There are widespread and growing concerns about the variable and too often inadequate quality of health care in the United States. As a result, health care quality is being questioned and subjected to scrutiny as never before. Awareness of the quality deficits, combined with rising health care expenditures and changing attitudes of payers and consumers, has given rise to a nascent but growing quality improvement movement. Multiple bar-riers must be surmounted by this movement, but sub-stantive work is under way on all fronts. Emergency medicine will definitely be affected by the quality im-provement movement and should quickly move forward to define and establish performance measures for high-quality emergency care in an era when chronic disease dominates the agenda. Emergency medicine should also aggressively work to operationalize a culture of quality to minimize medical errors, to practice evidence-based medicine, to translate research results into clinical prac-tice in a timely manner, and to establish accountability mechanisms for quality improvement and clinical excel-lence.Key words:quality; health care; emergency med-icine. ACADEMIC EMERGENCY MEDICINE 2002; 9:1078–1084.
EMERGENCY MEDICINE AND QUALITY IMPROVEMENT
Emergency medicine is challenged with many issues today. Overcrowding, sicker and more complex patients, unpredictable on-call backup, increased ambulance diversions, a looming professional liability insurance crisis, uncompensated care, bio terrorism preparedness, and too few nurses are some of the urgent issues competing for attention. With so many acute problems, one might ask why should quality improvement be on emergency medicine’s critical care list? There are at least three reasons why emergency medicine should be paying attention to and, indeed, giving priority attention to matters of quality and quality improvement. First, there are widespread and growing concerns about the variable and too often inadequate quality of U.S. health care.1–9 The quality of health care, including emergency care, is increasingly being questioned and subjected to public scrutiny. Everyone in health care needs to be mindful of and responsive to these concerns. Concern about quality extends across health care’s many constituen-cies, although the inherently multidimensional na-ture of quality means that the specific concernsvoiced by individual stakeholders will vary. Con-sumers are especially concerned about the qualityof interactions with caregivers and the quality of care outcomes. Payers are focused on the effective-ness and efficiency of care processes. Physicians prioritize the technical details of care, while public health officials are particularly concerned with pop-ulation health and equity of access to care. Whilethe particular focus may vary, the overall concerns about health care quality are widespread and seri-ous. Second, the growing awareness of quality-of-care deficiencies, combined with rising health care ex-penditures and other sociocultural changes, has given rise to a new era of performance oversightand an emerging health care quality improvement movement. The practice of medicine, including emergency medicine, will be significantly altered asa result of this movement. Whether it be from ef-forts to reduce medical errors, the need for more coordinated and integrated transfer of information among caregivers, or process-of-care changes stem-ming from new diagnostic and treatment technol-ogy, the emergency department (ED) will be center stage for many of the changes in practice that lie ahead. For example, it is clear that the ED will be the direct focus of a number of quality improve-ment initiatives in cardiovascular, respiratory, and infectious disease care. Third, quality of care and the need for quality improvement are likely to become the unifyingtheme for systemic reform of the U.S. health care system. The goal of health system reform has al-ways been to ensure the availability of and access to high-quality care. Attempts at systemic change based on method of financing, expanding access,cost control, or political ideology have produced in-cremental change over the years, but such strate-gies have failed to ignite the passion needed for fundamental reform,9and there is no reason to think that they will do so in the future. Because of its greater face validity and visceral appeal, quality improvement may well provide the necessary plat-form for aligning reform interests in the future.WHAT IS THE CURRENT STATE OF U.S.HEALTH CARE QUALITY?Health care in the United States in 2002 is a para-dox. On the one hand, U.S. health care practitioners are well educated and highly trained; state-of-the-art diagnostic and treatment technologies are widely available across the country; the U.S. bio-medical research program is the envy of the world;and per capita expenditures for health care far ex-ceed those of any other country.10For some persons,the quality of U.S. health care is truly excellent, and for many, it is certainly as good as that routinely found elsewhere in the developed world. On the other hand, health care delivery in the United States is fragmented and frequently difficult to ac-cess; too many people are not assured access tocare, or find their access limited by financial rea-sons; there is an uncertain return on investment, or unclear value, for a significant portion of healthcare’s considerable expenditures; and there is grow-ing disenchantment with the processes of care by patients, practitioners, and payers alike. Further,we now know that there are serious