Chapter 81
- Quality Improvement
- Peter J. Pronovost
- Sean M. Berenholtz
The need to improve quality of care is substantial. The purpose
of monitoring quality of care is to learn and improve. Improvement is facilitated
when providers regularly review performance, design interventions to improve, and
create a team to implement the intervention.[1]
Quality is a characteristic of the system in which care is delivered. To improve,
we need to reorganize work.
There is a growing demand for improved quality and safety in health
care from patients, providers, insurers, regulators, accreditors, and purchasers.
This demand is warranted; evidence suggests that safety and quality of care in hospitals
can be improved.[2]
[3]
[4]
[5]
[6]
In 1999, the Institute of Medicine (IOM) released a report, "To Err is Human," which
estimated that there are 44,000 to 98,000 preventable deaths every year in U.S. hospitals.
[3]
Although the epidemiology of preventable deaths
is debated, these estimates survived the challenges. Even if the lower estimate
of preventable deaths—44,000 per year—is used, that is more annual deaths
in the United States than from AIDS, motor vehicle accidents, or breast cancer.
The number of preventable annual deaths exceeds that of the World Trade Center tragedy
by 14-fold or equivalent to a World Trade Center-type event every 25 days.
An important limitation is that these estimates include only mistakes
of commission—things we do to patients. If mistakes of omission are included,
the numbers are larger. Patients can count on receiving only one half of the therapies
they should receive.[7]
The need to improve quality is predictable. Previously, research
funding and activities have focused on understanding disease mechanisms and identifying
effective therapies, whereas relatively little research focused on methods of delivering
those therapies safely, effectively, and efficiently. As a result, one of the greatest
opportunities to improve patient outcomes will likely come from discovering how to
deliver therapies that are known to be effective, rather than from discovering new
therapies.[8]
We may realize these improvements
with a more balanced research portfolio in which the end, health services research,
and the beginning of the translation superhighway[9]
[10]
are valued.[3]
[5]
[11]
The delivery
of care is a science as well as an art.
The same imbalance between discovery and delivery of health services
exists in health care institutions. To improve, caregivers need to know what to
do, how they are doing, and be able to improve the processes of care.[1]
[12]
[13]
[14]
Although the ability to monitor performance is fundamental to improving any system,
[1]
health care providers have limited ability to
monitor performance in their daily work, in part because of a lack of information
systems and a lack of agreement on how to measure quality of care.[5]
Information must be subjected to well-designed analyses to produce knowledge on
which caregivers can act. As a result, we often fail to learn from the daily practice
of medicine and restrict learning to formal clinical studies that enroll a small
percentage of patients who receive health care.
Nonetheless, it is possible to obtain feedback and learn from
routine practice. For example, improvements in surgical morbidity and mortality
derive in part from providing frequent feedback, generally as case series, regarding
what works and what does not work.[15]
[16]
[17]
[18]
[19]
[20]
Methods of continuous feedback from industrial
engineering may provide an opportunity to learn from routine practice and improve
quality of care.[21]
In this chapter, we consider the definition of quality of care,
provide a framework for improving quality, and explore how these principles may apply
to anesthesia.
