From the Editor-In-Chief Health AffairsVol. 30, No. 4: Still Crossing The Quality Chasm Still Crossing The Quality Chasm—Or Suspended Over It?Susan DentzerPUBLISHED:April 2011Free Accesshttps://doi.org/10.1377/hlthaff.2011.0287AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSQuality of careGlobal healthHealth disparitiesEthnic disparitiesHospital qualityOrganization of careAdverse eventsQuality improvementDiseasesPatient safety The famed 2001 Institute of Medicine report, Crossing the Quality Chasm , demonstrated that US health care suffered from so many shortcomings that it scarcely warranted the name. The report followed the equally famed 1999 IOM study, To Err Is Human , which estimated that avoidable medical errors contributed to 44,000–98,000 deaths at US hospitals annually. These reports established a clear consensus: To arrive at health care that was high quality—that is, safe, effective, patient-centered, efficient, delivered on a timely basis, and devoid of disparities based on race or ethnicity—would require a herculean effort to move the field across the abyss.Quality Journey How far we have come since then—and how far we still have to go—are the subjects of this thematic issue of Health Affairs , sponsored by the Robert Wood Johnson Foundation (which has itself made huge investments over the past decade in its Aligning Forces for Quality initiative). As a number of articles in the issue demonstrate, there’s no doubt we’ve made progress—but it’s also clear that making any headway has been agonizingly slow. If ever the state of high-quality health care appeared to be an achievable end point, we recognize now that—to paraphrase Ralph Waldo Emerson—quality, like life, is not a destination but a journey. On that point, a number of the articles in this issue deal with the evolving science of how to measure health care quality or document its absence. In some instances, as our measurement tools get better, the quality of care looks even worse. One example is determining how many so-called adverse events—injuries caused by medical management, not the underlying disease—actually occur in hospitals in the United States each year.Worse Than We Thought?There are various methods for tracking adverse events, but David Classen and colleagues tested out a rigorous chart-review methodology pioneered by the Institute for Healthcare Improvement. Disturbingly, the method picked up ten times more confirmed significant adverse events than other methods—and determined that adverse events occurred in one-third of hospital admissions, even in hospitals that had instituted advanced patient safety programs. To be sure, not all of these resulted in serious injuries to patients or deaths. But try to imagine the reaction if one of three patients arriving at hospitals were notified that something bad would happen during their stay—and that, to make matters worse, they might be stuck with higher hospital copayments as a result.Happily, case examples featured in this issue do show progress, such as at Ascension Health, one of the nation’s largest health care delivery systems. As David Pryor and colleagues report, an analysis carried out at Ascension in 2003 suggested that, on average, one in seven deaths occurring in patients admitted to Ascension hospitals were potentially preventable (excluding patients admitted for end-of-life care). By 2010, however, the system’s concerted efforts to reduce these preventable deaths were saving the lives of 1,500 patients annually. The Ascension system had also sharply cut rates of pressure ulcers, birth trauma, and hospital-acquired infections.National Success StoriesIn a similar vein, we chronicle what may be one of the first major national success stories in quality improvement: the campaign to reduce preventable bloodstream infections, which began in Michigan and spread to forty-five states. This multistep, multistakeholder process, described by Peter Pronovost and colleagues, created a “social community” around the effort that included federal and state agencies, clinicians, hospitals, and hospital groups. As a result, data from the Centers for Disease Control and Prevention show that the number of patients in US intensive care units suffering a bloodstream infection contracted through a “central line”—a tube inserted through the chest into the heart or vena cava—declined by 63 percent between 2001 and 2009.A more sobering story is told by Amal Trivedi and colleagues, who studied the Veterans Health Administration’s efforts to combat racial and ethnic disparities. The good news is that “process” disparities were narrowed; for example, rates of eye examinations for people with diabetes improved for both black and white populations. But disturbingly, in terms of health outcomes, there were either only modest improvements for African Americans or continued disparities between their outcomes and those of whites. The authors conclude that far more work will have to be done to determine causes of these outcomes disparities and to address any remaining gaps in care for these vulnerable populations.Next ChallengesThe next frontier to be crossed on the quality journey is discussed by Mark Chassin and Jerod Loeb of the Joint Commission: “high reliability,” or consistent performance at high levels of reliability. Advanced industries have embraced this standard, they note, including aviation. They call on health organizations to adopt “collective mindfulness,” to be “acutely aware that even small failures in safety protocols or processes can lead to catastrophic