and systemic problems with the quality of care that is provided for those who actually receive care.2–9As reported in the 1998 Institute of Medicine’s National Round table on Health Care Quality, ‘‘Se-rious and widespread quality problems exist throughout American medicine. These problems. . . occur in small and large communities alike, in all parts of the country, and with approximately equal frequency in managed care and fee-for-ser-vice systems of care. Very large numbers of Amer-icans are harmed as a direct result.’’8 QUALITY-OF-CARE PROBLEMS Health care quality problems can be divided into four broad categories: overuse, under use, misuse,and waste. A variety of surgical procedures, diagnostic tests,and treatments are overused (i.e., performed on the basis of unclear clinical reasons), unnecessarily in-creasing costs and exposing patients to the risk of complications, including death. Examples include cardiac catheterization, coronary artery bypass graft surgery, pacemaker insertion, tympanist,carotid endarterectomy, upper gastrointestinal en-dos copy, and hysterectomy.6 Additionally, a num-ber of medications, or categories of medications, are over prescribed, including non steroidal anti-inflam-matory agents, sedatives, tranquilizers, and antibi-otics. Overall, between 20% and 30% of acute andchronic care is not clinically necessary.11Conversely, there is clear evidence that manypeople do not receive the diagnostic and therapeutic-tic services, medications, and procedures that theyneed. Examples of underuse include failure to pre-scribe beta-blockers after acute myocardial infarc-tion, inadequate use of angiotensin-converting en-zyme (ACE) inhibitors for patients with congestive heart failure, insufficient use of mammography,failure to immunize against influenza and pneu-mococcal pneumonia, not providing smoking ces-sation, failure to regularly monitor the use of he-moglobin A1Cin diabetics, and failing to screen for depression or not providing mental health follow-up. While undoubtedly significant, the toll of un-deruse in terms of premature death and diminished quality of life, and its impact on health care expen-ditures, has not been well quantifed. Medical errors are the most common example of misuse. The problem of medical errors was indeli-bly imprinted onto the public’s consciousness bythe Institute of Medicine’s report showing that be-tween 44,000 and 98,000 in-hospital deaths in theUnited States each year are due to errors.3With be-tween 3% and 38% of hospitalized patients suffer-ing some type of iatrogenic illness or injury,12it isclear that medical errors are fertile ground for health care quality improvement. The 2 million no-socomial infections that occur in U.S. hospitals each year (causing about 90,000 deaths)13 and a pot-pourri of diagnostic and surgical errors are further examples of misuse.Finally, large amounts of waste are inherent toU.S. health care. This is primarily due to outdated,inefficient, disjointed, and, often, unnecessary ad-ministrative activities. An especially large problemrelates to the failure to transfer information across care settings in a timely manner, resulting in un-necessary delays and the provision of redundant services. Complex billing requirements, burden-some utilization review programs, illegible paper medical records, and excessive waiting times (in-cluding waiting for elevators) are some of the other specific contributors to the inefficiency, inaccuracy,and considerable hassle associated with the current system.A recent report estimates that the overall cost ofpoor-quality health care costs U.S. employers about$2,000 per covered employee each year.6WHY THE ‘‘QUALITY CHASM’’?Many factors have contributed to the current U.S.health care conundrum, but two dynamics, in par-ticular, are at the core of the chasm between the health care that is scientifically sound and possible today and the care that is actually provided to most patients.9The first dynamic is the knowledge – application of knowledge gap— i.e., the gap that exists between cur-rent medical knowledge, which has exploded in re-cent decades, and the clinical application of that knowledge. Far too often, the care actually pro-vided at the bedside is out of date with what should be done based on current medical knowledge. Many emergency care patients are testimony to this dynamic.The second dynamic is the increasing scope of chronic care needs. Today, the primary business ofU.S. health care is treating chronic disease — not acute illness, as was the case for much of the twen-tieth century. The nature of U.S. health care radically changed during the latter part of the twentieth century, although we continue to use the methods and manners of service delivery that were developed when acute illness was the predominant focus of health care.The net effect of these two dynamics is a major mismatch between the capabilities of the healthcare delivery system and the medical care needs of the population.WHAT ARE THE FORCES DRIVING QUALITY IMPROVEMENT?While its specific elements continue to evolve, a health care quality improvement movement is gaining momentum across the United States. Four cur-rents of change, in particular, appear to be converging toward the same end — i.e., quality improvement.The first current of change is simply knowledge of the deficits in quality. Now that it is widely known that U.S. health care does not perform at the level that it was formerly believed to be performing, nor at the level where it is believed that it can perform, many quality improvement