case studies and standardized and simulated patients.
Since the focus is no longer ‘continuous learning’ but rather ‘continuous quality improvement,’ some specialties, such as internal medicine, have incorporated systems analysis as part of their residency review requirements to increase residents’ awareness of patient safety, said Dr. Shine.
Young physicians need to learn leadership skills, so they can effectively be captains of the team, not just authority figures, he said.
Physician leaders also must focus on the specific leadership topics and tasks that will drive health care system improvement in the 21st century. Since as a profession, physicians lost control of cost and access issues, they must now speak loudly and take a leadership role in improving quality and safety, according to Dr. Shine.
Physicians must be willing to learn and use information technology to create the evidence-based data that support the necessary changes that are needed in the American health care system; quality cannot be measured if it is not quantified. This is how the value of what we do becomes part of the discussion with policy makers and how we can provide quality of care to our patients in a safe environment.
References
- Computer Physician Order Entry. Factsheet. The Leapfrog Group. February 27, 2007. www.leapfroggroup.org .
- Durieux P, Nizard R, Ravaud P, et al. A clinical decision support system for prevention of venous thromboembolism: effect on physician behavior. JAMA 2000;283(21):2816-21.
- Vital Signs Update: Doctors Say e-Health Delivers. Boston Consulting Group, September 2001, www.bcg.com .
©2007 The Triological Society