adverse outcomes.”As Floyd Fowler and colleagues write, it’s also critical to pull patients more deeply into the quality improvement process, through shared decision making about their care on the basis of medical evidence. As they note, another form of avoidable error is performing surgery on a patient who might have chosen not to have it, had he or she been accurately informed about the potential consequences and the other treatment alternatives.We thank the Robert Wood Johnson Foundation most sincerely for its support, and we are grateful that our journal continues to be one of the forces “aligned” with the foundation’s quality improvement efforts.Philip A. Musgrove, 1940–2011 “Not people die but worlds die in them,” wrote the Russian poet Yevgeny Yevtushenko, in his poem simply called “People.” Here at Health Affairs , a world has died for us with the untimely death of our colleague, Deputy Editor Philip A. Musgrove. Phil’s tragic death occurred March 21 on a visit to his beloved Latin America. He was en route to a panel discussion on Latin American health issues in Argentina, but took a brief holiday in advance. He and his companion, Elinor Schwartz, were on a tourist boat visiting Iguazu Falls on the Argentina-Brazil border. Something went amiss; the boat hit rocks, occupants were thrown overboard, and two Americans on board were killed—one of whom was Phil.Passion And SciencePhil was 70 when he died, but anyone who knew him realized he had as many as several decades left in him. A Haverford graduate with a Ph.D. in economics from MIT, he was an economist for the World Bank, the Pan American Health Organization, and the World Health Organization, predominantly in the area of global health financing. Colleagues remember his passionate commitment to development and his scientific and analytical rigor. He lectured widely and taught part time at several universities, including Johns Hopkins University’s School of Advanced International Studies. From 2002 to 2005, Phil served as a coeditor and coordinating economist on the Disease Control Priorities Project—an activity sponsored by the Fogarty International Center of the National Institutes of Health that involved more than 1,000 authors and reviewers worldwide from all corners of the globe. Then, in 2005, Health Affairs came calling. Prior to this time, the journal had almost exclusively focused on domestic US health and health policy issues, with its international coverage confined mostly to Western Europe and Canada. The Bill & Melinda Gates Foundation was eager to see health policy affecting the poorest contries get equally probing treatment, and offered Health Affairs a major grant to cover that area. Someone with expertise in the field was needed to oversee it, and that led the journal’s founding editor, John Iglehart, to Phil. Expansion Of CoverageUnder Phil’s guidance over the next six years, the journal produced a series of thematic issues and ongoing articles on critically important global health topics: in 2006, on Global Health Priorities; in 2007, on Global Health Financing; in 2008, on reforms in China and India. In 2009 the pace picked up, with one issue on global health delivery and a second on fighting HIV/AIDS and neglected diseases. The next year, 2010, brought two more global issues, including Battling Chronic Disease Worldwide, with a cluster of papers on chronic disease in Latin America produced under World Bank auspices and that Phil had a major role in shaping. Over his tenure with us, Phil shepherded more than 300 papers through the review process, and 175 of those through revisions and finally into print. “He worked extensively with authors before formal submission to help them craft their papers, shorten them, or whatever it took to make them more appropriate for submission,” recalls our executive editor, Don Metz. He conducted interviews, wrote book reviews, and represented the journal at countless meetings on global health topics. It was typical for him to return after an overseas trip with several more authors newly lined up to write for Health Affairs . Phil’s influence at the journal also stemmed from his talents as an economist, statistician, and methods reviewer on manuscripts. At weekly meetings to read through manuscripts submitted “over the transom,” Phil always turned instantly to a paper’s exhibits. Many a paper submitted with flawed or unimpressive data did not survive Phil’s scrutiny.Honoring His MemoryWe will have more to say about Phil in our forthcoming June 2011 thematic issue on vaccines, which we will dedicate to his memory. Suffice it for now to say that Phil endeared himself to his colleagues in many ways. He was always available to help out a fellow editor with any statistical or methods question. As he padded around our offices—frequently barefoot—he’d poke his head in the door and ask other editors about their kids. He wrote poetry and children’s books as a hobby, and was known for his wry humor and wit.El que teme la muerte no disfruta de la vida . He who fears death enjoys not life, goes an old Spanish saying. Phil enjoyed life to the fullest. We miss him greatly, and we hope to honor his memory by continuing to publish first-rate research and analysis that will advance the cause of better health for the world’s least fortunate. Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article MetricsCitations: Crossref 21 History Published online 1 April 2011 Information Project HOPE—The People-to-People Health Foundation, Inc. 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