Addressing the challenges outlined in Chapter 2 will require profound changes in how health systems are designed. At the heart of such systems are the skilled health care professionals without whom such a redesign could not take place. Preparing health care professionals to take on this task requires a common vision across the professions centered on a commitment to, first and foremost, meeting patients’ needs as envisioned in the Quality Chasm report (Institute of Medicine, 2001). The committee recommends the following as an overarching vision for all programs and institutions engaged in the education of health professionals:
All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics.
To this end, the committee proposes a set of simple, core competencies that all health clinicians should possess, regardless of their discipline, to meet the needs of the 21st-century health care system:
As a guide in formulating its five competencies, the committee examined core skills outlined in the Quality Chasm report and other core competencies formulated within and across the health professions. Following a brief review of that committee process, this chapter describes each competency in greater detail and contrasts these competencies with the corresponding current approaches in practice. Also provided is a scenario illustrating the effect on patient care when health care professionals do not apply such competencies. See Chapter 4 for more detailed discussion of the current state of practice and the implications of integrating these competencies into health professions education.
Origin of the Five Competencies
As acknowledged in the Quality Chasm report and in Chapter 2 of this report, there are many challenges facing health care in America. As a result, clinicians are increasingly being called upon to redesign better systems to address the health needs of the American population. The architects of the Quality Chasm report identify 10 important rules to guide the transition to a health system that better meets patients’ needs (see Box 3-1).
Ten Rules of Performance in a Redesigned Health Care System. Care is based on continuous healing relationships. Health professionals should provide care whenever patients need it and in many forms, not just face-to-face visits. Health professionals should (more...)
The authors of the Quality Chasm report also foresaw that health professionals would have to perform differently to meet these rules. Thus in the chapter “Preparing the Workforce,” they identified the key skills required by all health professionals to implement these new rules in the changing health care environment. The summit committee used this list of skills and the vision set forth in the Quality Chasm report as the foundation for its work, combining the list of skills into common groupings. The committee supplemented these groupings with a review of other seminal reform efforts that have articulated core competencies across or within the health professions. Many such efforts have emerged from the educational arena, both professional educational organizations and accreditation bodies, as well as from specialized private commissions, in response to the need to prepare the workforce adequately for the changing practice environment (ABIM Foundation, 2002; American Association of Medical Colleges, 2001; Brady et al., 2001; Center for the Advancement of Pharmaceutical Education [CAPE] Advisory Panel on Educational Outcomes, 1998; Halpern et al., 2001; O'Neil and the Pew Health Professions Commission, 1998).
One such major effort was undertaken by the Pew Health Professions Commission, which in 1992 articulated 17 competencies for future clinicians (O'Neil, 1992) and later expanded the list to 21 (Lenburg et al., 1999; O'Neil and the Pew Health Professions Commission, 1998). Debates centered on how to evaluate competency, focusing on the reliability, validity, and predictive ability of related measures. Nursing groups and some physicians cautioned against including only competencies that can be measured, such as those based on technical skills, as opposed to those that rely more on cognitive and critical thinking and difficult-to-assess interpersonal skills (Benner, 1982; Epstein and Hundert, 2002).
The five competencies are meant to be core and span the professions but are not intended as an exhaustive list. The committee recognizes that there are many other competencies that health professionals should posses, such as a commitment to lifelong learning. However, the committee believes the five competencies set forth in this report are most relevant across the clinical disciplines and best advance the 10 rules envisioned in the Quality Chasm report. (See Table 3-1 for how the competencies address the 10 rules.)
The committee recognizes that each of the disciplines has its own contribution and unique skills to bring to patient care—this is what makes the professions unique and valuable. The five core competencies are not discipline-specific and each profession will have its own way of operationalizing such competencies in practice. However, based on patient perspectives and needs, there are certain competencies that all health professionals should possess, regardless of their title or discipline.
The committee also recognizes that the definition of a professional’s competency will change over time. Indeed, professionals will likely progress from novice, the stage of their initial academic preparation, to expert, the stage toward the end of their career when they have learned to do their work intuitively (Batalden et al., 2002). However, the committee is also cognizant that the fundamental competencies that define health professionals over their career are unlikely to change greatly, even though the knowledge that they must acquire, and its application, will change dramatically.
Several cautions are in order, however. First, the competencies are interrelated (see Figure 3-1), and therefore, the maximum benefit can be derived when they are applied together. Second, health professionals should apply these competencies to most clinical interactions, but they do not cover every possible clinical decision. For example, not all care is delivered by teams. Third, the following discussion of the state of application of the competencies today is not intended to be pejorative, but to capture common practices and contrast these with the committee’s vision for the future.
The Five Competencies in Practice
Over the course of a lifetime, patients have numerous encounters with health care professionals. Often such encounters are effective, patients leave feeling satisfied with the care received, and their health improves. Unfortunately, this is not always the case, because health care professionals are often not supported by a system that aids them in providing optimum care. The scenario in Box 3-2, developed by the committee, is meant to illustrate some of the serious problems facing patients during an encounter with clinicians, and to show why the five core competencies outlined above are critical to improving health care. This scenario is not meant to be representative of all encounters, but is an example of a situation in which many elements have been problematic.
Problematic Scenario: Mrs. Johnson. Mrs. Linda Johnson is a married first-year graduate student in her early forties with two children in high school. She made an appointment with her primary care physician, Dr. Grady, because she was always thirsty, (more...)
