The balance of health benefits and harm is the essential core of a definition of quality.
In 2002, the Institute of Medicine published Crossing the Quality Chasm, an influential book that framed all future discussions of quality health care. Crossing came on the heels of the IOM publication To Err Is Human (2000) and a Journal of the American Medical Association report (1998) that warned of "serious and widespread quality problems...throughout American medicine." The report called attention to three broad categories of quality defects:
- underuse, whereby scientifically practices are not used as often as they should be;
- overuse, especially of imaging procedures and prescription of antibiotics; and
- misuse, when a proper procedure is not administered correctly (such as prescribing the wrong drug)
To Err Is Human estimated that as many as 98,000 people dies each year in hospitals from injuries or illness contracted during care.
In Crossing, the IOM outlined six specific aims (explained by Dr. Donald Berwick in the video above) that a health care system system must fulfill to deliver quality care:
- Safe: Care should be as safe for patients in health care facilities as in their homes;
- Effective: The science and evidence behind health care should be applied and serve as the standard in the delivery of care;
- Efficient: Care and service should be cost effective, and waste should be removed from the system;
- Timely: Patients should experience no waits or delays in receiving care and service;
- Patient centered: The system of care should revolve around the patient, respect patient preferences, and put the patient in control;
- Equitable: Unequal treatment should be a fact of the past; disparities in care should be eradicated.
Recognizing that aims must be accompanied by observable metrics, the IOM defined sets of measurements for each aim. For example:
- Safe: Overall mortality rates or the percentage of patients receiving safe care;
- Effective: How well evidenced-based practices are followed, such as the percentage of time diabetic patients receive all recommended care at each visit;
- Efficient: Analysis of the costs of care by patient, provider, organization, and community;
- Timely: Waits and delays in receiving care, service, or results;
- Patient centered: Patient and family satisfaction;
- Equitable: Differences in quality measures by race, gender, income, and other population-based demographic and socioeconomic factors.
Of course, this is all easier said than done. Hospitals could more easily follow evidence-based practices were there a national outcomes data base that provided population-based information. Effecting efficiency programs can mean a complete redesign of institutional culture, as in Virginia Mason's (Seattle) 20-year commitment to Lean management principles. Equitable care is unlikely without a sea change in national health policy (not that there is one) that extends well beyond the limitations of the Affordable Care Act.
The most encouraging developments in the industry-wide reassessment of quality are the recognition that safety and efficiency need not be mutually exclusive, an increased capacity for the practice of evidence-based medicine, and a new emphasis on patients when it comes to setting goals and measuring results.
Source: The Healthcare Quality Book (2nd edition), edited by Elizabeth R. Ransom, Maulik S. Joshi, David B. Nash, and Scott B. Ransom.