Partway across the quality chasm

Much has changed in the years since the Institute of Medicine published To Err is Human and Crossing the Quality Chasm, companion reports released in 1999 and 2001 that sounded the alarm about high rates of adverse events and the urgent need to adopt proven best practices in healthcare.

Government agencies have ramped up improvement efforts through public reporting mandates, demonstration projects, payment incentives and other programs. And many hospitals and health systems have undertaken large-scale initiatives aimed at lowering rates of hospital-acquired conditions, curbing readmissions and engaging patients in their care, all while implementing interventions to redesign care processes, improve culture and create high-reliability systems.

Experts say those efforts have led to some significant improvements, including recent strides in reducing rates of some types of healthcare-associated infections and improving coordination among providers. But there is still plenty of work to be done.

“I'm encouraged by the awareness and the progress over the last few years, but I'm also dismayed by how slow it has been,” said Julianne Morath, CEO of the Sacramento, Calif.-based Hospital Quality Institute, a new not-for-profit formed by the California Hospital Association and several regional hospital groups. “We're still harming people through pressure ulcers, falls, poor hand hygiene—less than we were before, but we're not close to zero yet.”

She pointed to particular areas of success, including hospitals' marked reduction in rates of central line-associated bloodstream infections.

“The problem is that as we solve one issue, there are others that replace it and they come in rapid succession,” Morath said. “Our physicians and nurses need more elegantly designed systems with accessible, interpretable data.”

In companion reports on healthcare quality and disparities, released in May, the Agency for Healthcare Research and Quality found that quality is continuing a slow but steady upward climb, while healthcare disparities showed little to no signs of improvement and access to care worsened.

Overall median quality improved 3.2% across the healthcare system, just slightly above the rate of change reported in previous years, according to the annual AHRQ reports, now in their 10th year, which draw information from a slew of sources, including administrative data, patient surveys, and home health and hospice reports. The overall rate of improvement in last year's report, for instance, was 2.5%.

“We have a long way to go, but when you step back and look at the progress we've made over the last 10 years, it does add up,” said Dr. Ernest Moy, medical officer in AHRQ's Center for Quality Improvement and Patient Safety. “We can look back and be proud that quality has consistently and persistently improved each year.”

Moy said he expects even bigger jumps in quality—and long-awaited improvements in racial, ethnic and socioeconomic disparities—in 2014, with the implementation of expanded coverage and state insurance exchanges under the Patient Protection and Affordable Care Act.

These latest AHRQ reports draw from data through 2009, with some from 2010, a period Moy said should serve as a baseline measure of the state of healthcare quality, access and equity before the earliest provisions of the ACA kicked in.

“I'm definitely hopeful,” Moy said of the prospects for future quality gains. “We're finally addressing the issue of access in a big way, and I'm looking forward to good news.”

But authors of a recent report from the Robert Wood Johnson Foundation argued that efforts to improve quality and patient safety will falter unless more attention is paid to improving performance measurement. The 31-page report, released May 21, included seven policy recommendations, such as moving aggressively from process to outcomes measures, measuring quality at the organizational level instead of the clinician level, investing in the science of measurement development and incorporating more patient-reported outcomes.

“It's a good time to reflect and take a critical look at the measurement enterprise,” said Dr. Harlan Krumholz, a professor of cardiology and health policy at Yale University, New Haven, Conn. Krumholz co-authored the report with Dr. Peter Pronovost, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins University, Baltimore, and Dr. Robert Berenson, a senior fellow at the Washington-based Urban Institute.

Krumholz said the policy recommendations listed in the report are “vital” for bolstering continued efforts to improve quality and safety. The authors also called for the formation of a single entity tasked with defining measurement and reporting standards, similar to the role the Securities and Exchange Commission serves for the reporting of corporate financial data.

“We're making so many changes to healthcare delivery, and we need to know how our work is impacting patients,” he said. “Without the ability to assess where we stand, I think we're going to be in the dark about what to do next.”

Follow Maureen McKinney on Twitter: @MHMMcKinney