Mrs. Johnson’s care failed on several accounts.
First, the health professionals she saw did not provide patient-centered care. They offered little education to help her understand her condition, such as the physical difference between Type I and Type II diabetes, the treatment process, and related complications. Mrs. Johnson and her health care providers lacked a partnering relationship in deciding how she should manage her diabetes. Her plan of care was not sufficiently individualized to account for her hectic lifestyle and issues related to being a wife, mother, and student. In addition, her providers did not address the impact the disease would have on the daily lives of her family and the family’s need to understand the condition.
Second, the various health professionals did not work as an interdisciplinary team in the development of an individualized treatment plan for Mrs. Johnson. Her care was characterized by a lack of collaboration and communication among the doctor, laboratory personnel, the dietician, and the pharmacist. Because of the necessary interdisciplinary nature of diabetes management, a team approach is required to provide quality patient care and prevent associated long-term complications. The team must consist of the patient and all involved health care providers, for example a nurse to coordinate care, a diabetes educator for general education regarding the disease, a dietician for nutritional education, a pharmacist for medication review and education, a physician for primary care, a podiatrist for foot care, and perhaps a psychologist to address anxiety or other mental health issues.
Third, the health professionals did not employ evidence-based practice in Mrs. Johnson’s care. The goal of diabetes education has been to promote self-management, but research has shown that knowledge alone is an insufficient predictor of an individual’s ability to incorporate new self-care behaviors. Educational programs that promote effective self-care among people with Type II diabetes should be designed to foster a belief in the efficacy of self-care along with other relevant health beliefs. Strategies to this end provide the patient the opportunity to demonstrate success in the self-management of diabetes, such as mastery of the glucometer in daily usage.
Fourth, the clinic did not apply quality improvement methods. A diabetes registry had been implemented, but it was not being used to improve the quality of care provided to patients. The diabetes team attempted to monitor the number of patients entered into the registry, the services they received, and outcomes related to changes in their health status. Since the registry was not continuously updated, the key measures for individuals, subpopulations, and the total population were incorrectly reported. As a result, trends could not be monitored. If the diabetes registry had been continuously updated, the provider’s office manager would have printed out the encounter form upon a patient’s visit and clipped it to the front of the chart. This form would have provided various graphs displaying a 6-month history of care while alerting health care providers to needed tests and services. In the paper-based system that characterizes the scenario in Box 3-2, patient input depends on each health care provider’s remembering to update encounter forms and office staff’s having time for data entry.
Finally, health professionals did not utilize informatics in the clinic visited by Mrs. Johnson. Administrators in the clinic had implemented the diabetes registry, but they had not designated a specific individual to be responsible for monitoring data entry and disseminating output reports. As a result, it was impossible to know whether health care providers had failed to update the encounter forms at the time of patient visits or had delegated the paperwork to their staff, who may not have completed it correctly, if at all. When inquiries were made about updating of the encounter forms, all the health care providers stated they were positive the necessary paperwork had been completed after each visit. Yet when they received monthly reports, they believed the statistics did not correctly reflect their patient load or the number of services provided; they thought the numbers should be higher in both areas. Without an effective monitoring system in place, however, it was difficult to validate those beliefs. In sum, the paper-based system limited the health care providers’ ability to search, retrieve, and manage client data from the diabetes registry.
In the following subsections, the rationale and a detailed definition for each of the five core competencies identified by the committee are presented. It should be noted that there is not in all cases a strong evidence base supporting the view that adopting a competency would result in better patient and population outcomes. Where such evidence is available, it is cited; where it is not, this lack is indicated, and the rationale for the committee’s espousal of the competency is provided.
Provide Patient-Centered Care
Shifting health care needs for the American population have added a growing need for care for chronic conditions to the once predominant need for acute, episodic care. Today, 4 in 10 Americans report having a chronic condition, and by 2020, this proportion will increase to half of the nation’s population (Wu and Green, 2000). Unlike those who receive acute, episodic care, patients with many coexisting conditions see a variety of health providers, in a multitude of settings, over an extended period of time. Disease-focused and clinician-centered care, which emphasizes treating a disease without attention to the needs of the patient and centers on the health professional as the sole source of control, is out of step with changing patient needs and demands. Patients are increasingly interested in customized treatment recommendations that are responsive to their preferences and beliefs and reflect an understanding of their environment, including home life, job, family relationships, cultural background, and other factors.
The health care financing system—which largely does not reimburse professionals for time spent coordinating and integrating care or providing care through alternative vehicles, such as over the Internet or via telephone—further constrains clinicians’ efforts to care for patients (Institute of Medicine, 2001). Significant work done by researchers and experts in this competency area reveals specific skills needed by today’s health professionals to be more responsive to patient needs (Gerteis et al., 1993; Halpern et al., 2001; Institute of Medicine, 2001; Lewin et al., 2001; Mead and Bower, 2000; O'Neil, 1992; Pew Health Professions Commission, 1995; Stewart, 2001):
Share power and responsibility with patients and caregivers.
Engage in an ongoing dialogue with patients that brings about understanding, acceptance, cooperation, and identification of common goals and related care plans.
Guide and support those providing care to patients (e.g., family members, friends) by involving them as appropriate in decision making, supporting them as caregivers, making them welcome and comfortable in the care delivery setting, and recognizing their needs and contributions.
