Health Care Quality and Safety - Patient Education
Background: How can we measure the quality of health care?
The
first person to examine this question was Ernest Codman
(1869-1930), a surgeon at Harvard
Medical School.
 During Codman’s time, no well-defined program for training surgeons existed. Unhappy
with what he perceived to be surgeon incompetence, Codman left Harvard to found the “ End
Results Hospital”, where he systematically measured the outcomes of care for each patient
treated. His methods were embraced by the American College of Surgeons soon after the founding
of the College in 1913. Around that time, William S. Halsted, a surgeon at the Johns Hopkins
Hospital, developed a formalized residency training program for young surgeons.
In 1951, the
American College of Physicians, the American Hospital Association, and the American Medical
Association united with the American College of Surgeons to create the Joint Commission on
Accreditation of Healthcare Organizations. The Joint Commission is a not-for-profit organization
dedicated to improving the safety and quality of the nation’s health care.
Central questions in modern outcomes research include:
- How effectively do health services yield the desired health outcomes for both individuals
and populations?
- What measures can be implemented to reduce the likelihood of adverse medical events,
including complications and medical errors?
Quality measures in the 21 st century
In 1996, the Institute on Medicine (IOM) launched a concerted effort to assess and improve
the nation’s quality of care. The findings of the first phase of this ongoing project
were published in 1999. In their landmark report, “ To Err is Human: Building
A Safer Health System”, the IOM reported that as many as 98,000 people die
annually as the result of medical errors and called for a national effort to make health
care safe. The IOM’s follow up report, “Crossing the Quality Chasm: A
New Health System for the 21 st Century”, examines the reforms that must take
place to bring existing practice up to higher standards in safety and quality.
Today, a number of national organizations dedicated to health systems improvement exist.
These include:
Quality in Surgical Care
Given its high-risk nature, the field of surgery has been subject to intensive scrutiny
in quality measures since the mid-1990s. Much of the early work in surgical outcomes arose
from the United States Department of Veterans Affairs Health System, Dartmouth University,
and the UCLA Center for Surgical Outcomes and Quality.
In two landmark studies published in the New England Journal of Medicine (1, 2), Birkmeyer
and associates analyzed certain complex operations (cardiovascular procedures and cancer
resections) and found that:
- Patients having surgery at high-volume hospitals (those performing a large ongoing number
of those specific operations) were more likely to survive.
- The improved survival was largely attributable to the experience of the individual surgeon
performing the operation.
Since then, a multitude of studies have examined the relationship between volume and outcomes
in surgery. Surgeon experience has been linked to favorable cancer-related endpoints (survival
and disease-free status) as well as improved economic outcomes (length of hospitalization
and cost of surgical care) (3, 4).
The volume-outcomes relationship in surgery has a certain “common sense” appeal:
The more you do something, the better you are at it. However, this viewpoint has been criticized
as inadequate, for several reasons:
- Regionalization of complex operations to high-volume centers may lead to worsening of
existing healthcare disparities, as socioeconomically disadvantaged groups are more likely
to seek care at low-volume hospitals (5).
- Excellent outcomes can, in theory, be achieved at any hospital if appropriate systems
and process measures are put in place (6).
How can I find the best care for myself and my family?
 Obtaining health care is a risky endeavor. In fact, quality advocates have reported that
the risks associated with hospitalization are many times greater than those associated with
commercial air travel.
Patients and their families should become engaged as active participants in their own
care, and use all available resources to seek out both the best doctors and the best hospital
setting for their particular problem. Though we are entering a new era of increased transparency
with respect to quality measures, good information remains a challenge to find. Here are
some places to start.
This material is exceptionally well-written, clear, and accurate. It
is essential reading for all patients. Some articles of particular interest include:
- Compare hospitals. U.S. Department of Health and Human Services has a quality tool that
helps you compare the care provided by hospitals in your area. This tool is available online
at http://www.hospitalcompare.hhs.gov
Currently, publicly available hospital information is limited to rudimentary measures
on topics such as heart attack, heart failure, pneumonia, and surgical care improvement.
The tool allows for comparison between various hospitals as well as comparison to state and
national benchmarks. Overall, it allows for a crude yet informative assessment of hospital
quality.
Another
way to compare hospitals is to examine national surveys such as the one published annually
by U.S. News & World Report.
Please
be advised that the methodology behind such surveys has been criticized. Read about how the
results are derived.
Conclusion: Tough questions, clear answers
 At this point, you are probably wondering why detailed quality information on individual
hospitals and doctors is not publicly available. Be patient, we are getting there. Information
of this nature is obviously very sensitive, and significant barriers to self-reporting exist.
It remains the patient’s responsibility to ask the right questions. One useful framework
for these questions centers around the structure, process, and outcomes of care as described
by Donabedian (7) . Some examples follow.
- Structure. Does the medical center possess the best physical, intellectual,
and technological resources necessary to treat your illness?
- Do the doctors possess the highest qualifications?
- Does the hospital possess the latest equipment (scanners, tools for specialized surgery,
etc.)?
- What is the volume of patients treated annually at hospital A or doctor B for disease
C?
- Process. Do systems or protocols of care exist to enable standardization
of treatment according to established medical science and to reduce medical errors?
- Are appropriate antibiotics administered to prevent surgical infections?
- Do heart attack patients receive appropriate care within 90 minutes of arrival?
- Outcomes. What are the end results of care?
- What is the risk-adjusted death or complication rate for surgery A by surgeon B at hospital
C?
- How long do patients survive after liver transplantation?
- What is the frequency of hospital acquired infection?
There are many ways to ask pointed questions such as these in a respectful yet deliberate
manner. Do not be afraid to ask these specific questions when you speak to your doctors.
Demand nothing less than direct, clear, preferably numeric answers. Remember, your health
is at stake.
1. Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and
surgical mortality in the United States. N Engl J Med. 2002;346(15):1128-37.
2. Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon
volume and operative mortality in the United States. N Engl J Med. 2003;349(22):2117-27.
3. Chowdhury MM, Dagash H, Pierro A. A systematic review of the impact
of volume of surgery and specialization on patient outcome. Br J Surg. 2007;94(2):145-61.
4. Martling A, Cedermark B, Johansson H, Rutqvist LE, Holm T. The surgeon
as a prognostic factor after the introduction of total mesorectal excision in the treatment
of rectal cancer. Br J Surg. 2002;89(8):1008-13.
5. Liu JH, Zingmond DS, McGory ML, et al. Disparities in the utilization
of high-volume hospitals for complex surgery. Jama. 2006;296(16):1973-80.
6. Khuri SF, Henderson WG. The case against volume as a measure of quality
of surgical care. World J Surg. 2005;29(10):1222-9.
7. Donabedian A. Twenty years of research on the quality of medical
care: 1964-1984. Eval Health Prof. 1985;8(3):243-65.
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