initiatives are being launched. More detailed knowledge is needed about the problem areas, but what is al- ready known requires that corrective action becommenced. It is disappointing, however, thatmuch of the impetus, at least at this time, for im-provement is coming from the payer and consumerconstituencies instead of from health care profes-sionals.Second, rising health care expenditures demandsystemic change. After a period of relative stabilityin the mid-1990s, health care costs began to riseagain in the late 1990s. For the past two years,health care costs have risen disproportionate to therest of the economy.Many of the factors driving up health care costscannot be turned around any time soon — e.g., thegrowing elder population and its increased needfor health care services of all types, increasingchronic care needs (among both elders and youngerpersons), new biomedical technology (includingpharmaceuticals), direct-to-consumer marketing,and changes in managed care that lessen its abilityto control costs. Therefore, reform efforts must fo-cus on true systemic change that makes delivery ofcare both more effective and more efficient.The nexus of rising health care costs and qualityimprovement is found in the connection betweenhigher quality and reduced expenditures. Consid-erable experiential data now show that improvingthe processes of care produces better care outcomes,more satisfied patients and caregivers, and reducedhealth care costs.14–22Savings of 25% to 35% arecommonly associated with true quality improve-ment activities.Third, changing purchaser and payer attitudesabout health care are forcing greater attention toquality. The growing understanding among thepayer community that health care quality can beaccurately assessed, routinely measured, and sys-tematically improved has prompted a growingnumber of payers to introduce programs aimedat rewarding quality.23,24The Leapfrog Group, theTri-Rivers Healthcare Coalition, the PittsburghRegional Health Initiative, the Central FloridaEmployers Coalition, and California’s Pay for Per-formance Initiative are illustrative of these pro-grams. The initiatives vary in size, scope, and spe-cific area of focus, but all have a common theme ofusing payment mechanisms to reward higher qual-ity. Over the next few years, payment mechanismswill be increasingly used in ways that will makethe business case for quality clear — something thathas not been the case in the past. While a numberof issues have to be resolved before the federal gov-ernment, the largest purchaser of health care in theUnited States, can use payment to reward higherquality, it is likely that specific steps in this direc-tion will be taken within the coming year. In understanding the changing attitude of pur-chasers about higher payment for higher quality, itis important to understand that, to date, the pur-chasers who have expressed a willingness to paymore for quality have not indicated a willingnessto pay more for health care overall. That is, payersview this as a zero-sum game in which higher pay-ment for better outcomes will have to be offset inother areas.It is not yet clear whether the financial incentivesbeing offered in the various initiatives (typically adifferential of 3% to 5%) will be sufficient to moti-vate providers to change their practices, althoughearly experience suggests that the altruism inherentto health care may make modest financial incen-tives powerful change agents.The fourth current of change behind the qualityimprovement movement is the changing attitude ofconsumers toward health care. Consumers are be-coming more demanding of information about theservices available to or provided for them, moredemanding of convenience and individually tai-lored care, and more demanding of overall higherquality. As with the other currents of change, thisone represents the convergence of multiple dynam-ics, including the aging of the baby boomers, in-creased longevity, and increased chronic care needs.All of these factors are shifting the consumer’s fo-cus away from acute, episodic care toward coordi-nated and continuous care.In the same vein, during the recent lengthy, un-paralleled period of economic prosperity, manyconsumers became accustomed to paying out-of-pocket for health care services. One only has to lookat the dramatic growth of the complementary andalternative medicine and cosmetic surgery indus-tries for tangible evidence of consumers’ willing-ness to pay out-of-pocket for interventions that theywant or think may be important, even when of un-proven benefit. Consumers are also expressingthrough their out-of-pocket expenditures a desirefor the ‘‘care’’ that modern Western medicine seemsless and less able to provide — i.e., care that in-cludes personal attention, a listening ear, and anoptimistic outlook.Finally, perhaps the most potent dynamic thathas changed consumer attitudes has been the In-ternet, both by providing cross-industry experienceabout how transactions can be completed (e.g.,banking, retail sales) and by democratizing medicalknowledge.In the early days of life-sciences-based medicine,the physician served as the repository of medicalknowledge, and it was not that difficult for the typ-ical physician to know the majority of what therewas to know of medicine. Rapidly, the body of medical knowledge has increased to the pointwhere the physician now serves primarily as an in-terpreter of medical knowledge. However, not in-frequently today, the consumer arrives at the care-giver’s office with both the knowledge and theinterpretation, compliments