Understand and respect patients’ self-management activities.
Provide physical comfort and emotional support.
Ease pain and suffering.
Provide timely, tailored, and expert management of symptoms.
Relieve fear and anxiety.
Communicate with patients in a shared and fully open manner.
Allow patients to have unfettered access to the information contained in their medical records.
Communicate accurately in a language that patients understand. Offer trustworthy information using patients’ preferred communication channels (e.g., face-to-face, e-mail, other Web-based communication technologies).
Explore a patient’s main reason for a visit, associated concerns, and need for information.
Take into account patients’ individuality, emotional needs, values, and life issues.
Provide care for patients in the context of the culture, health status, and health needs of the population of which each is a member.
Provide care that reflects the whole person.
Implement strategies for reaching those who do not present for care on their own, including care strategies that support the broader community.
Accept responsibility for enrolled members of a health plan, and consider the needs of underserved members of a community who do not initiate visits or present for care.
Enhance prevention and health promotion.
Apply population-based strategies to identify and reduce risk factors and to improve patients’ use of and access to appropriate services and providers.
Define and describe populations by health status.
Deliver health care services intended to prevent health problems or maintain health.
Understand and apply principles of disease prevention and behavioral change appropriate for specific populations with which patients may identify. Understand the links among healthy lifestyles, prevention, and the cost of health care.
Multiple studies demonstrate that meeting the aim of patient-centeredness can improve health status and other outcomes desired by patients (Benbassat et al., 1998; Henbest and Stewart, 1990; Kaplan et al., 1989; Lewin et al., 2001; Roter et al., 1995; Stewart et al., 1999). Evidence demonstrates that patients who are involved in their care decisions and management have better outcomes, lower costs, and higher functional status than those who are not so involved (Gifford et al., 1998; Superio-Cabuslay et al., 1996; Von Korff et al., 1998; Wagner et al., 2001). In a randomized controlled trial of a self-management program for chronic disease patients, participants who received the intervention showed improvement as compared with the control group in health behaviors such as frequency of exercise and improved communication with health providers, as well as improved health status and reduced hospitalization (Lorig et al., 2001). Providing patient-centered care also has been shown to lead to greater clinician satisfaction, a reduction in malpractice claims, and patient loyalty to the clinician (Meryn, 1998). Box 3-3 describes an example of care from the patient’s perspective.
Care From the Patient’s Perspective. Planetree is a nonprofit consumer health organization dedicated to providing a model of patient-centered care through its 33 affiliate hospitals throughout the United States. The model strongly emphasizes patients (more...)
Providing patient-centered care is particularly important in light of the ethnic and cultural diversity that increasingly characterizes much of the United States. Although minority populations represent less than 30 percent of the national population, they constitute about 50 percent of the population in some states, such as California (Institute for the Future, 2000). A culturally diverse population poses challenges that go beyond simple language competency and include the need to understand the effects of lifestyle and cultural differences on health status and health-related behaviors; the need to adapt treatment plans and modes of delivery to different lifestyles and familial patterns; the implications of a diverse genetic endowment among the population; and the prominence of nontraditional providers, as well as family caregivers (Institute of Medicine, 2002). Box 3-4 presents an example of a system of care that is designed to respond to cultural diversity.
Responding to the Diversity of the U.S. Population. In response to the rapidly changing demographic profile in the United States and rising health care costs, Kaiser Permanente created the Institute for Culturally Competent Care. The institute is devoted (more...)
Researchers caution, however, that though scattered studies demonstrate positive outcomes with the provision of patient centered care, more attention needs to be paid to the methodological quality of such studies. Currently there is no gold-standard measure for patient-centeredness. The absence of valid, reliable, and appropriate tools to assess the effects of interventions to promote patient-centered care has been a large obstacle in performing such assessments uniformly (Mead and Bower, 2000). Another obstacle has been associated with the definition of terms related to this competency. Though a widely used phrase, patient-centered care has little shared meaning within and across the health professions. In their systematic review, Lewin and colleagues (2001) note that more work needs to be done on defining common language and terms related to patient-centered care that can be operationalized in effectiveness studies.
Work in Interdisciplinary Teams
An interdisciplinary team is composed of members from different professions and occupations with varied and specialized knowledge, skills, and methods. The team members integrate their observations, bodies of expertise, and spheres of decision making to coordinate, collaborate, and communicate with one another in order to optimize care for a patient or group of patients. It should be noted that, although patients and their caregivers are increasingly performing tasks once performed strictly by health professionals (Hart, 1995; Lorig et al., 1999; Von Korff et al., 1997) and so could be considered part of the larger health care team when they so desire, this report focuses on the educational needs of trained health professionals. Thus this competency refers to the various disciplines working together to address the needs of patients. Interdisciplinary teams are critical in dealing with the increasing complexity of care, coordinating and responding to multiple patient needs, keeping pace with the demands of new technology, responding to the demands of payors, and delivering care across settings (Bluml et al., 1999; Hall and Weaver, 2001; Institute of Medicine, 2001). Teams tend to reduce the utilization of redundant or duplicate services, and they also tend to develop more creative solutions to complex problems because of their members’ diverse academic backgrounds and experience. Patients needing chronic care, critical acute care, geriatric care, and care at the end of life require smooth team functioning because of the complexity of their needs. Different means and settings for delivering care, such as managed care, community-based care, rehabilitation centers, and critical pathway systems, are gaining momentum and require interdisciplinary teams to provide the necessary coordination (Amsterdam et al., 1980; McDonough and Doucette, 2001; Weingart, 1996). Most but not all care should be delivered by teams, either formally or informally organized.
