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This conference was organized by
Hacettepe University
School of Health Administration
for the 35th anniversary of the establishment of
Hacettepe University
Time: May 6, 2003
Place: Hacettepe Üniversitesi Kültür Merkezi, Yeşil Salon
Hour: 10.00 - 12.30
Quality of Health Care in the
United States: Practice and
Promise
Professor Joseph D. Restuccia
Boston University School of Management
Quality of Health Care
“Degree to which health services
for individuals and populations
increase the likelihood of desired
health outcomes and are consistent
with professional knowledge.”
- Institute of Medicine (IOM)
Strengths of the United States
Health Care System
Modern, well-equipped hospitals and
ambulatory facilities
 Highly trained physicians, nurses and other
medical personnel
 Availability of high technology diagnostic
and therapeutic procedures

Weaknesses of the United States
Health Care System
Overuse and inappropriate care
 Underuse of effective care
 Misuse and error in medical care
 Inefficiency and waste

Assessment of US Health Care
System to Achieve 6 Aims
“In its current form, habits, and
environment, American health
care system is incapable of
providing the public with the
quality of health care it expects
and deserves.”
- IOM Committee on Health Care in
America
“Every Defect is a Treasure”
Japanese saying: every defect is a treasure
because identifying a defect enables us to
find the root cause and to eliminate it and,
thus, to make improvements in the future
 If defects are jewels, recent investigations to
identify and quantify defects in US health
care have discovered a treasure chest (or
Pandora’s box)

Weaknesses of the United States
Health Care System
Overuse and inappropriate care
 Underuse of effective care
 Misuse and error in medical care
 Inefficiency and waste

Overuse
(Rate of Inappropriate Use)
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Advanced Antibiotics for Otitis Media
Antibiotics Used for the Common Cold
Heart Revascularization
Hysterectomies
Hospital Admissions:
Hospital Days of Care:
30%
60%
10-20%
16-80%
5-15%
10-30%
Overuse
(Rate of Inappropriate Use)
Other procedures commonly overused:
 Bed Rest for Low Back Pain
 Prostate Specific Antigen Testing
 Ultrasound in Uncomplicated Pregnancy
 Sedation of elderly patients
Weaknesses of the United States
Health Care System
Overuse and inappropriate care
 Underuse of effective care
 Misuse and error in medical care
 Inefficiency and waste

Underuse (Financial Access)
Over 40 million people are uninsured at any
point in time
 Over 75 million are uninsured as some time
during the year
 About an equal number are severely
underinsured
 The majority of the uninsured and underinsured
are the working poor and their dependents

Underuse
(Rate of Use of Effective Care)
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Beta-blockers in Elderly Heart Attack Victims
Pneumococcal Vaccine in Elderly:
Appropriate Dx and Tx of Hypertension:
Physician Advice to Quit Smoking:
Eye Examination in Diabetics:
Pharmacotherapy of Depression:
21%
28%
30%
37%
46%
45%
Weaknesses of the United States
Health Care System
Overuse and inappropriate care
 Underuse of effective care
 Misuse and error in medical care
 Inefficiency and waste

Misuse
Adverse drug events (ADEs) caused
by medication errors occur in 1.8/100
hospital admissions
 ADEs add $4,700 per admission
 20% of ADEs are life threatening
 There are an estimated 500,000
preventable medication errors per
year causing 7,000 deaths

Misuse
An estimated 2.9% – 3.7% of hospital
admissions have an adverse event (from
all causes)
 Over 1 million adverse events per year
 Estimated national cost of adverse events
is $38-50 billion per year – almost half
preventable (2-4% of total health costs)

Misuse
An estimated 180,000 deaths per year
due to adverse events (= 3 jumbo jet
crashes every two days)
 Between 44,000 - 98,000 due to
preventable adverse events
 More deaths than due to motor vehicle
accidents (43,438), breast cancer
(43,297) or AIDS (16,516)

Weaknesses of the United States
Health Care System
Overuse and inappropriate care
 Underuse of effective care
 Misuse and error in medical care
 Inefficiency and waste

