"Health care today harms too frequently and routinely fails to deliver its potential benefits," a March Institute of Medicine report charged.
When a 1999 IOM report estimated that up to 98,000 U.S. deaths per year are caused by medical errorwhich experts say is probably a gross underestimatea public outcry followed. Many expected that IOMs next report would prescribe specific and detailed recommendations for improving patient safety, IOM president Kenneth I. Shine, M.D., said at a March colloquium in Boston.
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"Its the egregious errors that get the publicity, but almost everyone has had some experience with medical error," he said. For the purposes of quality improvement, he explained, medical error may be defined as the failure to carry through an intervention as planned, or poor decision-making because all potentially available information was not used.
In the past, doctors were regarded as the keepers of an esoteric body of knowledge, and how well they used it was the most important determinant of quality in medical care. But "in the 21st century, the use of personal knowledge by physicians has very little to do with quality of care," Shine said. "It is the systems of carefrom macro- to microsystemsthat determine outcomes."
"Its not about managed care versus fee-for-service," he added. "There are examples where each is better."
Shine said the new report, Crossing the Quality Chasm (online at http://www.nap.edu/books/0309072808/html), reaches many of the same conclusions as a 1999 report from IOMs National Cancer Policy Board. For instance, both reports say that outcomes for a given disease are typically better in institutions that treat large numbers of patients with that disease. In response to the NCPB report, the American Society of Clinical Oncology launched a study aimed at developing a monitoring system for cancer care, and the National Cancer Institute is forming a consortium of research institutions to study outcomes of care (see News, Dec. 6, 2000).
The report states that health care should be safe, effective, patient-centered, timely, efficient, and equitable. Its "10 simple rules for the 21st century health care system" reflect the shift to a systems approach (see box, next page). The belief that "do no harm is an individual responsibility" is replaced with the realization that "safety is a system property." While currently, "decision making is based on training and experience," the report projects that in the system of the future, "decision making is evidence-based." Perhaps the most radical change predicted by IOM is that in the future system, "the patient is the source of control," not the health professional.
Edward Guadagnoli, Ph.D., associate professor of health care policy at Harvard Medical School, Boston, noted that patients involvement in their own care decisions is sometimes a better indicator of quality than which treatment they get. Early research on breast cancer care often oversimplified the issues, he said. For example, early research equated a high ratio of mastectomies to lumpectomies with lower-quality care.
"I think the bigger issue is whether the woman is informed of her options and whether she has a role in making the choice for her surgery," he said.
The IOM report further states that "in many cases, the best window on the safety and quality of care is through the eyes of the patient." At the Dana-Farber Cancer Institute, Boston, for example, a patient and family advisory council has worked to expedite emergency admissions for neutropenic patients, minimize clinic wait times, and clarify for inpatients the roles of each care team member.
One priority identified by IOM is improving the use of information technology so that patient information is efficiently collected and accurately transmitted. A decade ago, the report noted that IOM called for nationwide implementation of computer-based patient records. "But progress has been slow," the report states.
Another priority listed in the report is to align payment policies with quality improvement. The report describes how, under the current system, hospitals frequently lose money by providing better care, for instance when healthier patients are shifted to diagnosis-related groups with lower per-case payment rates that fail to cover costs.
The report suggests that doctors could make much greater use of e-mail to communicate with patients when an office visit is not required, but the report also notes that there are no systems to reimburse them for this kind of patient contact, thus there is no incentive to spend valuable time on it.
Practice guidelines are another way quality could be improved if the guidelines are consistently implemented. Shine noted that five health plans that together cover nearly all Minnesota residents announced in March that they would standardize treatments for 50 common conditions such as high blood pressure and diabetes. This is the first time all major health plans in a state have agreed on standard guidelines.
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