Interdisciplinary teams have been shown to enhance quality and lower costs in some studies (Baldwin, 1996; Burl et al., 1998; Curley et al., 1998; McDonough and Doucette, 2001; Shortell, 1994; Wagner et al., 2001). The identification or addition of team members to achieve greater concordance with complex treatment protocols on the part of both providers and patients has improved outcomes for several chronic conditions (Wagner, 2000). Studies have also demonstrated a relationship between better interaction among team members in intensive care units and decreased risk-adjusted length of stay (Shortell, 1994). Still other studies have demonstrated some impact of effective team care on patient safety and reduction of medical errors (Silver and Antonow, 2000; Weeks et al., 2001). However, more research is needed to fully explore the effect of teams on patient outcomes and cost, as well as the effectiveness of teams in ambulatory settings (Cooper and Fishman, 2003). Summit participants suggested making systematic evaluation a part of all interdisciplinary team activity as an important first step. The committee decided to focus one of its recommendations on further developing the evidence base for this and other core competencies.
Evidence is lacking on how best to distribute patient care functions within a collaborative team and how to improve clinicians’ willingness or ability to collaborate (Lewin et al., 2001), as well as on the role of accrediting organizations in fostering interdisciplinary teams (Hall and Weaver, 2001). A great deal has been learned, however, about how to break down hierarchies and develop trust, and about the need for preplanning of roles. Experience has shown that being an effective team member requires health professionals to (Hall and Weaver, 2001; Halpern et al., 2001; Helmreich, 2000; Reese and Sontag, 2001):
Learn about other team members’ expertise, background, knowledge, and values.
Learn individual roles and processes required to work collaboratively.
Demonstrate basic group skills, including communication, negotiation, delegation, time management, and assessment of group dynamics.
Ensure that accurate and timely information reaches those who need it at the appropriate time.
Customize care and manage smooth transitions across settings and over time, even when the team members are in entirely different physical locations.
Coordinate and integrate care processes to ensure excellence, continuity, and reliability of the care provided.
Resolve conflicts with other members of the team.
Communicate with other members of the team in a shared language, even when the members are in entirely different physical locations.
In the future health care system, health professionals will have to understand the advantage of high levels of cooperation, coordination, and standardization to guarantee excellence, continuity, safety, and reliability. In short, they will have to think of themselves as a team working in and contributing to a larger system. As Don Berwick, Institute for Healthcare Improvement, said at the summit,
System-mindedness means cooperation. It means skills such as conflict resolution. It means asking yourself…not what are the parts of me, not what do I do, but what am I part of?
Employ Evidence-Based Practice
Using the ever-expanding evidence base, health professionals can consistently promote best practices and avoid the underuse, misuse, and overuse of care (Chassin, 1998). The committee believes it is critical for interdisciplinary health teams and each of the disciplines to be able to tap this evidence base effectively at the point of patient care, determining whether an intervention, such as a preventive service, diagnostic test, or therapy, can be expected to produce better outcomes than alternatives—including the alternative of doing nothing.
The notion of evidence-based practice refers to the integration of best research evidence, clinical expertise, and patient values in making decisions about the care of individual patients (Institute of Medicine, 2001; Straus and Sackett, 1998). Best research evidence includes evidence that can be quantified, such as that from randomized controlled trials, laboratory experiments, clinical trials, epidemiological research, and outcomes research; evidence based on qualitative research; and evidence derived from the practice knowledge of experts, including inductive reasoning (Guyatt et al., 2000; Higgs et al., 2001). Clinical expertise is derived from the knowledge and experience developed over time from practice, including inductive reasoning. Patient values and circumstances are the unique preferences, concerns, expectations, financial resources, and social supports that are brought by each patient to a clinical encounter. This definition of evidence is inclusive—it does not mean that all decisions must be based on the results of randomized controlled trials, as such results are not always available, nor does it discount clinician experience or the integration of information about a patient’s special circumstances. Rather, all such sources of knowledge may be relevant and valuable in deciding how to apply evidence. Box 3-5 presents an example of how clinicians can work in teams to apply the evidence base thus defined.
Working in Teams to Apply the Evidence Base. HealthEast, an integrated care delivery system including acute care, chronic care, senior services, community-based services, ambulatory/outpatient services, physician clinics, and wellness services in St. (more...)
Considerable progress has been made on identifying and disseminating best research findings about effective clinical practice. Such efforts include journals that summarize primary research, the Agency for Healthcare Research and Quality’s development of a national clearinghouse for clinical guidelines and launch of evidence-based practice centers to produce and disseminate evidence reports and technology assessments, the National Institutes of Health’s Consensus Development Program (National Institutes of Health, 2002), and the development of secondary databases of relevant research (Jadad and Haynes, 1998; Walshe and Rundall, 2001).
The committee believes that to employ evidence in practice, health care professionals should be able to (Davidoff, 1999; Grad et al., 2001; Rosswurm and Larrabee, 1999):
Know where and how to find the best possible sources of evidence.
Formulate clear clinical questions.
