Quality Gains Key to Health Care Reform

WASHINGTON – Quality improvement must be an integral part of any health reform plan, according to one expert.

Although there have been many improvements in medical care over the past few years, “with the miracles have come burdens,” Dr. Donald Berwick, president and CEO of the Institute for Healthcare Improvement, said at the annual meeting of the American Health Lawyers Association. “Miracles and hazards come hand in hand.”

Improving the quality of health care doesn't necessarily mean spending more money; in fact, the opposite is often true, Dr. Berwick said. “England spends 8%-8.5% [of its gross domestic product] on health care–about half of what we do–and has equally fine care.” And the Dartmouth Atlas Project has found that regions of the United States that spend the most on health care–areas with more hospital beds per capita and more specialists, and where more procedures are done–often have worse care outcomes.

“They have higher mortality and the same functional status among patients” as do those in lower spending areas, he said. “Doctors in these areas report more problems with continuity [of care], and patients are less satisfied.”

The biggest predictor of quality of care by far, however, is race, Dr. Berwick continued. “If you are black, that is the biggest count against you for health status; that's not true in the rest of the developed world.” A black male child born in inner-city Baltimore this year, for instance, has an 8-year-lower life expectancy than does a white child, he said. Using a strictly market-based approach won't solve quality problems, according to Dr. Berwick. “I simply do not think markets will work in health care,” he said. “But I think there is a way out, and it has to do with leadership.”

The health care system has to allow for the fact that people see what they expect to see and interpret the world accordingly, which can lead to errors in the operating room and other health care settings, Dr. Berwick said. “If we wish to be safe, we have to engineer dikes around human frailty. And it can be done. It's done in airplane cockpits and in nuclear power plants.”

He added that a well-engineered system “does not beat up on the workforce; it does not yell at the nurse for making a mistake; it does not blame [people] for being human.” Instead, “it's the design of work that determines the outcomes of work.”

For example, Dr. Berwick said, a big problem in hospitals has been central venous line infections. “We know now that if you adhere strictly to science, if you follow every single one of these five steps [good hand hygiene, maximal barrier precautions upon insertion, chlorhexidine skin antisepsis, optimal catheter site selection, and daily review of line necessity with prompt removal of unnecessary lines], you can … essentially abolish central venous line infections.”

These infections still occur in hospitals “because we haven't put in the reliable systems that make it go right every single time,” he said

Hospital governance boards must get involved to help make these changes happen, he added. “Think about it this way. If it's true that your hospital could abolish central venous line infections–and it can–and a patient tomorrow morning gets a central venous line infection, the board caused it. I know of no other way to think about it.”

Many health care organizations and communities working on quality improvement are using the goal of “triple aim”: better experience of care, a healthier population (through reductions in smoking, obesity, and other health problems), and reduction of per capita costs. The Institute for Healthcare Improvement “[has] about 40 or 50 organizations that have said, 'I want to achieve the triple aim for my organization,'” Dr. Berwick said. Grand Junction, Colo., and Green Bay, Wisc., are two of the communities working to achieve the triple aim in health care.

WASHINGTON – Quality improvement must be an integral part of any health reform plan, according to one expert.

Although there have been many improvements in medical care over the past few years, “with the miracles have come burdens,” Dr. Donald Berwick, president and CEO of the Institute for Healthcare Improvement, said at the annual meeting of the American Health Lawyers Association. “Miracles and hazards come hand in hand.”

Improving the quality of health care doesn't necessarily mean spending more money; in fact, the opposite is often true, Dr. Berwick said. “England spends 8%-8.5% [of its gross domestic product] on health care–about half of what we do–and has equally fine care.” And the Dartmouth Atlas Project has found that regions of the United States that spend the most on health care–areas with more hospital beds per capita and more specialists, and where more procedures are done–often have worse care outcomes.

“They have higher mortality and the same functional status among patients” as do those in lower spending areas, he said. “Doctors in these areas report more problems with continuity [of care], and patients are less satisfied.”

The biggest predictor of quality of care by far, however, is race, Dr. Berwick continued. “If you are black, that is the biggest count against you for health status; that's not true in the rest of the developed world.” A black male child born in inner-city Baltimore this year, for instance, has an 8-year-lower life expectancy than does a white child, he said. Using a strictly market-based approach won't solve quality problems, according to Dr. Berwick. “I simply do not think markets will work in health care,” he said. “But I think there is a way out, and it has to do with leadership.”

