Few would argue with the Institute of Medicine’s Committee on Quality Health Care in America that “the American health care delivery system is in need of fundamental change.”1 A recent study of the quality of health care delivered to adults in the United States concluded that “the deficits we have identified in adherence to recommended processes for basic care pose serious threats to the health of the American public.”2 Growth in medical knowledge and technology continues to outstrip our ability to translate these assets into safe and effective health care for the public. Continuing to rely on individual autonomy and accountability, paper transactions, and secrecy instead of transitioning to team care, systems thinking, a modern information infrastructure, and transparency has precipitated the current crisis that is characterized by limited access, patient dissatisfaction, unsafe care, double-digit inflation, and low morale among physicians, nurses, and other health care workers. Patient safety and quality improvement have been identified as critical clinical and research endeavors supported by the federal government, accrediting bodies, regulatory agencies, and patient-advocacy groups.
Fortunately, leadership in quality improvement and patient safety is emerging along a number of fronts. A public/private partnership, the National Quality Forum, has been created to establish quality standards and serve as an information clearinghouse. The Physician Consortium for Performance Improvement, organized by the American Medical Association, is another public/private initiative whose membership includes more than 50 medical specialty societies. In the corporate world, the Leapfrog Group—a consortium of some 120 large employers, purchasing coalitions, and states—has developed specific hospital quality standards to serve the group’s 33 million insured. Research support to address the many challenges outlined in the Institute of Medicine’s report is being provided by the Agency for Healthcare Research and Quality and foundations such as the Robert Wood Johnson Foundation and the Commonwealth Fund.
The Boston-based Institute for Healthcare Improvement (IHI), now in its 12th year, has been a leader in educating physicians, nurses, and other health professionals to improve the effectiveness and efficiency of their delivery systems. Recently, academic medical institutions have come together to improve patient outcomes by participating in IHI’s IMPACT network. This year-old initiative is open to all hospitals and health systems in the country. Through operational improvements and the education of future health professionals, the aim is to address the essential dimensions of patient care described in Crossing the Quality Chasm: safety, effectiveness, efficiency, timeliness, patient-centeredness, and equity. Each participating institution is working in one or more of five improvement domains:
* Patient safety to ensure that patients feel as safe in health care facilities as they do in their own homes
* Flow through acute care settings to reduce waiting times, redundancy, and waste throughout the hospital system
* Intensive care settings to improve care for patients in critical care units while reducing costs
* Office practice and outpatient settings to build efficient, proactive, patient-centered care systems for primary care, specialty practices, and ambulatory settings
* Workforce development to ensure a vibrant, motivated, available and skilled workforce
In addition, the chief executive officer of each participating organization focuses on a sixth improvement domain, leadership.
Among the more than 100 current members of the IMPACT network, 23 are academic medical centers (AMCs) (see Table 1). Although we are encouraged by the involvement of these AMCs, we need the participation of many more. The network’s aims may seem a daunting challenge to these exceedingly complex organizations that are under considerable economic stress. However, the stakes have never been higher for the future of medicine in the United States.
Past quality improvement approaches at AMCs have been highly variable. Patients who need complex procedures and treatments generally have superior outcomes at AMCs, but most of the services provided at major teaching hospitals also are found at community hospitals. At the same time, the nature and frequency of preventable deaths and other complications at both are also similar,3 perhaps much the same as were described at a prominent teaching hospital almost 40 years ago.4 The high frequency of medical errors occurring at the best teaching hospitals in the country is one such example.5 Another example is the large difference in the standardized mortality rates among hospitals (both teaching and nonteaching) in the United States, findings similar to those in hospitals throughout Great Britain. Whether AMCs provide better care than nonteaching hospitals is not the point, however. If the goal of improving the health of the public is to be achieved, all must constantly strive to raise the bar in our performance.
Raising the Quality Bar at AMCS
The infrastructure for raising this bar is improving at medical schools and teaching hospitals in this country. The emergence of interdisciplinary centers of excellence such as in neurosciences, cancer, and cardiovascular diseases may be superior structures for patient care, teaching, and research missions.6
Further, the streamlined governance of faculty practice plans (and innovations such as including lay members on the faculty practice board) has led to more effective strategic planning and accountable decision making. Improved practice plan management has led to the introduction of practice standards, the monitoring of compliance, and use of systematic feedback from patients to improve services.7
Leadership recruitment and development is another important trend among U.S. medical schools. There is less reliance on paper credentials and more attention to qualities of leadership among prospective vice presidents, deans, department chairs, and center directors.8 Some medical schools have created leadership development programs to improve the mentoring of young faculty.9
A commitment to quality has become a high educational priority at a number of medical schools. In a report released by the Association of American Medical Colleges in 2001, Contemporary Issues in Medicine: Quality of Care, strategies for the development of medical students’ knowledge and skills in the improvement of quality were suggested.10 Following up on the report’s recommendation, an informal collaborative of medical schools has recently been established to develop pilot curricula for medical students and to address the need for faculty development bearing on issues of quality.