Search for the relevant answers to those questions from the best possible sources of evidence, including those that evaluate or appraise the evidence for its validity and usefulness with respect to a particular patient or population.
Determine when and how to integrate these new findings into practice.
While there is evidence that the dissemination of research on effectiveness has improved patient outcomes in discrete venues, such as treatment of lower-back pain, acute myocardial infarction, and other conditions (Goldberg et al., 2001; Mehta et al., 2002), the extent to which this approach has had an effect on overall clinical practice is unclear (Jadad and Haynes, 1998; Walshe and Rundall, 2001). A large barrier is that, although the evidence base for medicine is robust and continually expanding, the evidence bases for the other professions are lacking. Nursing and allied health interventions are not captured in medical records, which provide underlying data for research studies that make up the evidence base. For example, problems of importance to nursing practice, such as patient pain, dehydration, skin breakdown, lifestyle change, knowledge deficiencies, noncompliance with therapies, and anxiety management, are largely not captured in research, clinical, and administrative data systems and so cannot be retrieved for use as evidence in practice (Lang, 1999). Another obstacle is that nursing and allied health interventions often are not evaluated using rigorous quantitative research designs, but are described in descriptive or qualitative studies (Department of Health and Human Services, 1998; Evers, 2001; Mazurek, 2002).
Nursing and allied health leaders advocate standardizing evidence in their fields and combining it with other bodies of evidence to achieve the best possible outcomes for patients and strengthening the evidence base to include more randomized studies (Denehy, 1998; Department of Health and Human Services, 1998; Lang, 1999; Zielstorff, 1998). Summit participants suggested that focusing on common core bodies of evidence and developing a common language and consistent terminology across the professions are also key to employing evidence-based practice in health care.
Significant barriers to employing evidence-based practice include difficulty in getting research findings to practitioners in a useful format at the point of care, time constraints on the part of busy health professionals, professional ideologies that emphasize practical rather than intellectual knowledge, the notion that evidence-based practice represents a cookbook approach to care, and practice environments that do not encourage information seeking (DiCenso et al., 1998; Haynes, 2002). In response, some have proposed a greater role for specially trained clinical librarians to assist health professionals in framing clinical questions and identifying the relevant literature (Davidoff and Florance, 2000).
Many efforts are also under way to make it easier for clinicians and patients to access and interpret findings reported in the literature and apply them to practice. These include a sizable number of online databases devoted to reviews of the evidence base. Examples include the American College of Physicians (2002) Journal Club, the Cochrane Collaboration’s (2001) regularly maintained reviews of evidence, the Database of Abstracts of Reviews of Effectiveness (NHS Centre for Review and Dissemination, 2002), and MEDLINE at the National Library of Medicine (2002)—the largest general biomedical research literature database. There are also various Web sites that organize information around particular health needs, such as the American Cancer Society’s (2002) site; numerous journals that summarize primary research, such as Evidence-based Medicine and Evidence-based Nursing; and the Agency for Healthcare Research and Quality’s (2002) evidence reviews. In addition, continuing advances in informatics, such as computerized decision support systems that remind clinicians to provide care according to the latest available evidence, are a promising development, although a meta-analysis by Hunt and colleagues (1998) suggests that the effects of such systems on patient outcomes have been insufficiently studied (Walshe and Rundall, 2001).
Apply Quality Improvement
The Institute of Medicine (IOM) has defined 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” (Institute of Medicine, 1990:4). As noted previously, two recent IOM reports—To Err Is Human: Building a Safer Health System (Institute of Medicine, 2000) and Crossing the Quality Chasm: A New Health System for the 21st Century (Institute of Medicine, 2001)—document abundant evidence of serious and extensive quality problems throughout the U.S. health care system. Poorly designed care processes or systems have led to unnecessary duplication of services, long waiting times and delays, and compromised patient safety, resulting in avoidable errors and harm to patients (Schuster et al., 1998).
In addition to an unacceptable number of errors, the health care system is plagued by waste and inefficiency. Waste involves the use of resources without benefit to patients: extra and useless tests; multiple entries of such things as physicians’ prescriptions and laboratory orders; classifications that add complexity without adding value, such as types of appointments and job classifications; and multiple layers of control, such as approvals. Inefficiency is apparent in the long waits patients must endure for both services and test results. Such waiting can result in a delay in diagnosis or treatment that leads to preventable complications (Institute of Medicine, 2001).
Health care organizations are increasingly adopting methods and techniques that originated in various industrial movements, such as total quality management and continuous quality improvement, to minimize waste, decrease errors, increase efficiency, and ultimately improve quality of care. Most commonly termed quality improvement in health care, these approaches require that health professionals be clear about what they are trying to accomplish, what changes they can make that will result in an improvement, and how they will know that the improvement has occurred (Berwick, 1996). More specifically, health care professionals need to be educated to do the following (Berwick et al., 1992; Donabedian, 1980; Halpern et al., 2001; Institute of Medicine, 2001; Schuster et al., 1998):
Continually understand and measure quality of care in terms of structure, or the inputs into the system, such as patients, staff, and environments; process, or the interactions between clinicians and patients; and outcomes, or evidence about changes in patients’ health status in relation to patient and community needs.
Assess current practices and compare them with relevant better practices elsewhere as a means of identifying opportunities for improvement.
Design and test interventions to change the process of care, with the objective of improving quality.
