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Quality Improvement: Do We Mean It This Time?

by Emily Friedman

First published in Hospitals & Health Networks OnLine, December 5, 2005

The recent flurry of activity in both the public and private sectors concerning the quality of care suggests that we are finally getting serious about making improvements. Or does it?

Something certainly seems to be happening. We are seeing all kinds of activity with regard to improving the quality of health care and enhancing patient safety. Payers, providers, consumer groups and the press are all showing renewed interest in the subject. Reports are spewing forth like confetti. Conferences are being held. Initiatives are being launched. Terms like "pay for performance" and "evidence-based medicine" are all the rage.

Do we mean it this time?

Déjà Vu All Over Again?

I know that sounds like a cynical statement. But the fact is that there have been many flurries of interest in quality improvement in the past, yet nothing very substantial resulted. And these blips on the screen go back a long way. In the mid-19th century, Florence Nightingale wanted the outcomes of surgery publicly reported, as did Harvard surgeon Francis Codman half a century later. Pioneering physicians struggled to convince their colleagues of the value of antiseptic approaches following the Civil War. Codman's work was responsible, in part, for the founding of the American College of Surgeons, which in 1917 issued a list of standards for hospitals and began on-site inspections in 1918. That effort eventually produced the Joint Commission. The discovery of antibiotics was a huge leap forward, but even while that revolution was in its infancy, Alexander Fleming, who is credited with discovering penicillin in 1928, warned that its overuse would lead to resistant bacteria. Too bad nobody listened.

Warnings about the consequences of undecipherable handwritten prescriptions have been echoing for decades. John Wennberg, M.D., first wrote about inconsistencies in medical practice and outcomes in 1969, and published the first data on medical practice pattern variations a few years later. Medicare launched Professional Standards Review Organizations to audit quality of care for beneficiaries in 1972; these entities have evolved repeatedly and are still with us today as Quality Improvement Organizations (QIOs).

Don Berwick, M.D., and his colleagues founded the Institute for Healthcare Improvement (IHI) in 1991. Wennberg and his colleagues published the first Dartmouth Atlas of practice variations in 1996. In 1999, the Institute of Medicine issued its landmark report, To Err Is Human, which estimated that annually, nearly 100,000 hospital inpatients die unnecessarily. Earlier this year, Karen Davis, Ph.D., president of the Commonwealth Fund, and Lucian Leape, M.D., of the Harvard School of Public Health, published a well-titled article, "To Err Is Human; To Fail to Improve Is Unconscionable" (available on the Fund's Web site, They pointed out that the authors of To Err Is Human expected a 50 percent reduction in hospital errors by 2005.

Needless to say, we didn't make it.

So, after 150 years of calls for better quality and patient safety, are we ready?

Are the Stars in Alignment?

A friend of mine said to me recently that she thinks "the stars are in alignment" for real action on quality improvement. I so hope she is right. In this ever-more-consumerist age, public tolerance for poor quality is eroding quickly. The ongoing malpractice litigation mess, which is demoralizing physicians and sparking political action in many states, is an extra incentive. As health care costs continue to skyrocket, the fact that good care costs less than bad care is starting to sink in. We are seeing the first glimmers of a practice that should have begun long ago: A few payers are starting to refuse to reimburse providers for major treatment mistakes. Data collection on outcomes is expanding at a record rate. New standards are being issued from a variety of quarters. The Medicare Payment Advisory Commission has urged that Medicare pay providers differently based on the quality of their services.

And providers, despite their qualms about what all this might mean in terms of litigation, public trust and payment, are embracing the idea of doing better. They are joining the IHI's 100,000 Lives campaign; they are releasing data; they are retooling their processes. Leo Greenawalt, president of the Washington State Hospital Association, wrote recently that he had never seen an issue galvanize his members as much as the movement for improving patient safety.

Barriers Remain

This is not to say that the road ahead will be smooth. There remains a great deal of resistance on the part of providers who fear lawsuits, costs, bad science and loss of autonomy. Most payment systems still reward bad care rather than penalize it. Physicians, especially, are not enchanted with all the new demands on them; indeed, recently a major teaching hospital implemented an extremely expensive computerized physician order entry system (CPOE) that the medical staff refused to use.

