Why the need for performance improvement?
In 1996, the National Academy of Science’s Institute of Medicine (IOM) launched an ongoing effort focused on assessing and improving quality of care. The first phase focused on cancer and concluded—“a wide gulf --- exists between ideal cancer care and the reality many Americans with cancer experience.”
Later the Institute of Medicine’s Committee on Quality of Health Care stressed the healthcare system must be radically transformed in order to close the chasm between what we know to be good quality care and what actually exists in practice.
The reports released during this phase were:
To Err is Human: Building a Safer Health System (1999) and
Crossing the Quality Chasm: A New Health System for the 21st Century (2001)
The Institute of Medicine defines quality as:
“---the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”
This is a working definition for practice improvement activities.
The growth of biomedical knowledge and technologies is stunning.
1 Since the first contemporary randomized controlled trial approximately 50 years ago, the number of trials conducted has grown to nearly 10,000 annually
2 Between 1993 and 1999, the budget of the National Institutes of Health increased from $10.9 to $15.6 billion,
3 Investments by pharmaceutical firms in research and development increased from $12 to $24 billion (Pharmaceutical Research and Manufacturers of America, 2000).
4 Genomics and other new technologies potent great promise.
5 Advances in rehabilitation, cell restoration, and prosthetic devices hold significant potential
Given the ever shortening half-life of a clinician’s biomedical knowledge, expanding policy directives and rapid changes in the organization of healthcare, continuous learning over a life time of practice applied to continuous efforts of practice improvement are imperative.
Further, Wennberg’s Dartmouth studies over two decades document wide geographic regional variations in practice patterns. Regions with greater spending rates do not have higher quality of care and have higher rates of discretionary surgery.
These studies find disturbing variation in the frequency of use of services across geographic regions of the U.S. Consider just a few examples:
1 Primary care visits vary by a factor of about three,
2 Visits to medical specialists by more than six,
3 Hospitalizations for cancer, chronic lung disease, and congestive heart failure by more than four.
In summary, the clinical experience of a patient varies as a function of geography and the amount spent on medical care does not correlate with quality of care one receives.
Such issues have created a public and professional mandate for practice improvement at both the level of the healthcare system and of the individual clinician.