Crossing the Quality Chasm: A New Health System for the 21st Century

4 Responses to “Crossing the Quality Chasm: A New Health System for the 21st Century”

1. Dawn McKenzie says:

   July 19, 2010 at 7:54 pm

   Fantastic book which is still relevant in these changing times. Healthcare is still a long way from delivering quality and this book clarifies the gaps
   Rating: 5 / 5
2. Kip Piper says:

   July 19, 2010 at 9:52 pm

   If you are in anyway caught up in health care, this is essential reading. Physicians, sickbay administrators, purchasers, health plot execs, and grad students must immediately place this on the top of their reading list. Lives may depend on it.

   In it, the highly respected Institute of Medicine builds a powerful case for how the current health care system is severely kaput and how it has produced a “chasm” between what we known must be done for patients (based on current science of medicine) and what is really done. The in rank conveyed is shocking but right. Even more significantly, the Institute gives us a plot for building a new, more accountable quality-driven approach to health care.

   Read it and perhaps you too will be motivated to take action to improve health care delivery in America.
   Rating: 5 / 5
3. Jack Warfield says:

   July 19, 2010 at 11:02 pm

   Brilliant reference to learn of the history/movement that prompted the EMR environment we are in today
   Rating: 5 / 5
4. George Dawson says:

   July 20, 2010 at 12:23 am

   This book is written as the product of an Institute of Medicine initiative to reduce the mortality and morbidity from errors in the American healthcare system. The Institute of Medicine is a private organization made by congressional charter to advise the federal government on specific matters. Their mission statement is to “advance and disseminate knowledge to improve human health.” This book is the final report of the Group on the Quality of Health Care in America. Their homepage is available by searching the Internet using the full group name. Membership of the group and sponsors of the project are available at that web site.

   The format of the book is to bestow evidence for quality problems in healthcare in America and make recommendations. The operational definition of quality used in the book is “The degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” There are thirteen recommendations presented initially and are discussed in relevant chapters. The recommendations vary in scope from suggesting that multiple parties need to be committed to quality as a way to fall the burden of disease to suggestions that specific agencies fund pilot studies to look at how reimbursement can be aligned with quality. Six major parameters are discussed as guiding quality and it is suggested that 15 specific conditions be a focus for improving quality.

   There is no difficulty in identifying literature studies that exhibit quality problems in sickbay and clinical populations. A survey of current research is included in Appendix A. A review of the tables in this appendix show the types of quality markers that are typically studied in the literature. The authors make the argument that errors due to quality lapses or deficiencies need to be actively worked on and that the current high error rates are not acceptable. Health care has become a major political come forth and the political factions are shaping up to be government and business on one side and physicians and other health care providers on the other. There has been a major revamping of the health care system in the past decade to control expenditure. That required the active cooperation of the insurance industry and government. There is still medical inflation and limited access with 40 million Americans uninsured. Should we judge that another cooperative effort between industry and government will improve quality any more than it has controlled cost or improved access?

   The authors acknowledge weaknesses in their suggestions about changing the face of American medicine, but they minimize the adverse impact of the current funding mechanisms for medical care and the come forth of in rank systems integration and wellbeing. A excellent example can be found in their application of engineering principles to clinical settings – - where teams see patients for four hours of direct contact time and the remaining time is for documentation and returning calls. That plot would not be economically realistic in many settings. The high cost and lack of flexibility of the current reimbursement schemes are not mentioned as a potential reason why these plans won’t work.

   In rank technology is seen as a way to enhance both productivity and safety. The authors suggest that e-mail can lead to productive exchanges between physicians and patients. Many physicians have been doing this for years. Many have also stopped with the advent of wellbeing concerns about medical privacy. With larger IT systems the critical come forth is backward compatability with older systems. That ordinarily requires custom designs that are extremely pricey. Those problems ordinarily need to be solved before bedside computing and choice support can be developed. Wellbeing is acknowledged as a problem that needs to be solved. In spite of a federal initiative in this area, the vital precedent to remember is how the financial privacy of Americans was protected. The authors top out that medical privacy requirements need to be more stringent than other industries. At the same time they top out that some opinions suggest that there is a trade off between privacy protections and the need to advance in rank technology in health care. If they are suggesting that the Internet should be at the heart of this infrastructure and the Internet is not secure, what does that mean?

   A matter-of-fact approach might be to focus on the areas where data is entered into computer systems and make sure that non-human analysis occurs at those levels. For example, all hospitals enter pharmacy orders into computer systems. Many hospitals require that physicians write separate discharge orders. Both of these points are areas where there may possibly be immediate improvements in accuracy. A focused study and solution may possibly be engineered now. The necessary software and hardware requirements may possibly be placed on a central web site and available for download by sickbay and clinic IT staff. Existing reviewers may possibly be charged with documenting the baseline level of errors and the degree of improvement.

   This book succeeds as a broad survey of what has been done about quality in certain settings. It contains some fascinating thoughts about what can possibly be accomplished by applying conceptual advances from other fields. It does not discuss the significant drawbacks of evidence based medicine. It lacks a matter-of-fact plot for transitioning to a new system and in effect makes a new chasm. With a work like this, whether you like the conclusions depends a lot on your interpretation of the evidence and your private experience. As a involved physician and a previous quality reviewer I have significant areas of disagreement with what is presented in this book. Areas of controversy are not elaborated upon. I suppose you may possibly say that level of analysis is not required, but recommendations about the future of health care in America should at least meet the criteria of “evidence based” and all the evidence should be discussed.

   George Dawson, MD
   Rating: 4 / 5