of the Internet. Andwhile the quality of health-related informationavailable on the Internet remains an area of con-cern, in an effort not to be left out of the Internetbonanza of the late 1990s, scientific journals, pro-fessional societies, and medical publishers alllaunched websites that provide the public with un-precedented access to up-to-date, accurate medicalinformation by the gigabyte. The ready availabilityof this information has markedly increased con-sumer knowledge about specific health-related top-ics, and has heightened the consumer’s awarenessof quality issues.WHAT ARE THE BARRIERS TOQUALITY IMPROVEMENT?While there are several strong currents of changepushing the quality improvement agenda forward,there are also multiple barriers that impede prog-ress. Resolution of these barriers will likely consti-tute a substantial part of the health policy agendafor the next several years.The first major barrier to quality improvement isthe lack of reliable and comparable data abouthealth care quality. Existing data provide broad es-timates of the magnitude of the quality problems.Unfortunately, to date, quality indicators and per-formance measures have not been standardized, soit is generally impossible to make valid qualitycomparisons using existing data. Standardizedand clinically relevant performance measures areneeded to motivate providers to improve qualitybased on recognized benchmarks, to assist pur-chasing decisions and encourage competition onquality, to facilitate informed consumer choice, toinform the public policy and regulatory process,and to facilitate assessment of progress. The crea-tion of the National Quality Forum (NQF) and itsfocus on national, standardized performance mea-sures should help address and resolve this bar-rier.25,26A second major barrier is the lack of widespreaduse of automated information management sys-tems in health care. Forty years ago, a vision wasborn of a computerized health care record thatwould integrate data from all caregivers and allcare sites to provide a continuous chronology of thepatient’s treatment and health status and thatwould allow instantaneous access to clinical, ad-ministrative, and financial information. This vision was not technically feasible at the time, but infor-mation technology progressed rapidly over the next20 years. By the 1980s, the vision was no longer astarry-eyed dream. Unfortunately, for the past twodecades, the potential dramatic improvement inhealth care quality, efficiency, and service that ispossible through widespread use of advanced in-formation technology (IT) has remained an unful-filled promise.Despite mind-boggling developments in patientcare and dramatic business process advances dueto use of advanced IT in other industries, healthcare has failed to widely adopt advanced IT. Failureto progress toward an enterprise-wide electronic in-formation infrastructure for health care is especiallyironic since health care is the most information-in-tense and information-dependent industry in theworld, as well the nation’s largest domestic enter-prise with current annual spending of $1.3 trillionper year.Except for a few isolated examples, health careproviders are still unable to integrate informationbetween and among caregivers in a manner thatfollows a patient’s progress through the health caresystem in near real time. In the judgment of manyexperts, the health care industry is two or three dec-ades behind other major industries in its use of ad-vanced IT. Health care still relies on paper recordsand regularly accepts a degree of inefficiency andinaccuracy that is unacceptable in other industries.While technological issues remain to be resolved,the primary barriers to widespread use of advancedIT in health care are political — i.e., the lack of dataand operating standards, the lack of broad-basedagreement among health care’s many stakeholdersof a enterprise-wide system concept, and legal con-cerns about confidentiality and privacy. There is agrowing consensus both within and outside ofhealth care that these issues must be resolved, andthis promises to be an area of intense activity in thenext several years.A third major barrier to quality improvement ispayment. Quite simply, prevailing payment policiesneither reward nor incentivize better quality — and,in fact, in some cases payment policy may actuallypenalize those who provide higher-quality quality.9As already noted, there are a number of nascentprograms under way in which payment mecha-nisms are being used to leverage higher quality, butsuch approaches remain the exception, not thenorm.Liability concerns present a fourth barrier, espe-cially in the area of medical errors. And while lia-bility concerns are sometimes inappropriately heldout as reasons for not doing things that should bedone, there are legitimate issues in this area that need to be resolved (e.g., consistent peer reviewprotection and liability protection for error report-ing when done for purposes of quality improve-ment).A fifth barrier to quality improvement is the lackof organizational and systems support for qualityimprovement efforts. In this regard, it is importantto remember that quality is asystemproperty.Quality is determined by measuring the interac-tion of structural, process, and outcome measures.Quality is a product of the interaction of individual,technical, organizational, regulatory, and economicfactors. While each part of a system may individ-ually be good, the overall quality of the system maybe poor if the elements do not interact in an inte-grated and coherent