And even as the drumbeat for a national health care information technology infrastructure resounds more loudly, and requirements for data reporting emanate from every corner, there is the teeny little question of who's going to pay for all the technology, data collection, analyses and necessary improvements in hardware, software, personnel and procedures. For smaller and rural facilities and for solo and small-group medical practices and clinics, the costs could be huge. This is going to be a very expensive lunch, and I don't see people falling all over themselves volunteering to pay for it.

Furthermore, although the science is clear for a number of situations (older patients and those with chronic illness should get flu shots; hospital employees should wash their hands often; rapid response teams cut mortality in the ICU; and so on), for many patients, the standard of care does not yet exist. Patients, being human beings, have a habit of differing from one another, and so do their responses to disease and treatment. A person who isn't very ill can get superb care and still deteriorate; a very sick person can get poor care and survive. We have a ways to go before science catches up with the current enthusiasm.

But none of these barriers can or should be used as an excuse to derail the quality improvement train. They can be overcome. And even if we can't do everything right now, we can do a heck of a lot. And we should.

10 Thoughts

To that end, I would like to offer 10 considerations for the new quality movement, which I hope will help it on its way.

Too many cooks spoil the effort. As I see the daily reports of who's doing what on the quality front, I cannot help but think that this is something of a free-for-all. We have (among many, many others) the Joint Commission, the IHI, the National Quality Forum, the QIOs, private insurers, the Centers for Medicare & Medicaid Services, the Agency for Healthcare Research and Quality, state governments, Premier, the Leapfrog Group, the Patient Safety Institute, Health Dialogue, private think tanks, the AHA, the AMA, state hospital associations, the University HealthSystem Consortium, the Health Services and Resources Administration, the U.S. Congress, state Medicaid agencies and, for that matter, U.S. News & World Report, Consumers Union and the Public Citizen Health Research Group all weighing in on quality and what to do about it. It seems to me that they might just get in each other's way. There needs to be some coordination and cooperation, and that will not be an easy task.

Which standards will prevail? When health insurance began the stampede to managed care in the 1980s, almost every hospital was suddenly faced with 25, 50, even 75 different contracts with HMOs, each with its own little eccentricities and demands. If providers are faced with the same smorgasbord of quality standards, with each payer, government agency and employer demanding different things, it's not going to work. If we are serious about quality, consistent standards will be necessary whenever possible. That said, some flexibility is necessary because of the vagaries of individual patients--and special attention must be paid to the needs and special circumstances of subpopulations, including women, minorities, the socially vulnerable and the chronically ill. The recent (and very welcome) emphasis on addressing disparities in health status and care will stall if everyone gets lumped together.

Who's going to pay for all this? A national effort to improve quality will require significant investment in everything from IT to better staffing to data collection, analysis and reporting. It ain't going to be cheap. The ability of various players to pay for it differs greatly. My view, for whatever it is worth, is that everyone should contribute to the national IT infrastructure, development of standards and monitoring of compliance--but the trade-off must be that everyone has access to the system and its information, and that includes the taxpayers (see the next point).

Public or private? Some years ago, a private think tank received millions of dollars from the federal government for a major research effort involving, among other things, quality and utilization of health care. Once the researchers had finished their work, they created a proprietary product from their findings, patented it and got rich selling it. The taxpayers who funded this effort, so far as I could see, got nothing in return. In a time when human genes can be patented (thanks a lot, Bernadine Healy, for allowing this during your stint as head of the National Institutes of Health) and every researcher has that entrepreneurial gleam in his or her eye, the question of what elements of quality improvement should be in the public domain and what elements can be proprietary is central to the success or failure of our efforts.

It helps if the clinical professionals are on board. Recently Teri Fontenot, president and CEO of Woman's Hospital in Baton Rouge, La., wrote in Most Wired OnLine that the success of her organization's IT adoption was due in large part to the fact that the medical and nursing staff were involved from the get-go. Other organizations have learned that lesson the hard way. Physicians are very nervous about some of the latest quality improvement efforts; both the AMA and the Medical Group Management Association have expressed grave concern about CMS' latest (voluntary) physician quality data-reporting initiative.

