Patient safety and quality improvement are critical clinical and research endeavors supported by the federal government, accrediting bodies, regulatory agencies, and patient-advocacy groups. The Boston-based Institute for Healthcare Improvement has led 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 the institute's IMPACT network. Each participating institution works in one or more of five improvement domains: patient safety, intensive care, patient flow, office practice, and workforce development. In addition, the chief executive officer of each participating organization focuses on leadership. The infrastructure for raising the bar of performance is improving at medical schools and teaching hospitals in this country. Important trends include interdisciplinary centers of excellence, improved faculty practice plan governance and management, leadership recruitment and development, and a commitment to quality as a high educational priority at a number of medical schools. Quality improvement efforts are intellectual activities that are consistent with the values of academic medicine and discovery. Academic medical centers are well positioned to lead the way in the improvement of quality of care. As institutions entrusted with the education of future health professionals and charged with developing new knowledge, the authors call for a complete commitment to the highest level of quality in patient care.
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.