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Quality Improvement/Patient Safety

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Physicians have an important role to play in improving patient safety and quality of care

The Institute of Medicine's 1999 report, To Err is Human, sounded an alarm when it revealed that between 44,000 and 98,000 Americans die each year from medical errors. A September 2001 conference, cosponsored by the Agency for Healthcare Research and Quality and the American Board of Internal Medicine, examined "The Role and Responsibility of Physicians to Improve Patient Safety." Three papers from the conference were published recently and are described here.

Editor's note: Select "Physicians' involvement in patient safety and quality of care may be pivotal to maintaining medicine's credibility" for a summary of an article by AHRQ Director Carolyn M. Clancy, M.D., and her colleagues that presents background information on the topic and an introduction to the conference papers.

Classen, D.C., and Kilbridge, P.M. (2002, October). "The roles and responsibility of physicians to improve patient safety within health care delivery systems." Academic Medicine 77(10), pp. 963-972.

These researchers propose a new organizational approach to patient safety and care quality that presents safety as an organizational effort and medical error as a shared problem between health care delivery organizations (HCDOs) and physicians. They assert that physician incentives, such as bonuses and leadership opportunities, are necessary to link physicians and the delivery system around the issue of quality and safety of care.

Their organizational model to improve patient safety and care quality includes eight components: organizational accountability; a culture of safety that defines the organization's approach to safety; learning environment; defined objectives for patient safety programs; internal monitoring/surveillance; implementation of standard process and technology solutions; measurement and monitoring of care; and integration of what's learned into new or modified program objectives.

The researchers suggest that HCDOs and their associated physicians pursue joint malpractice liability arrangements that are prorated for measured performance in safety. HCDOs and their medical staffs should work in concert to create a financial incentive structure to improve safety and quality without significant financial disincentives for either group. Practicing physicians should actively assess the impact of organizational patient safety and other quality improvement initiatives on the safety of care delivered to their patients. Finally, physicians' professional organizations should lobby for the addition of patient safety to medical education and training programs, and they should advocate for changes in professional scope-of-care laws to foster team-based, process-of-care initiatives to improve safety of care for the organization.

Becher, E.C., and Chassin, M.R. (2002, October). "Taking health care back: The physician's role in quality improvement." Academic Medicine 77(10), pp. 953-962.

Physicians are emerging victorious from the managed care battlefield, according to these authors. Managed care plans are reducing or eliminating utilization review, broadening their hospital and physician networks, and easing access to physicians within networks. However, employers, governments, and health plans are not returning to the days when they simply paid the increasing costs for whatever care physicians ordered. Instead, they talk about creating a market in health care in which consumers have information about quality and price and make their own choices.

These authors suggest that now is an opportune time for physicians and the organizations they guide to take a leadership role in improving care quality. This is one way that physicians and organizations can regain much of the autonomy over the practice of medicine previously lost to government and managed care. The authors describe how physicians can engage in quality improvement in a four- or five-physician primary care practice, a 50-physician multispecialty group, and a 450-bed community hospital.

Brennan, T.A. (2002, October). "Physicians' professional responsibility to improve the quality of care." Academic Medicine 77(10), pp. 973-980.

The medical profession has not clearly endorsed and participated in the measurement of quality—whether it be patient satisfaction, compliance with cost-effective guidelines, or outcome measures—in a way that shows professional commitment, asserts this author. Meanwhile, the field has been forfeited to some extent to insurance companies, government, and regulatory bodies.

The European Federation of Internal Medicine, the American Board of Internal Medicine, and the American College of Physicians/American Society of Internal Medicine have recently outlined the tenets of an activist medical profession in a draft Physician Charter. It consists of three major principles: commitment to lifelong learning and continuous professional development; commitment to honesty with patients, including errors in care; and commitment to improving the quality of care.

In keeping with this charter, the author notes that medical education must allow time for instruction in and discussion of quality issues and methods for improvement.

Recertification of doctors (like airline pilots) must be done in a continuous public fashion. Physicians must be honest with their patients, informing them when an injury has been caused by a mistake (physicians must endorse a blame-free environment focused on the need for system changes to reduce errors). And finally, physicians face a professional crossroads; they need to broaden the agenda on quality and not allow themselves again to be led by regulators, insurance companies, and employers if they are to retain the social trust critical to the profession.

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