Abstract
In this brief review, written from the perspective of a physician-leader who has fostered the development of comprehensive quality improvement efforts at two academic medical centers, I review the need for improvement, some conceptual barriers that must be overcome, the goals of a comprehensive quality improvement (QI) effort, some of the results we have obtained, and some observations on how to develop a culture of continuous improvement in an academic medical center. The mandate for quality improvement is clear; current healthcare is wasteful and error-prone, leading to excessive morbidity and mortality and unsustainably high costs. Successful quality improvement requires the abandonment of two paradigms: the craft model of medical practice and the notion that many forms of harm to patients are not preventable. I will describe how dramatic improvement has been achieved in reducing, by up to 10-fold, rates of central line infections, ventilator-associated pneumonias, peritonitis in peritoneal dialysis patients, and mortality due to cardiac arrest in hospital. I will describe as well how these methods can improve access to out-patient clinics dramatically and enhance the reliability and safety of hand-offs between covering physicians. To develop and maintain systematic quality improvement in all phases of medical care we must articulate a culture in which: everyone working at the medical center makes improvements every day; front-line staff, who know best how the work is done, are empowered to improve the processes of care; and multidisciplinary teams create the protocols that reduce variation that is due to physician preference, leaving only the variation required by the individual needs of patients. I will review as well the crucial elements of education of trainees and faculty members needed to guide and sustain a culture of quality. Finally, I will add some observations on how oversight boards and medical center leaders can help create systematic quality improvement in their medical centers.
Highlights
In this brief review, written from the perspective of a physician-leader who has fostered the development of comprehensive quality improvement efforts at two academic medical centers, I review the need for improvement, some conceptual barriers that must be overcome, the goals of a comprehensive quality improvement (QI) effort, some of the results we have obtained, and some observations on how to develop a culture of continuous improvement in an academic medical center
I will describe briefly multiple quality improvement efforts, completed successfully at two different U.S academic medical centers, as a way of proving the benefits of this approach. These brief vignettes represent a fraction of the total successful quality improvement efforts going on at University of Pittsburgh Medical Center (UPMC) and Beth Israel Deaconess Medical Center (BIDMC)
With the adoption of these and other quality improvement measures, length of stay in the ICUs fell 20%, permitting the same number of ICU beds to care for 20% more patients
Summary
Healthcare around the world is expensive, unreliable, and dangerous. In 1999, U.S experts estimated that medical errors cause 44,000–99,000 preventable deaths per year and account for over $10 billion per year in excessive costs.[1] mortality figures may be accurate, the cost figures are likely to under-estimate vastly the true costs of unreliable, highly variable, and poorly coordinated care. What is most tragic is that our technical capabilities have never been better, but we fail repeatedly to use these capabilities to benefit our patients.[2,3] Two major paradigms rampant in current medical practice block quality improvement
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