Biomedical subjects
Publications and source records attributed to D Neuhauser.
Health professionals are reporting progress in the application of improvement principles and methods to clinical care. Clinical quality improvement efforts have decreased unnecessary intravenous catheter use, improved preventive services, and decreased hospital costs for patients with chest pain.
The new health care environment--centered on patients, focused on health, and managed by generalists--requires new competencies for the generalist physician. Among these are knowledge and skills for the continuous improvement of health care. In many areas, generalist physicians already use quality improvement methods and principles to improve the health and health care of their communities. Efforts to teach medical students and residents to improve quality continuously in health care are beginning. Early lessons are: (1) quality improvement is most effectively learned in the context of real work; (2) initial emphasis must be on the basics; (3) the focus is on the needs of those we serve; (4) interdisciplinary skills are essential and best learned during clinical training; and (5) the best learning environment for future generalist physicians, one which results in optimism about the future and the ability to make things better, is an environment that is continuously improving.
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Because clinicians control more than 70% of the total costs of medical care, the success of managed care systems in containing expenditures depends to a large degree on their leadership. Clinicians must make cultural changes and develop core competencies and technical skills to promote the continuous improvement needed for the success of managed care.
Despite a long history in industry, the principles and methods of continuous improvement are new to medicine. Continuous improvement led to a 73% drop in the number of inadequate cervical smears in a large urban health center.
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BACKGROUND: Two key ideas in the practice of continuous quality improvement (CQI) in health care are knowledge for improvement as distinguished from professional knowledge in improving the end results of patient care and the failure of the bad apple theory to explain variation in outcomes. METHODS: As part of their eight-week primary care clerkship, medical students at Case Western Reserve University (Cleveland, Ohio) are assigned to more than 20 sites in the greater Cleveland area where they observe and report on the cost and outcome of care for a patient with asthma. (An earlier article presented run charts and fishbone diagrams based on these reports.) In continuing this project, as described in this article, students report on the frequency of causes of variation in costs and outcomes of care. RESULTS: Students are asked to cite the one factor they believe had the most important effect on the cost and clinical outcome of the asthma patient they studied. For cost variation ranked by frequency, disease severity and site of care are reported most frequently, each accounting for 18% of responses. The most frequently reported cause of outcome variation was disease severity. No correlation was found between cost and outcome; higher costs do not produce healthier patients nor are they associated with greater outcome severity. For the nine most frequently used sites of care, the one-way analysis of means for costs shows that average costs for eight of nine sites are well within the expected range. Only one site (G) falls outside the upper boundary. Bringing this one "bad apple" site into conformity would have very little effect on overall costs. The one-way analysis of standard deviations shows that there may be only one case in the site that explains the bad apple outlier. CONCLUSION: Although more than one half of the causes of asthma variation reported in this study fall outside traditional professional knowledge, most of the content of health professions education still falls within the professional realm. Real improvement will require combining traditional professional knowledge with knowledge for improvement.
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Rural health care requires a response system that is unique and substantially different from other, more traditional systems of health care delivery. Any reform of the present rural health care system must offer services that include the public health sector as well as other aspects of the social "safety net." The authors present a vivid picture of the multiple realities operating in the rural environment, and they explore the opportunity for the creation of Accountable Health Plans suitable for the rural health care delivery mechanism.
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There are no widely accepted measures of health status for asthmatic patients, and these must be developed. Criteria for good health status measures are described. Their intended use determines their form. The concepts of continuous quality improvement (CQI) are used here to define a new perspective about asthma health status measures. In the context of CQI, a patient-centered continuous measurement can be used to understand and reduce variance in health status. Ongoing health status measures can be applied to groups of patients or individuals. Medical students collected data about the health status of their asthmatic patients as part of a project to introduce them to CQI. These results are presented as an example of this new direction.
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Firms research combines parallel providers of care, ongoing patient randomization, and continuous experimental changes and improvement. This form of efficient research now has a substantial track record of published studies by a growing number of hospitals.
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In the future, health care delivery systems may need to respond to requests from payers to demonstrate the quality of care they provide for types of patients or diseases. Here, asthma is used as an example of what such a response might look like in the context of continuous quality improvement.
This article describes a medical school's effort to introduce quality improvement (QI) concepts and methods through experiential learning to students as part of a required eight-week primary care clerkship. Each student describes a patient with asthma, investigates the cost of care, and assesses the outcome through an interview with the patient. These patients are considered together as recipients of an areawide process of care. The statistical tools of QI were adapted in a workbook to help students understand care as a process and their role as physicians in improving it.