The health care system has to allow for the fact that people see what they expect to see and interpret the world accordingly, which can lead to errors in the operating room and other health care settings, Dr. Berwick said. “If we wish to be safe, we have to engineer dikes around human frailty. And it can be done. It's done in airplane cockpits and in nuclear power plants.”

He added that a well-engineered system “does not beat up on the workforce; it does not yell at the nurse for making a mistake; it does not blame [people] for being human.” Instead, “it's the design of work that determines the outcomes of work.”

For example, Dr. Berwick said, a big problem in hospitals has been central venous line infections. “We know now that if you adhere strictly to science, if you follow every single one of these five steps [good hand hygiene, maximal barrier precautions upon insertion, chlorhexidine skin antisepsis, optimal catheter site selection, and daily review of line necessity with prompt removal of unnecessary lines], you can … essentially abolish central venous line infections.”

These infections still occur in hospitals “because we haven't put in the reliable systems that make it go right every single time,” he said

Hospital governance boards must get involved to help make these changes happen, he added. “Think about it this way. If it's true that your hospital could abolish central venous line infections–and it can–and a patient tomorrow morning gets a central venous line infection, the board caused it. I know of no other way to think about it.”

Many health care organizations and communities working on quality improvement are using the goal of “triple aim”: better experience of care, a healthier population (through reductions in smoking, obesity, and other health problems), and reduction of per capita costs. The Institute for Healthcare Improvement “[has] about 40 or 50 organizations that have said, 'I want to achieve the triple aim for my organization,'” Dr. Berwick said. Grand Junction, Colo., and Green Bay, Wisc., are two of the communities working to achieve the triple aim in health care.

WASHINGTON – Quality improvement must be an integral part of any health reform plan, according to one expert.

Although there have been many improvements in medical care over the past few years, “with the miracles have come burdens,” Dr. Donald Berwick, president and CEO of the Institute for Healthcare Improvement, said at the annual meeting of the American Health Lawyers Association. “Miracles and hazards come hand in hand.”

Improving the quality of health care doesn't necessarily mean spending more money; in fact, the opposite is often true, Dr. Berwick said. “England spends 8%-8.5% [of its gross domestic product] on health care–about half of what we do–and has equally fine care.” And the Dartmouth Atlas Project has found that regions of the United States that spend the most on health care–areas with more hospital beds per capita and more specialists, and where more procedures are done–often have worse care outcomes.

“They have higher mortality and the same functional status among patients” as do those in lower spending areas, he said. “Doctors in these areas report more problems with continuity [of care], and patients are less satisfied.”

The biggest predictor of quality of care by far, however, is race, Dr. Berwick continued. “If you are black, that is the biggest count against you for health status; that's not true in the rest of the developed world.” A black male child born in inner-city Baltimore this year, for instance, has an 8-year-lower life expectancy than does a white child, he said. Using a strictly market-based approach won't solve quality problems, according to Dr. Berwick. “I simply do not think markets will work in health care,” he said. “But I think there is a way out, and it has to do with leadership.”

The health care system has to allow for the fact that people see what they expect to see and interpret the world accordingly, which can lead to errors in the operating room and other health care settings, Dr. Berwick said. “If we wish to be safe, we have to engineer dikes around human frailty. And it can be done. It's done in airplane cockpits and in nuclear power plants.”

He added that a well-engineered system “does not beat up on the workforce; it does not yell at the nurse for making a mistake; it does not blame [people] for being human.” Instead, “it's the design of work that determines the outcomes of work.”

For example, Dr. Berwick said, a big problem in hospitals has been central venous line infections. “We know now that if you adhere strictly to science, if you follow every single one of these five steps [good hand hygiene, maximal barrier precautions upon insertion, chlorhexidine skin antisepsis, optimal catheter site selection, and daily review of line necessity with prompt removal of unnecessary lines], you can … essentially abolish central venous line infections.”

These infections still occur in hospitals “because we haven't put in the reliable systems that make it go right every single time,” he said

Hospital governance boards must get involved to help make these changes happen, he added. “Think about it this way. If it's true that your hospital could abolish central venous line infections–and it can–and a patient tomorrow morning gets a central venous line infection, the board caused it. I know of no other way to think about it.”

Many health care organizations and communities working on quality improvement are using the goal of “triple aim”: better experience of care, a healthier population (through reductions in smoking, obesity, and other health problems), and reduction of per capita costs. The Institute for Healthcare Improvement “[has] about 40 or 50 organizations that have said, 'I want to achieve the triple aim for my organization,'” Dr. Berwick said. Grand Junction, Colo., and Green Bay, Wisc., are two of the communities working to achieve the triple aim in health care.