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Aspiration or Way Station?

The report overview as well as the full case studies of the four hospitals discussed in this overview report are available at:

Two other related commentaries are available:

In the report, Hospital Quality: Ingredients for Success, Jack Meyer and his colleagues synthesized findings from the journeys of four carefully chosen, exemplary hospitals. After extensive study and analysis of the four hospitals, the authors provide hospital leaders with helpful advice on quality improvement, organized in the following four categories:

  • developing the right culture for quality to flourish;
  • attracting and retaining the right people to promote quality;
  • devising and updating the right in-house process for quality improvement; and
  • giving staff the right tools to do the job.

The authors also provide a list of 18 action steps for senior executives to follow. The action steps provide a useful outline for reaching the level of quality exemplified by these four hospitals.

The report will contribute positively if its contents are interpreted as a "way station" on the journey to the quality of care to which society is entitled. While the four hospitals examined are exemplary by today's standards, simply copying their current approaches would not reach the Institute of Medicine's vision for patient-centered care.

The authors chose examples from each of the hospitals to illustrate practices worthy of emulation. Each of the specific cases contains encouraging examples of improvement, but also illustrations of the shortcomings of the performance of these select hospitals. For example, one of the cases describes the use of residents in quality improvement projects. One of these projects resulted in a reduction of inappropriate use of telemetry from 35 percent to 13 percent. In a relative sense, this is very impressive. In absolute terms, an expensive and lifesaving resource continues to be wasted.

Several aspects of the report provide a sobering measure of the length of the journey still to come, the journey beyond the "way station." One of these aspects is the apparent omission of a patient-centered focus in the dialogue with the four hospitals. The words "patient," "family," or "community" do not appear anywhere in the 18 recommended action steps. In addition, the absence of almost any quantitative data on the performance of these hospitals reinforces the concern of academic physicians and researchers that quality improvement is not science.

Health care leaders wishing to more clearly define the aspiration of excellent, patient-centered care can augment the sound advice in this report with the vision articulated in the 10 rules appearing in Chapter Three ("Formulating New Rules to Redesign and Improve Care") of the Institute of Medicine's (IOM's) report, Crossing the Quality Chasm: A New Health System for the 21st Century. These rules are:

  • Care based on continuous healing relationships;
  • Customization based on patient needs and preferences;
  • The patient is the source of control;
  • Shared knowledge and the free flow of information;
  • Evidence-based decision making;
  • Safety as a system property;
  • The need for transparency;
  • Anticipation of needs;
  • Continuous decrease in waste; an
  • Cooperation among clinicians.

Integrating the IOM's rules with Meyer's four categories provides a vision of how "right" might be defined for hospitals aspiring to move beyond the current best performance.

The right culture
The right culture would value the patient as the source of control, endorse a free flow of medical information to patients, and expect to supply information transparently to the community about performance on quality, safety, and patient satisfaction. Such a culture is not yet fully developed anywhere and appears very distant from the current environment. This culture cannot be installed but must evolve as patient-centered goals are pursued and processes for accomplishing them are tested and implemented.

The right people
As the report suggests, doctors, nurses and other caregivers with strong professional skills are essential ingredients for successful quality improvement efforts. To move beyond current best performance, however, additional skills will be needed from these professionals. These include the ability to cooperate with other clinicians and the ability to make the patient the source of control while simultaneously practicing evidence-based medicine. Hospital executives must expand and refine recruiting and hiring processes to find this type of talent. In the long term, perhaps the academic community will increase the supply of clinicians with these skills by fundamentally redesigning their recruitment and education processes.

The right processes
The right processes can efficiently customize care and support healing relationships that are not bound by location or time. These processes seem far off, with no plans or blueprints available. To design and implement these processes will take investment in research and development. Making this investment separately at every hospital seems wasteful and not likely to produce the magnitude of change needed. Hospital executives could lobby foundations and government agencies to redirect some of their funding into efforts to design and evaluate such systems.

The right tools
The tools described in the report will be necessary to reach the "way station," but not sufficient to accomplish the aspirations articulated in the IOM rules. New tools, likely found outside of health care, will be needed. For example, to solve the complex problem of delays in health care systems, it will take tools developed by clinicians collaborating with experts trained in queuing methods and system flow. Typically, these experts are engineers, operations researchers, and statisticians. Initially, it will be difficult to build these relationships because of the vastly different experiences and perspectives of the participants. But with some persistence and good will, these different perspectives can be reconciled by agreeing on the common purpose of achieving improved results for patients.

Combining the IOM rules with the advice in this report provides hospital leaders with a vision of the purpose of the journey, and guidelines for passing through the "way station" to truly excellent care for patients.

The views presented in this commentary are those of the author and should not be attributed to The Commonwealth Fund or its directors, officers, or staff.

Publication Details



Aspiration or Way Station?, Thomas W. Nolan, Ph.D., The Commonwealth Fund, July 2004