Identify errors and hazards in care; understand and implement basic safety design principles, such as standardization and simplification and human factors training.
Both act as an effective member of an interdisciplinary team and improve the quality of one’s own performance through self-assessment and personal change.
A growing body of studies indicates that applying quality improvement methods and principles mitigates errors, waste, inefficiency, and delay (Holman et al., 2001; Kiefe et al., 2001; O'Connor et al., 1996). One study found that implementation of a quality improvement program was associated with a high level of adherence to quality-of-care indicators for acute mycordial infarction (Mehta et al., 2000). Using quality improvement methods, researchers were able to improve medication management for depression (Unutzer et al., 2001). And physicians and other health professionals involved in cardiac surgery in northern New England used continuous improvement techniques to reduce their inhospital mortality rate after coronary artery bypass graft surgery; after 2 years, a 24 percent reduction in the in-hospital mortality rate was achieved (O'Connor et al., 1996). Box 3-6 presents an example of how interdisciplinary teams can apply quality improvement strategies to reduce errors.
Working in Teams to Reduce Errors. Luther Midelfort Hospital in Eau Claire, Wisconsin, is a 300-bed facility, part of the Mayo Health System. An interdisciplinary team of a nurse, a physician, and a pharmacist was formed to examine medical errors in the (more...)
Quality improvement emerged from the industrial sector as an effective package of theory and practical tools for reducing errors in the production process. As applied to health care, it has been praised by some, but has spread slowly. One notable constraint has been the lack of a supporting information infrastructure. Another has been an absence of leadership and support and a lack of enthusiasm from and often skepticism among health care providers regarding the effectiveness of the approach (Blumenthal and Epstein, 1996; Brennan, 1998; Ferlie and Shortell, 2001). Such skepticism is understandable, given that the evidence for the effectiveness of the approach is largely anecdotal (Blumenthal and Kilo, 1998), and the rigor of much of the evidence available is questionable (Shortell et al., 1998).
Regardless of the barriers outlined above, the committee believes that the question is not whether health professionals should apply quality improvement approaches, but how they can implement such approaches more successfully within health care. One review of the studies to date suggests that quality improvement approaches should be better adapted to the realities of health care and be more related to the needs of clinicians and to patient-related problems (Grol, 2001). Summit participants advocated that the health care system build on the experience of groups in other industries that have been able to demonstrate gains in quality through the use of quality improvement methods.
Health care informatics is more than information technology; it is the development and application of information technology systems to problems in health care, research, and education (Masys et al., 2000). Informatics has made many contributions to the health care environment in recent years: applications of information technology to administrative and financial transactions, such as billing and ordering; a virtual explosion of health-related information available to consumers via the Internet; and gains in making syntheses of evidence, practice guidelines, and health services research more accessible to health professionals, researchers, and patients. Informatics has begun to be applied more directly to the clinical realm as well through such applications as reminder and decision support systems, order entry systems, telemedicine, teleradiology, online prescribing, and e-mail. Box 3-7 describes the efforts of one government program to improve quality through the use of informatics. The committee believes, and past research has shown, that through the utilization of such tools, health professionals will be able to perform four key tasks—reduce errors, manage knowledge and information, make decisions, and communicate—more effectively than has been the case in the past.
Quality Improvement and Informatics Leading to Better Patient Outcomes. The Veterans Health Administration (VHA) operates the largest health care system in the nation, providing care at more than 1,200 sites, including 172 medical centers and more than (more...)
Information system applications have been shown to enhance patient safety by standardizing and automating certain decisions and by flagging errors, such as adverse drug interactions, before they are allowed to occur. Likewise, computerized medical records, with their elimination of handwritten data, are integral to error reduction. Computerized prescriber order entry systems can eliminate errors caused by misreading or misinterpreting handwritten instructions. They also can intercept orders that might result in adverse drug reactions or that deviate from standard protocols. One study found that the use of a physician order entry system resulted in a 55 percent reduction in medical errors and a 17 percent decrease in the preventable adverse drug event rate (Bates et al., 1998); 80 percent of medication errors unrelated to missed dosage were also found to be eliminated by such systems (Bates et al., 1999). Computer-generated reminders have been shown to be effective in reducing errors of omission as well (Overhage et al., 1997). E-mail communication, electronic medical records, and computer-aided decision support systems also offer the potential to improve care across clinicians and settings, thus reducing the chances of errors resulting from poor coordination (Blumenthal, 1997). One example of the use of online patient registries is described in Box 3-8.
Use of Online Registries. Group Health Cooperative of Puget Sound (GHC) has developed online registries for diabetes, heart care, depression, breast cancer, and pediatric immunizations. The registries provide member-level clinical data for those with (more...)
Manage Knowledge and Information
Online databases can make it possible for health professionals to access the knowledge base and literature sources needed to conduct evidence-based practice (Gambrill, 1999). Onsite computerized databases or disease registries can enable the meticulous collection of personal health information throughout a patient’s life, which health professionals can access to manage the many forms of chronic illness that require frequent monitoring and ongoing patient support (Bodenheimer et al., 2002). Electronic medical records, which can be held physically or digitally in a variety of locations, can make the latest information available for patients and health professionals (Institute of Medicine, 1997; Masys et al., 2002). Many electronic medical records feature computer prompting that asks for missing information and therefore enables more complete documentation (Raymond and Dold, 2002).
