Health Care Quality and Safety

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. Read Codman’s biography.

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.

• Joint Commission
• Read about William Stewart Halsted, known as the father of American surgery
• Read Halsted’s biography

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.

• Read about the Institute on Medicine’s Report: “ To Err is Human: Building A Safer Health System” Read the full text
• Read about the Institute on Medicine’s Report: “Crossing the Quality Chasm: A New Health System for the 21 st Century” Read the full text

Today, a number of national organizations dedicated to health systems improvement exist. These include:

• The Joint Commission on Accreditation of Healthcare Organizations
• The Institute for Healthcare Improvement
• The Agency for Healthcare Research and Quality
• The American College of Surgeons National Surgical Quality Improvement Project
• The National Patient Safety Foundation
• The Rand Corporation
• The Leapfrog Group

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.

• Read about 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).

• Read about outcomes in endocrine surgery

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.

• Read an editorial on improving safety by noted health care reformers Donald Berwick
  (Institute for Healthcare Improvement) and Lucian Leape (Harvard School of Public Health)

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.

• Quality and Patient Safety provided by the U.S. Department of Health & Human Services
  (Agency for Healthcare research and Quality)

This material is exceptionally well-written, clear, and accurate. It is essential reading for all patients. Some articles of particular interest include:

• Having surgery? What you need to know
• 20 Tips to Help Prevent Medical Errors: Patient Fact Sheet
• 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.

• Beware the internet. Quackery abounds on the world wide web. It is our opinion that, in its current disorganized, confusing, and frequently biased state, medical literature on the internet is more of a disservice than a service. Patients must be skeptical and use reputable sites as much as possible.
• Read about how to critically evaluate medical information on the web
• More on healthy web surfing from the U.S. National Library of Medicine and the National Institutes of Health
• Evaluating Internet Health Information: A Tutorial from the National Library of Medicine

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.