manner. Said differently, one’sdoctor may be highly skilled, the nurses very com-passionate, the drugs effective, and the surgery suc-cessful in correcting the defect, but the care may belousy because the nurses and the doctor do not ef-fectively communicate, so the treatment is dis-jointed and delayed, which leads to complicationsand a preventable prolonged hospitalization.In this regard, in U.S. health care there is not yeta ‘‘culture of quality’’ such as is prevalent inhighperforming organizations(e.g., as seen in nuclearpower, aviation, maritime transportation, and somechemical manufacturing).27–29In a culture of quality,policies and processes are aligned to consistentlyand predictably achieve desired outcomes. To besure, health care has islands of quality, but we arenowhere near having a universe of quality. Some ofthe general attributes of a culture of quality arelisted in Table 1.Unfortunately, the educational framework neededto support a culture of quality is not provided bythe U.S. medical education system. Concepts andprinciples of teamwork, human factors and perfor-mance, incident analysis, information management,complexity theory, and quality management, toname some of the requisite underpinnings, are nottaught to any significant degree in medical schoolor postgraduate training programs, nor are theytaught in nursing, pharmacy, or other health pro- fessional schools. We continuously upgrade theclinical and scientific content of our curriculum, butperpetuate an anachronistic culture of health caredelivery.Finally, a seventh barrier to quality improvementis the lack of quality improvement goals. As inother activities, goals are needed to provide focus,direction, and a vision to guide change. Despite thegood work of many dedicated individuals, much ofthe quality improvement activity of the past decademight be characterized as Brownian motion. Therehas been a lot of activity, but it has been diffuse,unfocused, and uncoordinated. Goals are needed tohelp prioritize resource use and harness energy ina unified direction. Again, this is an area where theNQF is helping to clarify the agenda. ARE THERE SOME EMERGENCYMEDICINE-SPECIFIC QUALITY ISSUES?In concluding this overview of the emerging im-perative for health care quality improvement, it oc-curs to me that emergency medicine might wish tofashion a quality improvement agenda based onthe following three things.First, what is high-quality emergency medicalcare when the primary business of health care istaking care of chronic disease? Concomitantly, whatare the performance metrics that will tell youwhether you are providing high-quality emergencycare?In addressing this issue, the following quality-related questions, among others, should be an-swered: How well does the care provided appro-priately address the patient’s immediate healthneeds in a timely manner? How well does theemergency care provide a foundation for ongoingcare, when needed? Is the amount of care providedappropriate but not excessive? Are provisions madefor ongoing care, and how will the emergency carefindings be integrated into the ongoing care? Howwell does the patient understand his or her condi-tion and the need for ongoing care?Second, specific quality improvement goals andopportunity areas should be targeted. Among theareas that should be given particular considerationare the following five: 1) promoting a culture ofquality; 2) minimizing medical errors and the riskof adverse events; 3) practicing evidence-basedmedicine; 4) translating research results into clinicalpractice in a timely manner; and 5) establishing ac-countability mechanisms for quality improvementand clinical excellence.If a culture of quality is too big a step, then per-haps promoting a ‘‘culture of safety’’ could be anintermediate step. While being predicated on many of the same principles as a culture of quality, a cul-ture of safety is primarily aimed at ensuring thatthe processes of care do not cause harm.In a culture of safety, one must ensure that thereare well-understood and efficient methods andmechanisms for reporting and analyzing errors oradverse events, as well as ways to implement ac-tions recommended from the analysis of incidents.Such reporting and analysis must be performedwithin the context of a non-punitive environmentin which leadership is actively engaged in the pro-cess and in which there is an entity that providesoversight and coordination of the activities. Finally,there must be a means to provide feedback to thefrontline caregivers in a timely manner and publicdisclosure.Third, a strategic plan should be developed fortranslational research. Emergency medicine needsto be at the forefront of examining the effectivenessand cost – effectiveness of diagnostic strategies, co-ordination of care, and disease or care managementstrategies. There is a need to define the costs andoutcomes of emergency care policy decisions, es-tablish performance and outcomes measures thatare realistic and meaningful for emergency medi-cine’s unique care environment, assess outcomes ata system level, and evaluate methods of imple-menting research results.SO WHAT’S THE BOTTOM LINE?In closing, I think the Institute of Medicine’s Qual-ity of Care Committee summarized the currentstate of affairs and what is needed very nicely whenit said, ‘‘The American health care delivery systemis in need of fundamental change. The current caresystems cannot do the job. Trying harder will notwork. Changing systems of care will.’’9I wouldsimply add that quality improvement must be thecornerstone of the redesigned system.