Beginner’s Guide to Healthcare Quality Improvement

Another foundational aspect of performing robust quality improvement is the identification of variation. The field shows that variation within a process is more likely to result in variation in the output. While this variation may intermittently lead to stellar outcomes, it may also result in dangerous ones as well. W. Edward Deming helped champion these concepts for the manufacturing industry, but these concepts can be mapped to healthcare as well.

While there are several ways to use the EHR to reduce variation, order sets are textbook examples. Order sets are a group or "menu" of orders that clinicians can place with a single click. Imagine working in the emergency department and a patient appears to have stroke-like symptoms. A single “Stroke Order Set” would include all of the necessary orders: CT scan, neurology consult, coagulation tests, among many others. Without an order set, Physician 1 may always order the CT scan, but forget to order the neurology consult and, as a result, delay time to deliver life-saving care. On the other hand, without an order set, Physician 2 may have been taught to get an X-Ray during their residency, so they weren’t aware that CT scan was the standard of care. In these examples, you can see how decreasing variation with an order set can lead to more reliable and effective care delivery that aligns with the best available practices.

Variation with Random Ordering

"While there are several ways to use the EHR to reduce variation, order sets are textbook examples. Order sets are just that, a set of orders that clinicians can employ with a single click."

COST

One often thinks of “quality” as simply being produced well and, as a result, there is an association with it being expensive. In healthcare, quality improvement is frequently associated with cost containment as well. Healthcare spending in the United States, as of 2019, reached $3.8 trillion, which is 17.7% of the entire gross domestic product (GDP). In light of these large costs to our society, it is imperative that healthcare stakeholders include costs when they strive to improve healthcare.

The EHR is important for delivering and documenting patient care, but the mandatory clinical decision support tools it provides can also be a rich source of cost savings and unrealized revenue. For example, interventions like alerts and defaults in order sets can provide clinicians with information around more cost-efficient choices in medications.

Commonly Referenced Terms

This is a very limited list into some commonly referenced terminology that you may stumble across in your quality improvement explorations.

SIX DIMENSIONS OF HEALTHCARE QUALITY

The Institute of Medicine released a report in 2001 entitled “Crossing the Quality Chasm.” This landmark paper outlined six aims that helped define what it means to deliver healthcare quality. The six dimensions are:

• Safe: “avoiding injuries to patients from the care that is intended to help them”
• Effective: “providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse, respectively)”
• Patient-Centered: “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions”
• Timely: “reducing waits and sometimes harmful delays for both those who receive and those who give care”
• Efficient: “avoiding waste, including waste of equipment, supplies, ideas, and energy”
• Equitable: “providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status”
  
  

THE TRIPLE AIM

When looking at the Six Dimensions of Healthcare Quality, you’ll notice the focus on direct care delivery. The IHI recognized that the health of a population doesn’t exist only within the walls of a hospital room or doctor’s office. The Triple Aim incorporates the health of communities that could include important factors like healthy food accessibility and affordable public transportation. The three aims are typically presented as a triangle with the following points:

• Improving the patient experience of care
• Improving the health of populations
• Reducing the per capita cost of healthcare
  
  

Landmark Reports

The following represent commonly referenced reports that helped transform society’s perspective on healthcare quality and patient safety.

TO ERR IS HUMAN: BUILDING A SAFER HEALTH SYSTEM (1999)

The Institute of Medicine (IOM) released this report and it helped open the eyes of many to the dangers of healthcare in the United States. The findings included the recognition that as many as 98,000 patients died every year as a result of medical errors. The analogy of a jumbo jet crashing each day was used to highlight the significance of these numbers. It’s no coincidence that the same year, the Agency for Health Care Policy and Research changed its name to Agency for Healthcare Research and Quality (AHRQ).