Valuing Quality Improvement
Quality improvement efforts are intellectual activities that are quite consistent with the values of academic medicine and discovery. An excellent example is the report by O’Connor et al.11 that shows that training in quality improvement techniques reduced hospital mortality rates associated with coronary artery bypass graft surgery. Published results strengthen the marriage of traditional academic rigor and practical quality improvement methods in health care settings. Faculty who have contributed to knowledge through structured clinical interventions or research in clinical services are being recognized and rewarded. This change is reflected in the number of such faculty who are medical school deans, chairs of clinical departments, or elected members of prominent national medical societies.
Also notable are trends within the profession to strengthen attention to quality. These include the serious efforts of some professional societies and specialty boards to ground and support physicians in quality improvement. Two examples are the new requirement of the Accreditation Council for Graduate Medical Education that residents develop competency in the measurement and improvement of quality of care and the accomplishments of the VA Health System in improving the quality of care rendered for veterans and their dependents.
AMCs are well positioned to take advantage of recent initiatives that provide financial reward for health care quality. One is the trend toward higher payments to centers and physicians that provide higher quality. Teaching hospitals and their faculty practices will have to demonstrate that, in addition to better outcomes for complex procedures, they also score highly on such measures as patient safety, “best” practice, and patient satisfaction. Also, the trend to keep health care payments closer to annual levels of inflation will stimulate expensive providers such as AMCs to get the most from existing dollars through process improvements, the redesign of their patient care work.
These important infrastructure trends at AMCs imply a responsive environment for addressing issues of quality. Those who have joined in the network have accepted this challenge, but we represent only a few of the AMCs in this country and we need others to join us. To help get this work started, we suggest leaders of the academic community pose the following questions and challenges to their organizations:
* How familiar is your leadership with the major issues in health care quality? The executive summary of Crossing the Quality Chasm should be required reading for the leaders of medical schools and teaching hospitals, hospital board members, and/or university trustees. This summary is a powerful treatise on the health care quality imperative and is now the basis for many national movements in health care quality. With its framework, leaders can clarify their vision for the medical center and commit to the cultural and organizational changes needed.
* Is quality improvement embedded in the medical center in all its missions? If not, there are straightforward ways to get started. In clinical care, the institution should commit to a systematic, ongoing study of opportunities to improve the quality of health care services. Consider outcomes such as unanticipated deaths and test changes to improve dramatically the outcomes. In education, there are many opportunities for influencing change. The papers presented in the October 2002 issue of Academic Medicine, devoted to health care quality and safety, offer a wealth of ideas about how AMCs can contribute to the goal of improved health care through attention to undergraduate, graduate, and continuing medical education and to quality improvement practices in clinical settings. Quality improvement can be applied to research and research training. The support mechanisms for the generation of research proposals, grant budget tracking, recruiting and supporting research trainees, and for dealing with clinical research regulations can harbor systems problems that require attention.
* Is the AMC using its academic expertise to share research and research training experiences with others in the field of quality and safety? This step could be facilitated through structures that are already in place such as the National Quality Forum, the IHI, the Physician Forum for Performance Improvement, or the University Health System Consortium. A small group of leaders at each AMC should become intimately familiar with the activities of these national quality improvement resources. Recently introduced Web-based programs such as IHI’s QualityHealthCare.org and The Agency for Healthcare Research and Quality’s monthly morbidity and mortality (M&M) rounds are excellent resources for reporting and sharing improvements in quality and safety and are available to all.
In preparing its report, Crossing the Quality Chasm, the Institute of Medicine’s Committee on Quality Health Care in America envisioned twenty-first-century health systems as “learning organizations.” Learning organizations explicitly measure their performance along a variety of dimensions, including outcomes of care, and use that information to change or redesign to continually improve their work. Our challenge, thus, is to compete against standards of quality, not other hospitals or health systems. We are beginning to make the changes needed to become such organizations. As institutions entrusted with the education of future health professionals and charged with developing new knowledge, we should expect nothing less than a complete commitment to the highest level of quality in patient care. We ask our colleagues at other medical schools and teaching hospitals to join us in this exciting venture.
The Academic Medical Center Working Group wishes to thank Frank Davidoff and Paul Barach for their input and suggestions for improvement of the final article.
1.Committee on Quality Health Care in America. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st
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7.Association of American Medical Colleges Center for the Assessment and Management of Change in Academic Medicine. Managing Change: Strategies from Case Studies of Medical Schools and Teaching Hospitals. Washington, DC: Association of American Medical Colleges, 2000.
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10.Association of American Medical Colleges. Contemporary Issues in Medicine: Quality of Care. Washington, DC: AAMC, 2001.
11.O’Connor GT, Plume SK, Olmstead EM, et al. A regional intervention to improve the hospital mortality associated with coronary artery bypass graft surgery. The Northern New England Cardiovascular Disease Study Group. JAMA