It is extremely important that everyone involved in these efforts recognize that in the end, it is the physicians, nurses and other hands-on caregivers who will produce success or failure. They are the ones who make the decisions--sometimes split-second--and who must implement the procedures and processes, monitor the results and change what isn't working. Leaving them out of the loop is not only foolhardy; it's stupid.

Should payers be in the lead? A great many things happen by default in health care (if no one else is doing it, well, heck, I guess we will). But when insurers, public payers and employers end up taking the lead in quality improvement, I think we may be justified in being a little anxious. In the best-case scenario, these payers will wield enormous influence in making providers accountable for the consequences of poor quality, and they will have the power of payment to back up their demands. In the worst-case scenario, quality will become hopelessly confused with cost containment, and I'm not sure quality will win out. When the insurers who are encouraging sick patients to cut their pills in two in order to save a little money are also the insurers who are dictating quality standards, one cannot help but worry. There is a potential conflict of interest here of significant proportions, and protections must be part of the equation. On the other hand, if providers had seized the opportunity to push quality improvement earlier, then payers might not be in the catbird seat today.

Reward or punishment? As many observers have pointed out, under the current payment system, providers who pursue good quality are often penalized, whereas providers whose care is substandard are often rewarded. Furthermore, payers are loath to stop paying anyone, no matter how awful the consequences. When a couple of cardiologists at a for-profit California hospital were found to be performing angiographies and bypasses on perfectly healthy patients, it was months before any payers pulled the plug. What were they thinking? How could any employer or insurer or government agency allow patients to go to a hospital where such things were happening? In their article, Davis and Leape wrote about medical errors generally, "We can't afford this kind of care anymore. And we shouldn't pay for it." Amen to that. Pay for performance is a good concept, as is any scheme that rewards providers for doing the right thing. But there should also be penalties for doing the wrong thing, especially if it is done repeatedly.

How will the information be used? As medical records go online nationally, and data on patient care and outcomes are reported all over the place, serious questions arise about who will have access to this information and how it will be used. On the one hand, there is nothing like public exposure to get someone or some organization to clean up his/her/its act. On the other hand, I don't think anyone believes that simply providing fodder for the plaintiff's bar is a good idea. On the third hand (as it were), the value of the data and the ability of lay people to interpret them remain open questions. Remember when the feds were releasing raw hospital mortality data in the 1980s? All kinds of mischief resulted as certain hospitals were associated with high mortality rates. A brilliant health services researcher friend of mine, upon viewing the data, said, "You better hope that the big teaching hospitals have higher mortality rates, because it means that they are treating the most difficult cases. You should be wary if the rates at a small rural hospital are high." Yet how many patients and lay people think in that analytical way? If these data are to be useful for patients and the public at large, they have to be accurate, trustworthy and transparent, not to mention intelligible. I don't think we're there yet.

What are the implications for malpractice litigation? The honest answer is, no one knows. Although many providers, like the rest of us, would prefer to work in a no-fault, no-accountability environment, the chances of that aren't good. When I asked some high-level insurance executives why they had continued to pay for care at that California hospital where the unnecessary cardiac procedures were performed, they gave the same answer I have heard thousands of times: "We would have gotten sued." Well, my late (and much-missed) friend, attorney David Manoogian, who spent his entire career defending providers and health plans against malpractice claims, always said, "I would a thousand times rather defend a client who tried to protect patients than one who tried to cover up for someone." The best defense against malpractice predators is to reduce malpractice, get rid of people who should not be providing care and shut down shoddy providers. If there is nothing to eat, the sharks swim away.

The bell curve. Whenever major change comes to health care, the response can be seen as a bell curve, with the early adopters embracing the change, the middle adopters doing the same once the risks have diminished, the late adopters straggling along behind and the nonadopters refusing to play. Who goes with the program and who does not is a complex sociological study, and who does what is not necessarily compatible with our assumptions. Small organizations and practices may adjust easily; large, prestigious organizations may not. But at some point, once science and practice demonstrate that this is the road we should be on, some pressure must be exerted to see that even the most resistant get with the program--or get out of the game. Let's hope that the latter situations will be few and far between.

In the end, there is nothing to be saved but lives, money, trust and honor. That would seem to me to be incentive enough.

First published in Hospitals & Health Networks OnLine, December 5, 2005

© Emily Friedman 2005

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