Inefficiency and Waste

Waits and Delays

Operating Room Throughput
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Emergency Department Diversions
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Time to Treatment of Coronary Conditions
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Medical Records Availability
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Mismatch Between Capacity and Demand
Assessment of US Health Care
System to Achieve 6 Aims
“In its current form, habits, and
environment, American health car
is incapable of providing the public
with the quality of health care it
expects and deserves.”
- IOM Committee on Health Care in
America
IOM’s Six Aims for Improvement
• Safety
• Effectiveness
• Patient-centeredness
• Timeliness
• Efficiency
• Equity
Safe Care
A patient receiving medical care should be
as safe as he is in his own home
 Example: Computerized physician order
entry system to prevent medication errors
 Example: Surgeons “sign your site” of the
body part that will be operated upon

Effective Care
Avoid overuse and underuse of services
 Example: Redesign processes based on best
practices such as ensuring that patients at
risk for heart disease take appropriate
medications
 Example: Implement utilization
management to reduce inappropriate
hospital use

Patient Centered Care
Respect patient needs, preferences, and
culture
 Example: Give patient access to his own
medical record
 Example: Give patients information on
alternative treatments and decision-making
in treatment choice

Timely Care
Reduce waits for those who receive and
who give care
 Example: Availability of appointments after
work hours and on weekends
 Example: Email and telephone access to
physicians and nurse practitioners
 Example: “Open access” to physicians and
nurse practitioners

Efficient Care
Reduce waste of facilities, equipment,
supplies, and people
 Example: implement inventory management
systems to reduce amount of drugs and
other supplies
 Example: Use flexible staffing systems
based on patient numbers and needs to
adjust number of nurses per patient care unit

Equitable Care
Reduce racial, ethnic, geographic and socioeconomic differences
 Example: Provide interpreters for nonEnglish speaking patients
 Example: Train more physicians from
minority racial and ethnic groups
 Example: Establish universal health
insurance coverage

Purpose of Health Care System
“To reduce continually the
burden of illness, injury, and
disability, and to improve the
health status and function of the
people of the United States”
- President’s Advisory Commission on
Consumer Protection and Quality
Focus of Quality
Quality must be defined in terms
of experience and outcomes of
the patient and the population
that generates patients
Levels of Needed Health Care System Change
Patient
Microsystem (patient units, physician offices)
Organization (hospitals, medical groups)
Environment (insurers, purchasers, government)
Levels of Needed Change
The patient’s experience
 The functioning of small units
(“microsystems”) that provide patient care
 The functioning of organizations that
contain microsystems
 The environment of policy, payment,
accreditation and regulation

Levels of Needed Health Care System Change
All levels of the system must work together
to meet the patient’s needs
 The patient must be at center, the first
priority of the health care system
 The major question to ask in changing the
system or in treating the patient must be,
“Is this the best thing we can do for the
patient?”

Examples of Efforts by
Provider Organizations to
Achieve the IOM’s Six Aims
Cincinnati Children Hospital
Medical Center
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Includes families of hospitalized children in
morning physician rounds
Permits adolescent patients with chronic
diseases (e.g., juvenile diabetes) to set their
own schedule of treatments and activities and
to make entries into their medical records
Pays physicians for involvement in major
quality management activities
Cambridge Health Alliance
Developed registries for chronic patients to
identify needed diagnostic and therapeutic
interventions, help teach patient selfmanagement, and track patient outcomes
 Provides translators for over 30 languages
 Works with governmental agencies to
establish coverage programs for the
uninsured
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Tallahassee Medical Center
Conducts surveys of satisfaction on every
inpatient and outpatient and shares results
broadly
 Implemented palliative care project to
ensure that terminal patient receive comfort
care instead of intensive care
 Put communication devices in ambulances,
moved EKG lab, and changed cardiologist
schedule to enable PTCA within 90 minutes
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Hackensack Medical Center
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Hired physician “intensivists” to care of
hospitalized medical patients
Developed nursing career ladder to help hire,
retain and further train nursing staff
Implemented advanced practice nurses to work
with physicians and patients to coordinate care
Implemented daily multidisciplinary patient
rounds (physician, nurses, ancillary therapists,
etc.) to improve communication and teamwork
Brigham and Women’s Hospital
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Developed computerized physician order entry
system (CPOE)
Physician orders entered via terminals
 Test results and treatment summaries
transmitted to electronic patient record
 Orders screened against knowledge base of
rules to detect medication errors
Reduced serious medication errors over 80%
CareGroup
Developed internet-based electronic
medical record
 Allows physicians password protected
internet access to patient records
 Allows patients password protected internet
access to their own records
 Allows patients to write in their own record
and to request appointments with physicians