Computerized decision support systems serve as reminders to help primary care teams comply with evidence-based practice guidelines or as sources of feedback to providers to show how they are performing on various care measures (Bodenheimer et al., 2002). Such systems have been effective in encouraging physician compliance with recommended guidelines that support improved drug prescribing, dosing, and administration; treatment; and prevention and monitoring (Bates et al., 1999; Cooley et al., 1999; Evans et al., 1998; Hunt et al., 1998; Lobach and Hammond, 1997). In a meta-analysis of 33 studies on the effect of prompting clinicians, 25 of which used computer-generated reminders, the technique was found to enhance performance significantly for all 16 preventive care procedures studied (Balas, 2001).
By communicating via e-mail and accessing their electronic medical records and hospital information systems via the Internet, patients can share and exchange with health providers information about their general health, symptoms, and concerns. Likewise, clinicians can use their knowledge and skills to respond with pertinent medical information, and in many cases reassurance (Brotherton et al., 2001; Jadad and Haynes, 1998; MacDonald et al., 2001). Using e-mail, health providers can also send appointment reminder messages, discuss a prescription renewal, and notify patients of test results. The creation of communities of patients and clinicians with shared interests is also enabled through the Internet, facilitating the self-management needed for better disease management (Cain et al., 2000; Houston and Ehrenberger, 2001).
There is ongoing debate among the health professions as to whether informatics is discipline-specific, requiring distinct core curricula, training programs, and professional identities (Masys et al., 2000). Nonetheless, the committee agrees that all health professionals need the following general informatics competencies, regardless of their discipline (Bader and Braude, 1998; Mallow and Gilje, 1999; Masys, 1998; Saba, 2001; Saranto and Leino-Kilpi, 1997; Sinclair and Gardner, 1999):
Employ word processing, presentation, and data analysis software.
Search, retrieve, manage, and make decisions using electronic data from internal information databases and external online databases and the Internet.
Communicate using e-mail, instant messaging, listservs, and file transfers.
Understand security protections such as access control, data security, and data encryption, and directly address ethical and legal issues related to the use of information technology in practice.
Enhance education and access to reliable health information for patients.
In addition to improving the quality of health care, information technology has significant potential for use in measuring the level of performance of health care providers. Specifically, information technology can facilitate the collection of process and outcome data that can be used to assess of the competency of health care professionals (Blendon et al., 2002).
The committee acknowledges that certain legal and regulatory issues need to be addressed before widespread utilization of informatics becomes a reality. The regulatory requirements governing e-mail use with patients, such as the Health Insurance Portability and Accountability Act (Centers for Medicaid and Medicare Services, 2002), are designed to help guarantee the privacy and confidentiality of patient medical records. Achieving compliance with such standards, particularly for health care providers, means that future and currently practicing health professionals must be educated and trained in technologies for protecting access to provider–patient communications. Evolving issues related to the use of informatics by health care professionals include the need for standards for data so that they can be shared across settings, decisions about who should have access to patient-based information, documentation of provider–patient communications in patient records, and medical practice liability concerns (National Committee on Vital and Health Statistics, 2000).
Box 3-9.Applying All Competencies for Quality Care
Wagner and colleagues (Wagner, 1998; Wagner et al., 1996) have developed a Chronic Care Model that guides health care providers in efficiently managing the care of patients with chronic illness. Using the model, health professionals collaborate and involve patients in decisions, with patients directly controlling their diet, exercise, and medication. The model also emphasizes interdisciplinary teams—physicians treat patients with acute problems, while other professionals support patient self-management, arrange for routine periodic tasks, and ensure appropriate follow-up. The teams employ evidence-based practice guidelines supported by informatics. Computerized reminder systems help teams comply with practice guidelines; feedback systems show how each patient is performing on chronic illness measures; and computerized disease registry systems help teams plan and improve individual patient and population-based care. More than 300 diverse health care systems are introducing elements of the model in the context of quality improvement collaboratives for asthma, congestive heart failure, depression, diabetes, and prevention of frailty in the elderly.1
Clinica Campesina, a community health center providing care to a largely uninsured Hispanic population around Denver, Colorado, joined the diabetes collaborative in 1998. The interdisciplinary team established a patient registry, enabling them to learn which of their patients had poorly controlled diabetes or difficulty coming to the clinic. Using this information, the team is able to regularly provide outreach to patients, including through diabetes fairs in the community. Employing evidence-based guidelines, the team developed a flow sheet with simple algorithms of care for providers. The team encourages patients to manage their illness through diabetes education and collaborative setting of diabetes treatment goals during each clinic visit.
Premier Health Partners joined the collaborative in 1998. Premier is a complex integrated health system with two hospitals, 100 private practices, a long-term care facility, and a home health agency in Dayton, Ohio. Developing and employing evidence-based practice, diabetes guidelines, academic detailing, and a toolkit of printed materials that incorporates the guidelines into the day-to-day care of diabetic patients, providers are able to support patient self-management, including individual and group classes and flowcharts on which patients record their own laboratory test results. Interdisciplinary teams of physicians and nurses work to monitor the diabetes flow sheets. Computerized medical record reviews in each primary care practice generate physician-specific data on diabetes measures and are then circulated to providers. The information system will soon be generating physician and patient reminders.
