Trends

An updated version of this essay appears on the Nothing but the Truth about Quality book.

JCAHO just released its goals for patient safety. How we define our goals says a lot about what we're doing - or not doing - right now. See what next year's goals say about current patient safety.

What our goals say about where we are now

• IOM Reports on Quality of Healthcare
• JCAHO National Patient Safety Goals
• What's wrong with this picture?
• Why is quality such a problem?
• A modest proposal
• References

September 2003

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recently announced its 2004 National Patient Safety Goals. It's very revealing to review these goals and ponder the state of quality in healthcare. If quality means doing the right thing right, patient safety means doing the right thing right to the right patient (and NOT doing anything else wrong).

The JCAHO patient safety goals are a result of reports and recommendations made by the Institute of Medicine (IOM). In the year 2000, IOM issued a report "To Err is Human" [1], which triggered the patient safety movement. IOM estimated there are 44,000 to 98,000 deaths per year as a result of medical errors, primarily due to errors in the administration of pharmaceuticals. In 2001, IOM issued another report "Crossing the Quality Chasm" [2], which makes recommendations for improving the healthcare system. JCAHO's emphasis on patient safety can be seen to be a direct response to recommendations 2 and 3 in the IOM report. [The remaining IOM recommendations deal with establishing a national infrastructure for initiating change, building organizational support for change, and establishing a new environment for care.]

Recommendation 2. All health care organizations, professional groups, and private and public purchasers should pursue six major aims; specifically, health care should be safe, effective, patient-centered, timely, efficient, and equitable.

Recommendation 3. Congress should continue to authorize and appropriate funds for, and the Department of Health and Human Services should move forward expeditiously with the establishment of, monitoring and tracking processes for use in evaluating the progress of the health system in pursuit of the above-cited aims of safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.

Note that safety is first on the list of the six specific aims for improvement. Safety is really just one dimension of quality. The other five characteristics are also dimensions of quality, but priority is given to the "do no harm" aspect, which certainly fits with the Hippocratic oath and its code of ethics for medicine.

JCAHO National Patient Safety Goals

What follows are the statements of the goals without the JCAHO explanatory notes and requirements for implementation.

Goal 1. Improve the accuracy of patient identification. [Be sure you've got the right patient for whatever test or procedure being performed!]

Goal 2. Improve the effectiveness of communication among caregivers. [Verify any verbal communications, particularly the numerical results of lab tests, to be sure they are understood by the person at the receiving end!]

Goal 3. Improve the safety of using high-alert medications. [Don't leave highly dangerous pharmaceuticals laying around where they might be misused. This is sort of like poison control in the home!]

Goal 4. Eliminate wrong-site, wrong-patient, and wrong-procedure surgery. [Unbelievable that this would have to become a national goal for patient safety in this day and age! And the surgeons who make these mistakes are the highest paid people in the entire healthcare system.]

Goal 5. Improve the safety of using infusion pumps. [For this to become a national patient safety goal, there must not be anyone in healthcare who assumes responsibility for this equipment!]

Goal 6. Improve the effectiveness of clinical alarm systems. [Test them to make sure they work! Probably the same problem we have with smoke detectors at home.]

Goal 7. Reduce the risk of healthcare acquired infections. [Certainly obvious, though not simple to achieve! This is probably the only goal that should really be on this list. The others should have been taken care of long ago.]

What's wrong with this picture?

Most patients will be shocked to see that healthcare is just now coming to grips with such basic and fundamental issues of quality. They should rightfully wonder what has been going on that leaves healthcare quality in such a sad state. Here's some of what's wrong.

Healthcare organizations focus on compliance rather than quality. In spite of the myriad of programs that have included the word "quality" in their name - quality assurance, total quality management, quality improvement, continuous quality improvement, etc. - healthcare organizations have been mainly interested in complying with government regulations and accreditation standards. Healthcare quality programs are mainly concerned with accumulating sufficient documentation to overwhelm anyone who inspects the organization. This "compliance mentality" leads to the minimum quality necessary to stay in business, not excellence. Excellence has to do with eliminating and preventing problems, not documenting that those problems exist and are no worse than in other organizations.

Healthcare delivery is not yet a process with minimal variation. Physicians consider themselves to be individual "artists" entitled to their own individual standard of practice. The "art of medicine" is still the best description of medical practice. As long as individual physicians practice in their own individual ways, medical care cannot become a standard process with controllable and predictable outcomes. Instead of one process for a given medical service, there are as many variations of that process as there are physicians on that service. Outcome depends on the physician, not the process. That is the antithesis of quality management where outcome should depend on the process, not the individual.

The healthcare team is really a myth. Different healthcare professionals must work together, but their often are strong rivalries that create problems, rather than prevent problem. Physicians have been taught in Medical School that they are the boss of the team and that it is their job to take control. Nurses are challenging that practice. Other professionals are in the distance and often minimally consulted - laboratory scientists being a good example. Communication is not really very good because the different professionals often don't respect each other and don't want to talk to each other. I recall a recent hospital experience where three different professionals all did the same interview, asked the same questions, and collected the same information for each of their own records. Would have been interesting to give each of them different information and see if anyone detected the conflicting data.