Rosemont Medical Center
Developed “open access” program for
patient appointments
 Produced same day access for most patient
visits
 Reduced average wait time for routine visits
from over 2 months to 1 day
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Massachusetts General Hospital
Implemented utilization management to
reduce inappropriate hospital days
 Case managers apply MCAP (derivative of
the AEP) to facilitate day to day decision
making and data collection to change system
 Over 10 years, inappropriate days have been
reduced by more than 50%
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SSM Health Care
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Continuous Quality Improvement (CQI) - 13
year sustained effort
Alignment of goals and measures of
performance throughout the organization
Use team work to solve problems and motivate
employees
Human resources are part of strategic plan
Only health care organization to win Malcolm
Baldridge National Quality Award
Continuous Quality Improvement
Top Management Commitment
 Worker Empowerment
 Team Work
 Customer focus
 Application of Scientific Method
(Measurement and Reporting)
 Recognition of success

AIM/PDSA Model for Internal Quality Improvement
1. AIM: What are we trying to accomplish?
2. MEASURES: How will we know that a change is an improvement?
3. CHANGES: What changes can we make that we predict will lead
to an improvement?
7. ACT
4. PLAN
6. STUDY
5. DO
Examples of Efforts by
Government Agencies to
Achieve the IOM’s Six Aims
Department of Veterans Affairs
Health System
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System of 171 hospital medical centers, 350
outpatient centers
Implemented electronic patient record & CPOE
Implemented open access (reducing wait time
by 90% in Region 1)
Implemented Quality Enhancement Research
Initiative (QUERI) to give providers evidencebased care on 8 priority conditions
Recognized by IOM for these efforts
Agency for Health Care Research
and Quality (AHRQ)
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Supports research on patient outcomes
 Prevention, diagnosis and treatment
 Quality measurement and improvement
 Medical errors and public safety
Examples
 Diagnosis of heart attack
 Screening for pregnant women
 Consumer Assessment of Health Plans
Survey (CAHPS)
Agency for Health Care Quality
and Research (AHRQ)
National Guidelines Clearinghouse of
evidence-based clinical practice guidelines
 National Quality Measures Clearinghouse
 CAHPS survey
 CONQUEST quality measures
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Health Care Cost and Utilization Project
(HCUP) Quality Indicators
AHRQ HCUP Quality Indicators
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Prevention - ambulatory sensitive conditions
 Bacterial pneumonia
 Dehydration
Inpatient Care
 Acute myocardial infarction mortality rate
 CABG volume
Patient Safety
 Birth Trauma
 Complications of anesthesia
Center for Medicare and
Medicaid Studies (CMS)
Quality Improvement Organizations
monitor Medicare quality
 Nursing Home Public Reporting Quality
Initiative
 Home Health Public Reporting Quality
Initiative
 Hospital Quality Information Initiative
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CMS Hospital Quality Initiative
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In collaboration with JCAHO, NQF, AHA and other
national hospital associations
Voluntary reporting of quality measures
Examples
 AMI: aspirin and beta blocker at hospital arrival
and discharge
 Pneumonia: initial antibiotic timing, vaccination,
oxygenation assessment
Considering paying providers on the basis of quality
instead of just fee for service
CMS/AHRQ CAHPS Surveys
National survey of Medicare beneficiaries
 Also used for Medicaid and commercial
beneficiary surveys
 Administered by CMS for Medicare
 Comparative Medicare Medical Care Plan
Reports are publicly available on internet
 Comparative Hospital Reports Scheduled
for internet availability in 2003-2004
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HCAHPS - Example Questions
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How often did nurses/doctors listen to you
carefully?
How often did nurses/doctors spend enough
time with you?
How often was your pain well controlled?
Before you left the hospital, did you get
information in writing about activities you
could and could not do?
Would you recommend this hospital to your
friends and family?
Examples of Efforts by
Private Organizations to
Achieve the IOM’s Six Aims
Joint Commission on Accreditation of
Healthcare Organizations (JCAHO)
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Develops standards for optimal healthcare
Applies accreditation process to 17,000
healthcare organizations
Provides information to health care
organizations, professionals, and the public
on strategies to improve safety
Plans to make public comparative
performance reports on provider
organizations (in 2004)
Examples of JCAHO Initiatives
Quality Performance Measurement
 Core (required) measures
 Provider selected measures
 Pain Management Standards
 Staffing Effectiveness Standards
 Patient Safety Standards
 Sentinel Event Policy and Alert
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Foundation for Accountability (FACCT)
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Advocates an accountable and accessible health
care system responsive to consumers
Members: consumer organizations and purchasers
Collaborates with government and private health
care organizations
Reports on federal and state health policy
Provides consumers with information to help
assess quality of care and select providers and
tools to help manage their own health, e.g.
CompareYourCare)
National Committee for Quality
Assurance (NCQA)
Accreditation and certification of health
plans and utilization review organizations
 Administers Health Plan Employer Data
and Information Set (HEDIS)
 HEDIS is used to compare health plans and
choose quality - results released to public as
Quality Compass

