Recently, I had a spirited debate with a colleague on whether health care quality and patient safety have improved over the past two decades. Given the tremendous amount of quality measurement and improvement activity in that time, one might think the answer would be an overwhelming “yes.” But as with many things in health care, the issue is much more complex than it initially appears.
In 1999, the Institute of Medicine's landmark report, To Err Is Human, brought to the general public's attention the problem of preventable medical errors and the tens of thousands of associated hospital deaths each year. Two years later IOM's Crossing the Quality Chasm defined quality as care that is not only safe and effective but also patient-centered, timely, efficient, and equitable, and offered guidance on health system redesign to improve care delivery.
Although these reports didn't start the health care quality movement, they contributed to its rapid growth, to include not only providers but also private and public payers, multiple government regulatory and oversight bodies, numerous independent nonprofit organizations, and for-profit entities.
THE CASE FOR YES
It is no surprise that a large health system today might have dozens of full-time quality improvement staff, in addition to hundreds, perhaps thousands, of front-line workers who participate in quality measurement and improvement as part of their day-to-day work. We also have many more tools at our disposal, ranging from simple checklists to electronic health records and other technologies that can help reduce errors and unwarranted variation and provide evidence-based clinical guidance.
Still, is quality better and patient care safer? According to the Agency for Healthcare Research and Quality's 2016 National Healthcare Quality and Disparities Report (published in 2017), among 172 measures tracked annually from 2000 to 2014-15, 58 percent improved, 33 percent didn't change, and 10 percent worsened.
Some of these improvements have been impressive, such as a 65 percent decrease in central venous catheter-related bloodstream infections from 2008 to 2014. Such evidence has led some to conclude that, yes, quality and patient safety are better.
Yet given the enormous resources dedicated to quality, improvements in only 58 percent of measures is discouraging. Further, these are measures that are being actively tracked: those that aren't arguably have a far higher likelihood of not changing or getting worse.
The more useful question is,
“What should we do to ensure that quality and safety
move in the right direction?”
And while many procedures have gotten safer, as health care continues to be deinstitutionalized the patients who remain in hospitals or nursing homes are sicker and more medically complex, increasing the opportunities for errors and adverse events. With no comprehensive, global quality or safety measure we cannot, in fact, be certain about overall improvement.
THE BETTER QUESTION
Ultimately, whether overall health care quality and patient safety is improving is likely the wrong question. That there remain wide variations in quality is universally acknowledged. And it's clear that there are persistent disparities and gaps in care for low-income, minority, and uninsured populations. The more useful question, then, is “What should we do to ensure that quality and patient safety move in the right direction?”
The answer depends on where you sit, whether as provider, payer, regulator, or patient. At UHF, we're using a multi-pronged strategy to address this issue, with a special focus on disadvantaged populations. We continue to work across institutions, bringing together professionals from diverse backgrounds to learn from each other and from experts in the field—in our joint UHF/Greater New York Hospital Association Clinical Quality Fellowship Program and our antibiotic stewardship and other collaboratives—to develop a new generation of quality leaders.
We also work with policymakers and regulators to promote the right environment for quality improvement, whether that means aligning measures across stakeholders, setting priorities, or helping delivery system innovations to thrive. And we are working to elevate and strengthen the voices of patients and caregivers in the quality dialogue: to a surprising extent, the quality enterprise has largely evolved without them—a shortcoming we are both committed and well-suited to addressing.