Financial incentives strongly influence the practice of medicine. So, what's new about this, isn't this the American way? Yes, this is the influence of business on medicine, but it is getting worse. You can almost see the gleam in the physician's eyes when a certain test result provides justification to perform another billable procedure. I had a PSA that was slightly elevated recently and the doctor became indignant when I insisted that the test be repeated rather than immediately having a biopsy. When the repeat came back normal, I was happy, but the doctor was very disappointed! In my opinion, physicians need to be paid $alarie$ like everyone else so their medical decisions are not being influenced by the dollar$ going into their own pocket$.

"Business ethics" have become healthcare ethics. As the business model has become the example for healthcare to emulate, business practices and ethics have transferred to healthcare organizations. Business ethics today basically means any practice is okay as long as you can get away with it. All the "Evils of Enron" can be expected now in healthcare organizations. Indeed, we have recently seen the same kind of financial and accounting scandals in HealthSouth, which is under investigation for fraudulent earning statements and accounting practices.

Pharmaceuticals have become American medicine. A big part of modern medicine is prescribing drugs. That's the main thing done by many doctors these days. Therefore, it would seem that the practices and processes for managing pharmaceuticals, their administration, and their control should have been developed to cope with the expected consequences and side-effects. It shouldn't be a surprise that pharmaceuticals need to be managed carefully. The dependence of American medicine on pharmaceuticals didn't happen in just the last few years, but has been developing for the last 50 years. An effective system for managing pharmaceuticals should have been developing during this same time.

Why is quality such a problem?

If I knew the answer to this question, I'd be rich. Even though I'm not, I have some opinions about this.

Quality won't be achieved until quality is valued on its own! Even most quality management programs try to sell their benefits on the basis of saving money as a result of improving quality. Remember Deming's statement that improved quality will lead to improved productivity (because of reducing waste and rework) which in turn leads to reduced costs or financial savings [2]. While I truly believe this, the financial incentive ultimately collapses because many of the savings are hypothetical rather than real dollars. For example, I can save $25,000 a year by getting a quality education from the University of Wisconsin rather than from Harvard. Again, I truly believe I can get a quality education from Wisconsin, but is the $25,000 savings "real"? After four years of school, I won't have a $100,000 bank account I can go and spend. True, I didn't have to spend that extra 100 grand at Harvard, so presumably I was able to do other things with that money. But for some people, if there isn't money in the bank, the savings don't count.

If improvements in speed and efficiency in the laboratory provide turnaround times that allow faster treatment and discharge of patients, does anyone actually recognize those savings? They can be estimated, but there isn't an extra pot of money that can be spent. Nor can you cut someone from the staff because of the improvements.

At some point, quality has to become important to the healthcare organization because quality is important.

Bigger does not make better quality in healthcare! Perhaps one of the major causes of the current quality crisis is the consolidation of healthcare facilities and organizations. The "bigger is better" idea may work for the financials, but it doesn't work for quality. Quality is very much affected by complexity, which increases with the size of the organization, the number of people involved in a process, the number of steps in the process, even the distance traversed by the process. With a bigger organization and more people involved in the treatment of a single patient, there are more chances for miscommunication, etc. - many more ways for dropping the ball. If one caregiver could be attached to a patient throughout the whole treatment process, most of the patient safety issues would be resolved. That person would know if this is the right patient, the right procedure is being performed, the right information was being communicated correctly, and could assure that no harm be done. Today you need another member of your family along to guide, guard, and protect you during your passage through a healthcare system. That's your own best strategy for dealing with patient safety in healthcare.

Healthcare management is distributed without cohesion and control. Another fundamental of quality management is that managers are responsible for any problems with quality. If quality is not happening in the organization, the problem resides with management. Managers are the only people who can make quality happen because they make the decisions that control the people, policies, procedures, and processes. The problems with patient safety clearly show that the managers in healthcare organizations do not take quality seriously. A big part of that problem might be due to the divisiveness of the management structure. There are the official managers - administrators, directors, etc.; independent care managers - the physicians; and intermediate care managers - nurses and other allied health professionals. Quality will be difficult to achieve until all of these managers make a serious commitment to work together.

A modest proposal

The big overhaul of the healthcare system may or may not happen. Look what CLIA has done to quality in the laboratory. Instead of improving healthcare with its quality standards, it became the compliance maximum - now few laboratories attempt to do more than CLIA requires. Is there any reason to think a national healthcare initiative supported by the government will lead to real improvements in quality?

Nonetheless, individual healthcare organizations can readily improve quality by solving one problem at a time. Given that problems are due to processes, not people, then process-oriented people are the key to improving quality. Clinical Laboratory Scientists are the best process-oriented professionals in all of healthcare. Yet few healthcare organizations tap their potential for working outside the laboratory. Here is a golden opportunity for both the healthcare organization and the CLS profession.

References

To Err is Human: Building a Safer Health System. Institute of Medicine Committee on Quality of Health Care in America. Washington DC:National Academy Press, 2000.


Crossing the Quality Chasm: A New Health System for the 21st Century. Institute of Medicine Committee on Quality of Health Care in America. Washington DC:National Academy Press, 2001.


Deming WE. Quality, productivity, and competitive position. Cambridge, MA:Massachusetts Institute of Technology, Center for Advanced Study, 1982.

James O. Westgard, PhD, is a professor of pathology and laboratory medicine at the University of Wisconsin Medical School, Madison. He also is president of Westgard QC, Inc., (Madison, Wis.) which provides tools, technology, and training for laboratory quality management.