Challenges to Achieving the IOM Attributes of a High Quality Healthcare System

 
               Most people agree the Institute of Medicine’s (IOM) description of the attributes of a high quality healthcare system are appropriate and worthy of trying to achieve. But it has turned out to be quite difficult to make progress. In a news article earlier this year, Nancy Foster, vice-president of quality and patient safety for the American Hospital Association (AHA) described four key insights from the AHA-McKesson Quest for Quality applicants.[1] I am repeating her four observations here as they outline issues I have been addressing in other articles.
 
Patient Safety Continues to be a Challenge
 
               Ms. Foster notes that progress has been made, but “much work remains to eliminate medication errors, diagnostic errors, miscommunications during patient transitions, and other threats…”
               Many hope that electronic health systems and bar coding will eliminate medication errors. But I have encountered an interesting phenomenon in our hospital—medications not given “on time” are counted as errors, so nurses will sometimes want to give medications even though the patient is NPO for a test. While once daily medications are taken by the patient at home whenever they are accustomed to doing so, in the hospital, if not given at 0900 are an error. If the goal is to avoid patient harm, we need a more subtle, and relevant signal. Just because the time is easy to count does not mean it is necessarily important.
               Diagnostic errors is an interesting term. Does it mean always making the right diagnosis? If it does, then we are doomed to failure. The imperative to treat without adequate information has, and probably always will, be with us. Further, all tests have less than 100% sensitivity and specificity. As a general rule, you need at least a 10% pre-test probability of disease for a good test to be helpful. I think the biggest “error” I see is the lab barrage, which is fired in hopes of “not missing anything” rather than with a specific diagnosis in mind. Most young clinicians don’t seem to understand that Bayes’ theorem is alive and well.
               Miscommunications is clearly a problem, as all patients will transition care teams every twelve hours even if they don’t go off for radiology or other diagnostic and treatment tests. There is a role for standardized language as is used in crew management to reduce airline accidents, but a lot of this also depends on the quality of teamwork, an error often not addressed because of its difficulty to define and maintain.
 
Authentic Engagement of Patients and Families as Partners in Care Delivery is Difficult to Achieve
 
               Amen. I have addressed this issue repeatedly, as I see it as a major weakness in current thinking about how healthcare is organized and delivered. Patient portals, for instance, are thought to be important, but I don’t find they are activating patients. The ones who access the portal tend to be the ones who called the office rather when they had a question or concern. Now they send an email
 
Hospitals Often Can be Data Rich, But Information-Poor
 
               “It would be easy to think that the abundance of data equates to a wealth of information, but many applicants found this was simply not the case. The data provide a signal, but don’t become useful information without analysis and discussion.”
               This problem afflicts the whole healthcare system. CMS, in particular, thinks it knows what the data show—we are wasting money. So they use the data to force changes without any clear idea if it is going to work to either save money or improve patient care. But it is a present reality contributing to the strains seen everywhere.
               I find most people feel like they need to “do something,” without a clear idea about what it will cost, how it will be done, and if it is likely to be relevant from the patient’s perspective. A case in point.
Yesterday I saw a patient in follow up from a hospitalization where he underwent stenting for salvage of his leg. His complaint, though, was that he had not had a good experience of care this time, and stated he did not want to go back to that hospital. When I pursued this, it turns out he had two specific factors underlying his attitude. First, he was on anticoagulants as part of his limb salvage, which meant he had blood draws in the middle of the night. While clearly reasonable from a patient safety perspective, this was a major annoyance for him. The second complaint was that every time he want to get up to use the toilet, he had to summon two nurses, usually both women, to help him go. He thought it was quite unreasonable to expect him to be able to urinate with two women holding him up. I explained to him the hospital had adopted a detailed program to reduce falls, and he qualified because of his age, heart disease, and impaired circulation in his leg. Since he had not fallen, this did not particularly reduce his discomfort. So, even though he got a good result, as evidenced by the fact he was walking more than he had in a couple of years, and the care was free of major adverse events, he was not “satisfied” with his care. He did admit he felt better about it after talking to me, but I told him our goal was to keep him out of the hospital, so there was no reason to worry about it too much.
 
Achievement of the IOM’s Six Aims Requires a Well-Planned and Coordinated Strategy
 
               “Several applicants achieved remarkable progress on one or two of the Six Aims, but little progress on the remaining ones. When striving to achieve any set of aims, progress is rarely uniform, but we cannot achieve the best possible results for our patients unless we continuously strive to make progress on all six of the IOM aims.”
               Making progress on the six aims requires that improvement programs have multiple perspectives and objectives, but few organizations have structures that permit this kind of process. My perspective as a practicing physicians don’t always include financial perspectives, and we may all be blind to the patient’s perspective, as my anecdote illustrates. Most of the programs give little consideration to the issues involved in actual implementation—the who, what, when, and how sort of questions. Lastly, it is very difficult to balance competing projects and priorities. Left to their own devices, people will naturally attend to those priorities that are right in front of them, even though less visible priorities might actually be more important. Keeping all the teams focused and maintaining the priorities requires as type of leadership skill that is rare and hard to sustain. Given the complex structures of hospitals, it may not be possible for most to get there.
 
28 November 2015


[1] H&HN, August 2015, p. 10. www.hhnmag.com.

Further Reading

Clinical Integration 2015:  A Hospital Perspective
Health care organizations now assume "clinical integration" is necessary for economic survival, but the FTC continues to enforce antitrust actions blocking mergers and acquisitions.  Furthermore, clinical integration usually means different things to hospitals and physicians.  In this article I consider some immediate steps that can be done without legal complications to improve patient care and save money.  All that is really required is a change in our mental models.


The Practicing Physician and Medicare


What Hospitals Are Doing
How are hospitals and health systems responding to change? An AHA survey provides some insights, but suggests few are really working to improve the function and resiliency of their teams, and are thus likely to fail in attaining their strategic objectives.