Outcomes for both settings, described above, have shown substantial increases in preventive measures for patients, such as eye and foot exams, better glycemic control, lower HgA1C, and substantial increases in the percentage of diabetic patients with at least two hemoglobin tests within a year (Bodenheimer et al., 2002; Institute for Healthcare Improvement and National Coalition on Health Care, 2002).
The Health Disparities Collaborative is a joint effort by the Bureau of Primary Health Care, The Robert Wood Johnson Foundation’s project Improving Chronic Illness Care (Robert Wood Johnson Foundation, 2002), the Institute for Healthcare Improvement, and the National Association of Community Health Centers to improve health outcomes for medically underserved people with chronic diseases.
A Vision of the Prepared Health Care Professional
The core competencies described in this chapter can lead to fundamentally better care. Having begun in this chapter with a scenario that depicts a patient encountering significant deficits and gaps in care (Box 3-2), we conclude with a scenario developed by the committee that depicts care as it could be if health care providers exhibited the five competencies (Box 3-10).
Future Scenario: Mrs. Johnson. Mrs. Linda Johnson is a married first-year graduate student in her early forties with two children in high school. She made an appointment with her primary care physician, Dr. Grady, because she was always thirsty, losing (more...)
Mrs. Johnson’s health care needs were met in several ways.
First, health professionals provided patient-centered care as they shared information on the decision-making process and the management of diabetes with the patient. It was evident that Mrs. Johnson valued her education and family. In the interdisciplinary team meeting, she voiced her frustration regarding the amount of time it was taking her to learn how to self-manage her diabetes while attempting to meet her responsibilities as wife, mother, and graduate student. She was fearful that she would have to quite graduate school. The interdisciplinary team members reviewed Mrs. Johnson's short-term self-management goals with her and emphasized her successes. In addition, they discussed options that would allow her to meet her varied responsibilities. By the end of the interdisciplinary team meeting, Mrs. Johnson felt confident that she was making progress in the self-management of her condition. In addition, she and her husband decided that instead of quitting graduate school, she should decrease her course load to one class per semester until she felt comfortable with juggling the self-management of her diabetes and her other responsibilities.
Second, the health professionals worked in an interdisciplinary team in approaching Mrs. Johnson’s care. She was referred to a number of health care providers who offered education and support according to the recommended standards of care. The team members, including Mrs. Johnson and her husband, met to communicate and coordinate the treatment plan.
Third, the health care professionals employed evidenced-based practice. Health professionals frequently expect newly diagnosed diabetics to change multiple behaviors to decrease their risk of complications. Patients often fail at self-management because they are overwhelmed by the number of changes. In accordance with the current literature, the diabetes educator and dietician each had Mrs. Johnson choose one basic self-management goal. They provided her with the information and tools necessary to be successful, and then on her follow-up visits, they reviewed her progress.
Fourth, the team applied quality improvement in the provision of care through use of the diabetes registry. Key outcome measures were tracked for individual patients, a subpopulation, or the general registry population. At Mrs. Johnson’s next appointment, health care providers will print out a record that displays data and graphs of visits and care provided for the past 6 months. Doing so allows providers and patients to note trends. In addition, care reminders can be printed out and given to health care providers to remind them of needed services, or a letter can be sent to the patient as a reminder for care.
Finally, health care providers utilized informatics as a way to communicate and manage Mrs. Johnson’s diabetes care. All the health care providers used PDAs to input data into the diabetes registry so they had continual access to updated information. Mrs. Johnson was able to obtain results of her EKG and laboratory tests from an automatic recorded information system. If she had questions related to diabetes and self-management, she had email access to her health care team. In addition, she was encouraged to seek out current diabetes information on the Web while obtaining support from others with diabetes through a chat room.
In conclusion, the committee stresses that narrowing of the quality chasm can be realized, at least in part, by reforming health professions education:
For health professionals, there is a set of core competencies that can advance adherence to the rules of a redesigned health care system as envisioned in the Quality Chasm report: provide patient-centered care, work in interdisciplinary teams, employ evidence-based practice, apply quality improvement, and utilize informatics.
The extent to which current health professionals are implementing these competency areas does not meet the health care needs of the American public.
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3 - Develop a checklist that includes several requirements for system output, input, process, performance, and control.
Patient’s personal information (at or before appo
intment time) Capstone Case: New Century Wellness Group Tegan Hatch o Includes Name, address, phone number, employment, insurance
Patient History includes current medications, medical history, lab results, etc.
Information for Billing/Insurance Claims o this would include the patients name, address, and insurance information as well as coded procedures for visits or labs.
Patient History o Accessed by the doctor at the time of the appointment.
Supplies o sends a notice when supplies are used based off what is done at each appointment
Procedure to Codes o makes sure that each procedure is assigned the appropriate billing code
Medication Cross Checking o Double checks to make sure that medications prescribed by a doctor do not conflict with other medications. Would produce a pop-up that shows the doctor the conflict and allows for over-
ride if the doctor still feels it’s the be
The system must be operational during clinic hours
The system must provide information quickly and cleanly Control Examples
The system must require a log-in to protect patient confidentiality. This also allows for tracking who makes what changes Questionnaire
4 - Design a questionnaire to learn how New Century patients feel about insurance procedures and appointment scheduling. Your questionnaire should be designed for a sample group of patients, and should follow the suggestions in this chapter. After you complete the questionnaire, select a sampling method and explain your choice.