How is Quality Defined?
Patient Safety, Quality Improvement, and Pay-for-Performance
In Crossing the Quality Chasm: A New Health System for the 21st Century, the Institute of Medicine (IOM) calls on all healthcare organizations, professional groups, and private and public purchasers to adopt as their explicit purpose "to continually reduce the burden of illness, injury, and disability and to improve the health and functioning of the people of the United States." Through our mission statement, "Working for the Best Ear, Nose, and Throat Care," the Academy has indicated that delivering the highest quality healthcare to our patients is our core mission. But what does that really mean and how can the Academy support its members in providing the highest quality care in daily practice?
The IOM lays out six characteristics of high-quality care, which have been widely adopted by other organizations active in improving the quality of healthcare.
Figure 1: Six Steps to High-Quality Healthcare
Care must be safe
Patient safety is fundamental to high-quality healthcare. When the first IOM report, To Err is Human, was released, many healthcare providers were incredulous. They couldn’t believe that millions of people were harmed annually because of errors, and that up to 98,000 of these patients died as a result. Unfortunately, additional studies indicate that the numbers of patients harmed by errors may be even higher. If patients can’t be confident that they will not be unintentionally harmed or killed by care that is intended to help them, the other aspects of high-quality care have little meaning.
Most errors occur as a result of multiple interrelated contributing factors—not just the behavior of one individual. Assuring that all care is safe for all patients requires examining the systems and processes of care, identifying the points of failure, and modifying the factors that cause systems to break down.
Care must be effective and reliable
Effective care means that patients do not receive care that cannot help them and/or where the risks of care outweigh the benefits, and that patients reliably receive care where the known benefits outweigh the risks. To say that healthcare is effective implies that there is an evidence base to support that claim. Unfortunately, for many aspects of healthcare, the data to support best practices are inconsistent and do not reflect the full range of conditions and treatments relevant to day-to-day practice.
Reliable care implies that patients will consistently receive the same standard of care regardless of when, where, and from whom they receive care. However, there continues to be significant variation in the quality of care that patients receive. A 2004 study by RAND Corporation shows that for many clinical conditions with known best practices for quality care, only about 50 percent of patients receive care consistent with the guidelines for recommended care.
Care must be patient-centered
Patient-centeredness focuses on the patient’s experience of illness and healthcare and the degree to which systems succeed or fail in meeting individual patient needs. Anyone who has ever been seriously ill knows the fear, anxiety, and helplessness that are part of being a patient. Patient-centered care works to relieve this emotional pain as well as the patient’s physical pain. Truly patient-centered care is characterized by:
- respect for patients’ values, preferences, and expressed needs;
- accurate information about their condition and treatment, given in a language that patients understand;
- relief from unnecessary physical pain and discomfort, such as shortness of breath, especially at the end of life;
- emotional support to address the anxiety that accompanies all injury and illness; and
- accommodation for family and friends on whom patients rely for support and comfort.
Care must be timely
Timeliness of care is interrelated with safety, efficiency, and patient-centeredness of care. Long waits in physicians’ offices, emergency rooms, on gurneys in hallways, and long waits for test results not only result in emotional distress, but may result in physical harm. For example, a delay in test results can cause delayed diagnosis or treatment—resulting in preventable complications.
Waits also affect the providers of care. Surgeries are delayed and doctors and nurses wait while staff try to track missing information that is vital to a patient’s care. Delays and barriers in care, such as referral and authorization processes, consume time and energy. Any high-quality process should flow smoothly.
Care must be efficient
An efficient healthcare system uses its resources to get the best value for the money spent. The current system is characterized by a great deal of waste—resources used without benefit to the patients the system is intended to help. Efficiency can be improved at all levels of the system, from the solo office practice to regional health systems to national healthcare programs. There are a number of strategies that can be used to reduce waste—managing access to care by matching supply to demand; managing flow through the system by eliminating tests, processes, and layers of control that add complexity or are not necessary; avoiding duplication of tests and procedures through consistent, accessible record keeping; and appropriate recycling and reuse of resources or wise substitution of more efficient resources.
Care must be equitable
Equity in healthcare operates at two levels: at the population level and at the individual level. At the population level, the goal of the system is to improve health status and reduce disparities among subgroups. At the individual level, the goal is for healthcare providers to treat all individuals fairly and deliver high-quality care regardless of personal characteristics, such as age, gender, race, ethnicity, education, disability, sexual orientation, income, or location of residence.
Quality improvement and pay-for-performance
It is possible to find physician practices and healthcare facilities that exemplify one or more of these characteristics of high-quality care, but it is rare—if not impossible—to find an organization that consistently meets all of them. We know that it is possible to do better. Other high-risk endeavors, such as the airline industry or operating nuclear-powered aircraft carriers, do a better job than the healthcare industry in consistently producing appropriate outcomes and preventing adverse events.
Quality improvement is the science of analyzing where organizations and systems fall short of providing high-quality care and the practice of devising, testing, and evaluating tools and techniques to address those shortcomings. Many organizations, public and private, are working to improve patient safety and the quality of care. Many of the resources necessary to evaluate and improve care are publicly available. In the coming months, the Academy will be working to provide the linkages our members need to implement practical quality improvement processes in their practices.
Pay-for-performance (P4P) programs, when designed primarily to improve the effectiveness and safety of patient care, attempt to align the incentives of all members of a healthcare delivery system toward the common goal of providing high-quality care encompassing all six IOM dimensions. Physicians will want to assure that P4P programs ensure quality care, foster the physician/patient relationship, offer voluntary physician participation, use accurate data and fair reporting, and provide fair and equitable program incentives prior to choosing to participate.
How is the Academy preparing for P4P
We are actively participating in the Surgical Quality Alliance (SQA) to develop accurate and fair measures of surgical care for the Centers for Medicare and Medicaid Services’ (CMS) Physician Voluntary Reporting Program (PVRP) beginning January 2006. We are working to develop a supply of ENT-specific measures to offer to CMS and other private and public P4P programs. Watch the Academy website for new tools and resources, workshops, and educational programs, and new and updated clinical guidelines and outcomes measures related specifically to the practice of otolaryngology and head and neck surgery.
Questions? Contact us!