The current increased focus on quality and the willingness of hospital boards to back quality initiatives are results of a long progression from a darker era in U.S. healthcare, says a board member who has seen the before and after.
Quality professionals should work to ensure the momentum continues and not let boards slide back into the complacency of yesteryear, says Tracey Klein, JD, shareholder with the Polsinelli law and consulting firm in Chicago.
The To Err Is Human report from the Institute of Medicine (IOM; now called the National Academy of Medicine) in 1999 spurred greater interest in quality improvement and alerted some hospital and health system boards that they should be more involved in quality issues, she says.
The IOM report kicked off the patient safety and quality movement in U.S. healthcare, with its premise that most errors are systemic in nature and are not solvable at the level of the individual provider. In 2001, a subsequent IOM report, Crossing the Quality Chasm, drew further attention to quality improvement, and that was when Klein became heavily involved in the issue, serving on a board as legal counsel and speaking to many others about incorporating quality issues more effectively.
“Prior to that time, most boards concentrated only on financial metrics. Although we have come a long way since the late 1990s, the foundational concepts that really moved the healthcare industry to track and report quality data, as well as review and assess medical errors, really were an outgrowth of those two reports,” she says. “It was extremely uncommon for boards of directors to in any way review quality data. Incidents and/or medical errors were not reported up the chain of command, or worse yet were whitewashed.”
Many health systems were slow to adopt policies and procedures to assess unexpected deaths or near misses and thereby improve safety and learn from incidents as they occurred, Klein says. Results of such investigations and assessments often did not reach the board level, she says.
“Many of us who had devoted our lives to healthcare were simply horrified by what we saw when we looked in the mirror at that time. Boards were advised to create quality committees and require management to devote resources to routinizing care and monitoring outcomes,” she says. “Boards were advised to listen to the stores of injured patients and to receive sentinel event reports directly. Board members were recruited who understood the implementation of quality or safety systems in healthcare or other industries.”
Peer review of physicians was amped up, with reports to the board or a committee, Klein notes. There was more focus on ensuring that practitioners actually had current clinical competence, and effort put behind monitoring physician performance.
Reimbursement principles also changed to emphasize that providing the right care at the right time reduced costs and enhanced outcomes, Klein notes.
“In short, a lot of good work was accomplished to transform healthcare to make it safer and better. Transformation was time-consuming and expensive,” Klein says. “Many standalone hospitals and small systems merged with bigger institutions. Often part of the justification was the small systems could not transform fast enough to keep pace in the quality arena.”