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Experts See 'Fundamental Change' in Drive to Improve Health Care Quality

APRIL 1, 2005 — The nation has made significant preparations for big leaps forward in the quality of health care but now has to muster the gumption to jump. That was the message Monday from two leaders in the quality improvement field who lauded the health care system for real change but slammed it for huge shortcomings.

"I think a fundamental change is occurring" in health care quality, Dr. Carolyn M. Clancy, administrator of the Agency for Healthcare Research and Quality (AHRQ) said in a speech to the Health Care Quality Summit sponsored by the agency. "That change comes from what we've learned, and what we've done, to measure quality." Quality improvement guru Dr. Donald Berwick said "the lights are coming on," illuminating how and where change should occur. Berwick is CEO of the Institute for Healthcare Improvement in Cambridge, Mass.

But Clancy said health care professionals should feel "impatience, anger, and even outrage" at how "agonizingly short" health care is of where it could be. Berwick was more blunt. "It is a politically correct mantra to claim that the U.S. has the best health care system in the world. It does not." And Berwick had some harsh words for the latest thing in quality improvement—"p4p," or "pay-for-performance," at one point calling it "treacherous."

Both Clancy and Berwick lauded the public–private Hospital Quality Alliance that unveiled data last week comparing the quality of hospitals nationwide on measures of heart attack, heart failure, and pneumonia treatment.

The pair also praised the annual issuance of reports on the quality of the nation's care and on racial and ethnic disparities in access to care as major strides forward. But enormous gaps exist in the quality of care, not only within the United States but between it and other nations, the speakers said. And while measurement sets the stage for action, it shouldn't be confused with action itself, they warned.

"We need to summon up the energy that this difficult job demands," Clancy said. "As health professionals and as citizens, we should be feeling 'shock and awe' when we see these chaotic differences in quality of care."

Berwick faulted Washington for not investing more money in researching how to improve care and urged a national investment in giving doctors and hospitals technical help through information technology and other means to improve treatment practices. Berwick also took a swipe at the current trend toward holding individuals more responsible in the marketplace for health care spending decisions.

The argument that things will improve if more costs are pushed to consumers is an "unethical view of the relationship between suffering and health," he said. The responsibility of the individual "is a tiny, tiny piece" of what must be done to improve care, he said.

Berwick said pay-for-performance is a misunderstanding of what motivates doctors and called it insulting. Doctors need technical and financial help organizing systems to improve care, not a "wake up, dummy" approach that assumes paying a bit more is what it takes to make care better, he said. Doctors "need payment not for performance, but to support performance," he said.

Investment in technical help would assist the many doctors who provide health care in small group practices or in rural areas, he said. Berwick has advocated a model of helping such doctors along the lines of agricultural extension services that help individual doctors.

Just as the nation took real action to improve air quality, so too does it have the real power to improve care. "We can set a goal as a nation," he said. Strong leadership is key to the next stage in quality improvement, Berwick emphasized. Hospitals and doctors will respond if leaders give the health care field a specific focus as well as technical assistance, he said.
By way of example, Berwick pointed to the response to his institute's "100,000 Lives Campaign." By the end of the month it will meets its goal of signing up 2,000 hospitals in an effort to prevent 100,000 unnecessary deaths by June 2006, he said. The campaign began only a little over three months ago.
How are hospitals mobilizing to meet the goal? By committing to develop "rapid response teams" that respond more promptly to patients whose condition deteriorates; to adopt consistency in heart attack treatment procedures; and to add procedures to prevent adverse drug interactions, surgical infections, and ventilator-associated pneumonia.

The effort has been endorsed not only by the Centers for Medicare and Medicare Services, but also by the American Medical Association, the American Nurses Association, and the Joint Commission on the Accreditation of Healthcare Organizations, Berwick says. "I'm absolutely sure we can turn the corner," Berwick said. "Why? Because we're starting to."

In issuing her call to action, Clancy did not play down the need for added measurement, however. Clancy highlighted new data showing how individual states rate on different measures of care and announced that her agency is making available a million dollars to help states and other organizations learn from each other how to improve care.

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