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Five Steps to Bad Healthcare

Jim Molpus, for HealthLeaders Magazine, January 13, 2009
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The same problems seem to block, stumble, or ruin quality improvement programs.

Those in charge of making sure healthcare gets better often point back to 2000, when the To Err is Human report from the Institute of Medicine was supposed to deliver a transformative call for vast improvement for quality in healthcare.

The report and others like it fathered countless goals, initiatives, and conferences dedicated to creating better awareness of quality and giving attention to improvement. The only thing missing is the improvement.

The most recent National Healthcare Quality Report from the Agency for Healthcare Research and Quality found that on such indicators as Centers for Medicare & Medicaid Services core measures, the annual percentage change actually declined from 2000 to 2005 (see chart, next page). So it might seem that there is an inverse relationship to the attention given to quality and the results coming from it. Yet at a basic level, what's keeping much of healthcare from getting better is a list of roadblocks that hospitals and health systems have not managed to overcome despite a decade of heavy attention to quality programs.

1. Not knowing when to declare victory
Whether it is in our hobbies, pastimes, or workplaces, we measure not just to compare, but also to find moments of celebration. Improving healthcare quality for the patient, unfortunately, is a never-ending process of countless measures not all necessarily coordinated to a master improvement plan. James Conway, MS, senior vice president for the Cambridge, MA-based Institute for Healthcare Improvement, says he spent almost two years speaking to hospital associations and conferences on the IHI's campaigns, and he always asked a single question: Does your organization have annual quality and patient safety goals?

"In no audience did more than half of the hands go up, and in one audience only about 25% of the hands went up," he says. "One of the first struggles is there is no clarity on what success looks like."

Success is complicated by hundreds of process indicators that drain motivation for caregivers, Conway says. The board and C-suite can help by setting definable goals in both the expected rate of improvement and the time frame.

"[Detroit, MI-based] Henry Ford Health system at the board level set a goal that in three years they were going to reduce mortality by about 25%, and the way they were going to reduce it was by focusing on a series of interventions, including infection, by focusing on sepsis, by focusing on medication," Conway says. "So all of a sudden the people out in the unit and in QI could see how the thing they were working on helped you achieve an overall goal."

2. Not explaining why the task is important
Nurses, physicians, and other clinicians got into the profession because they have a skill set that is part science, part caregiver. As scientists they need to know that their parts of the experiment will cause the right reaction. The caregiver in them needs to know that the process matters to the patient.