The American healthcare system is currently facing increased scrutiny as a result of several high-profile reports that reveal that medical errors are common and have led to many patient deaths. In particular, the Institute of Medicine's (IOM) report, `To Err Is Human: Building a Safer Health System,` his attracted much attention and commentary. IOM followed up this report with a series of publications that further focus on the safety and quality of care. Taken together, these reports have drawn considerable interest from all healthcare stakeholders, causing them to challenge the conventional wisdom that quality is a given in American healthcare today.
Quality of healthcare has been a recurring theme in the United States since the early part of the twentieth century, when the Flexner report, `Medical Education in the United States and Canada,` which outlined the inadequacies of the medical education system, was published. This report ushered in an era of setting scientific standards and marked the beginning of the construction of the world's most sophisticated, technologically advanced, and expensive healthcare system. Given these beginnings and Americans' support of technological breakthroughs, it is understandable that a common assumption exists that the American healthcare system delivers the highest quality of care. This perception persists despite numerous scientific studies suggesting that the quality of care in the United States is highly variable and poorly measured.
As in other industries, public perception of the healthcare industry is often only altered by spectacular mishaps. Several recent notable accidents have contributed to an increased public awareness of the importance of quality in healthcare, such as the death of Betsy Lehman, the health editor of the Boston Globe, from an easily preventable overdose of a chemotherapy drug; the death of 8-year-old Ben Kolb from a drug mix-up during minor surgery; and the amputation of Willie King's good leg. Predictably, these and other such events have energized politicians, regulatory agencies, and industry and consumer groups to focus on improving quality in this area, with a resulting flurry of proclamations, legislative and regulatory activities, and reports on the subject. These activities in turn have energized the public to demand a much greater transparency for healthcare quality.
As such, JCAHO is now requiring healthcare delivery organizations to track and report inpatient processes and outcome measures that are indicative of quality; this information will soon be made public. In addition, other healthcare organizations—the American Hospital Association, the Centers for Medicare and Medicaid Services, and the Agency for Healthcare Research and Quality—have developed a voluntary quality-reporting initiative that allows hospitals to directly report certain quality measures for public availability; many similar efforts are ongoing. A tipping point has clearly been reached in providers' reporting of healthcare-quality information to the public. No longer will hospitals be able to use public-relations approaches to shape the public's view of the quality of care they provide. This information will now be controlled by other entities, creating a new era of accountability for the quality of care delivered by hospitals.
Although most healthcare delivery organizations can tell plenty of success stories surrounding their quality improvement efforts, many of these organizations have encountered barriers that have limited the impact of their quality efforts. These issues have included the cost of quality programs, the narrow impact of these programs, the inability to disseminate improvements throughout the organization, the difficulty of sustaining improvements, and the lack of true financial incentives in the marketplace for improved quality. Time and again, when these organizations get into financial difficulty, their quality programs are often the first to see reductions or elimination. Despite an increased focus on quality, many organizations are reeling from financial difficulties related to reimbursement issues, regulatory burdens, staffing shortages, and rising costs. It is fortuitous timing, as virtually all excess costs have been removed from most organizations through belt tightening; only a fundamental reappraisal of the processes of care, and of clinical processes in particular, can yield further significant savings while improving the quality of care. Nonetheless, without clear financial incentives, many organizations are hesitant to invest in new quality improvement programs.
Several new initiatives have begun addressing the issue of paying for better performance in safety and quality of care, the best example of which is the Leapfrog Group initiative. This group has developed three highly specific and well-publicized patient-safety standards that seek to financially reward publicly transparent hospital performance on these three standards. These standards have catalyzed significant interest and movement among hospitals in implementing these practices because of the impact on reimbursement. However, the Leapfrog Group's effort is not isolated; similar initiatives are also being implemented, such as the Pay for Performance Program in California and the Bridges to Excellence Program in the Midwest, which have begun to institutionalize the practice of better reimbursement for demonstrably higher quality care.
Timing is everything, and Diane Kelly's new book, Applying Quality Management in Healthcare: A Process for Improvement, arrives at a critical evolution point. As healthcare managers begin to see the impact of public demands for transparent accountability for quality, as regulators mandate the reporting of quality performance information, and as payers align reimbursement approaches to reward higher quality, they will need to quickly develop expertise in managing quality as a new skill set and ultimately as a core competency. To date, expertise and critical skills in this area have resided within the quality improvement or quality assurance department and occasionally within clinical departments. Managing the quality of care has not been a critical skill for healthcare management nor an inherent part of the manager's educational experience. However, these skills will quickly become an indispensable part of any manager's knowledge base. Rather than long-winded educational programs that revolve around theories of quality, managers will need a practical guide to quality that is long on examples, adequate on theory, and easy to understand from the management perspective—a how-to guide for managing quality. This is exactly what they will get from this book.
Not only does this book supply the fundamental theory that underlies successful management of quality, it also provides ample real-world examples and numerous exercises to help the reader quickly master the concepts. This book does not rehash old approaches in quality, but it picks up many of the fundamental issues and themes raised by IOM's reports. It offers an integrated approach to quality in complex systems that overcomes many of the inherent limitations of quality improvement in years past. Organizations would do well to use this book not only as a principal educational tool for managers but as a required one at that. Indeed, this book will quickly become the manager's healthcare quality survival guide.
In the past, organizations' focus was on marketing quality of care. In the future, it will be on delivering quality of care as part and parcel of the business operations of any successful healthcare delivery organization. Applying the principles and techniques in this new book is essential for any organization's continued existence.
David С Classen, M.D., M.S.
Associate Professor of Medicine, University of Utah
Vice President, First Consulting Group
Salt Lake City, Utah