A Better Approach to Quality Improvement

April 17, 2011

In the April issue of the journal Health Affairs, my colleagues and I descibe the success of a broad collaborative effort that has been in place in Michigan to improve quality of health care. The focus of the April Health Affairs is what has happened since the seminal work by the Institute of Medicine – Crossing the Quality Chasm – was published.

The Quality Chasm was published by the IOM in 2001 and contained a virtual litany of the failures of the American health care delivery system to provide quality care (in this context, I would note that it isn’t entirely clear that other systems in the developed world are any better).

The issue is worth taking a look at for the breadth of its commentary on efforts around the country to improve quality of care in the wake of Quality Chasm and its 1999 predecessor, To Err is Human. There are many positive stories, including one by Peter Pronovost, who profiled his efforts in partnership with the Michigan Hospital Association (MHA) to encourage the use of simple checklists to improve quality and safety.

Pronovost’s work in partnership with MHA’s Keystone group has shown remarkable results. The effort was also low cost, and could be implemented without reliance on changes in information or other hospital technology. The idea is now part of the global dialog on safety in health care.

Interestingly, Pronovost’s work borrowed heavily from safety improvement strategies in the airline industry that are also simple and yet, powerful.

There are key lessons that can be drawn from Pronovost’s and MHA’S Keystone effort and the work my colleagues and I have done on Collaborative Quality Initiatives reported on in our article. The lessons are profound, and if used by policy makers, can provide insight into strategies included in the Affordable Care Act and elsewhere to improve quality.

Key lessons include:

1. To really improve quality and safety, we must take systemic approaches to changing culture and practice patterns. It is not enough to dictate that something will happen (or won’t). Dictating outcomes by payers may feel good and have some short term effect, but in the end, it won’t do much to change the underlying reasons for safety/quality issues.

2. Collaboration among providers in a peer setting is a powerful tool to create change. It is only in a peer setting where problems can be discussed openly without fear of reprisals. The airline industry has pioneered this insight. In punitive cultures or with punitive policies, people will react by hiding the truth (hmm, we seem to know this in parenting but not in health policy!) rather than by seeking to understand and fix underlying programs.

3. Solutions can be low cost and low tech. The health care world seems to have fallen in love with information technology as the answer to the cost and quality of health care. While these approaches may well help improve quality, they are harder to deploy than people would like to think and their impact on quality and safety is likely somewhat over-valued. The approaches we and Peter Pronovost described can be implemented without special technology and make a profound difference.

4. Infrastructure and data are fundamental if real change is to occur. We don’t like to pay for infrastructure because it feels like unnecessary overhead. But, the reality is that clinicians need to focus on taking care of patients and don’t have time to put together the information and tools that are essential if systemic issues are to be addressed. Sharing robust data and funding for the infrastructure to support its interpretation is essential if progress is going to be made.

There isn’t a lot of magic in these lessons: they should be common sense based on an understanding of how human beings function best and what we know from other fields.

But, if we look at health policy coming out of Affordable Care Act and elsewhere, these lessons don’t yet seem to be fully embraced. Susan Dentzer’s opening piece in the April Health Affairs issue, Still Crossing the Quality Chasm, notes that we still have far to go if we want to make real, sustained progress in improving the quality of clinical care.

The idea we have shared is only one way to get to this goal. But, without a doubt, it is an idea we can all build on.