HEDIS 3.0 Reporting Set Measures
Effectiveness of Care
Childhood Immunization Status
Adolescent Immunization Status
Advising Smokers to Quit
Flu Shots for Older Adults
Eye Exams for Diabetics
1st Trimester Prenatal Care
Follow-up after Hospitalization
for Mental Illness
Low Birth Weight Babies
Check-ups After Delivery
Treating Child Ear Infections
Beta Blockers after MI
Breast Cancer Screening
Cervical Cancer Screening
Medicare Health Outcome Survey
Leapfrog Group
Group of very large US companies
 Mission is to stimulate improvement in
quality, customer service and affordability
 Recognizes and rewards health care
organizations that implement evidencebased patient safety measures
 Encourages members to buy health care
from these organizations

Leapfrog Group Patient Safety
Measures
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Referral of specific complex procedures to
hospitals with high volume (estimated to
reduce deaths > 30%)
Intensive care unit staffing with physicians
certified to practice critical care medicine
(estimated to reduce ICU deaths > 10%)
Computer physician order entry (estimated to
prevent > 500,000 fewer serious medication
errors per year)
Institute for Healthcare
Improvement (IHI)
Mission: is “driving the improvement in
health by advancing the quality and value
of health care”
 Conferences
 Collaborations
 Courses
 Training Material
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Institute for Healthcare
Improvement (IHI)
National Director of Robert Wood Johnson
Foundation Pursuing Perfection Program
 Publishes QualityHealthcare.org (with
British Medical Journal)
 Website: www.ihi.com
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Institute for Healthcare
Improvement (IHI)
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Examples of Topics for Collaboratives:
 Achieving Workforce Excellence
 Adult Intensive Care
 Adverse Drug Events
 Care for Chronic Conditions
 Delays and Waiting Times
 End of Life Care
 Patient Flow
 Patient Safety
Major Quality Improvement Will
Require Fundamental Changes
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Evidence-based medicine
Evidence-based management (CQI)
Electronic patient record with CPOE
Recognition of system interdependence between
microsystem, organization, environment
Alignment of incentives and strategy at all levels
 Payment based on quality, not just services
 Public reporting of comparative provider
quality
Universal health coverage