the workplace must not focus on punishing individuals for errors. Instead, root cause analysis, a standardized method of analyzing errors, must be conducted to determine individual practice and system problems that result in errors. The expectation is that healthcare organizations will then use these data to eliminate or at least reduce the system problems that compromise patient safety. Safe care does not imply that the care is thereby of higher quality; however, safe care does increase the likelihood of quality care. It would be easy to say that a strong regulatory and enforcement approach is the strategy for solving this problem, but use of appropriate technology is another means to reduce errors. A national mandatory reporting system for errors will also provide useful information to improve safety. Finally, in any of the recommended strategies, leadership is critical.
does not use its resources efficiently. This report identifies quality as a system property with six important improvement aims: Health care should be (1) safe, (2) effective, (3) patient-centered, (4) timely, (5) efficient, and (6) equitable. All healthcare constituents or stakeholders, including policy-makers, purchasers, regulators, health professionals, healthcare trustees and management, and consumers, must commit to a national agenda emphasizing these six aims for improvement. The goal is to raise the quality of care to unprecedented levels. The recommendations from this report are included in Appendix C. In addition, the report states 10 rules to guide major stakeholders to reach positive outcomes through collaboration. These rules are drawn from the work of Donald Berwick, M.D. (2008), who also notes the fundamental differences between the new rules and the current system. These differences are discussed in Part 4.
the report recognizes the influence of the patient: The patient’s desired outcome and preferences influence treatment and healthcare consumerism. The quality report matrix is discussed in Part 4.
and facilitates standardization of care where appropriate. Additional discussion about informatics is found in Part 4.
healthcare delivery system (for example, Kaiser Permanente); the hospital perspective; and the nursing perspective.
QI has many purposes. The purpose of research is very different from experiential learning, which is also an important part of QI.
The specific context is important when attempting to generalize across settings.
It is unclear where QI research belongs in academic settings. It should be interprofessional, but this is difficult to implement.
Most staff involved in QI projects do not have traditional research backgrounds.
Ethical oversight is critical for research, but it is not clear how this applies to QI. Is QI human subject research, and does it thus require institutional review boards (IRBs)?
There are methodological differences between the biological sciences and the social sciences. QI is not based on tightly controlled conditions of clinical interventions, so it is more difficult to generalize from QI studies.
Much of the published QI research has been poorly conducted.
There is a lack of common vocabulary for QI and implementation research terms.
socioeconomic inequities. Healthcare disparities occur consistently across a variety of illnesses and delivery services. The findings of the Sullivan Commission (2004), though not one of the IOM reports, are relevant. That commission examined disparities in health care and concluded that a key contributor to this growing problem is disparity in the nation’s health professional workforce. This imbalance impedes minorities’ access to health care and undermines understanding of their needs. The Sullivan commission suggested that the solution is to increase the number of minority health professionals. This translates into increased admission into professional schools, something the United States has historically failed to accomplish. Today, with increased competition for positions in nursing, this problem can only grow. Many minority students do not have a strong basic education prior to entering college. If they are admitted, they often do not graduate. At-risk students should receive assistance to give them a greater chance of completing the program.
Similar to the National Healthcare Quality Report, the annual disparities report flows from the earlier IOM reports on diversity and disparity in health care. This report also correlates with the quality framework. The framework used to assess measures of healthcare disparities is described in Part 4.
patients, and vulnerable populations. Some provide the care because it is mandated by law or stated as part of an organization’s mission. In many cases the providers serve a mix of patients: some belong to these vulnerable populations and others do not. The IOM investigation into the healthcare system found it fragmented, consisting of a patchwork of service settings such as clinics, physician offices, and multiple healthcare organizations. It is also not financially secure. Several safety-net hospitals have closed over the last few years, while others are struggling to maintain services. Who, then, provides care in the safety-net system, and for how long? The most common providers are public hospitals, local health departments, community health centers, academic healthcare centers (not all but most), and specialty services such as AIDS clinics and school health clinics.
As the number of uninsured people increases, there is more need for safety-net services. Healthcare reform over time will reduce the number of uninsured, but not completely.
The direct and indirect subsidies that have helped to finance uncompensated care are eroding (for example, a decrease in federal Medicaid funds to states). Some providers are no longer able to provide “charity care” because it is harder to transfer these costs to paying patients. With the increase in unemployment, there are more people without coverage, only increasing the stress on the safety-net system.
Hospitals that care for a large number of Medicaid patients are unable to improve care as rapidly as hospitals that have better funding (Reinberg, 2008). With greater emphasis on performance, these safety-net hospitals experience a secondary impact when their lower performance means they get less funding. Less funding means less improvement—and the cycle continues.
for Life programs, Veterans Health Administration (VHA), and Indian Health Services (IHS) program—are examined for quality enhancement processes. These six programs serve about a third of all Americans. The difficulty with implementation of the recommendations in the IOM reports has been the lack of reliable, valid indicators of quality. This analysis stresses the need for the U.S. government to lead in establishing quality performance measures and improving safety and quality of care. The federal government serves in four healthcare delivery roles, which makes it uniquely suited to move the quality initiative forward.
It serves as regulator when it sets minimum acceptable performance standards.
It is the largest purchaser of care through six major government health programs, and thus can have a major impact on other purchasers of care.
As a provider of care for veterans, military personnel and their dependents, and Native Americans, the federal government can implement model quality improvement programs and gather data about their outcomes—programs that could then be used by other providers.
Finally, it is a research sponsor, particularly in applied health services research.
Identify nationwide health improvement priorities;
Increase public awareness and understanding of determinants of health, disease, disability, and opportunities for progress;
Provide measurable objectives and goals applicable at national, state, and local levels;
Engage multiple sectors to take actions to strengthen policies and improve practices that are driven by the best available evidence and knowledge; and
Identify critical research evaluation and data collection needs.
Attain high-quality, longer lives free of preventable disease.
Achieve health equity; eliminate disparities.
Create social and physical environments that promote good health.
Promote quality of life, healthy development, and healthy behaviors across life stages.
framework in identifying these elements: the life course perspective or life stage and the health determinants and health outcomes. The IOM report discusses each of the indicators in detail.
EXHIBIT 1-1 The IOM and Healthy People 2020: Topics, Indicators, and Objectives