Chapter 1: Advancing the Quality & Safety of Care

INTRODUCTION

Hippocrates’ famous dictum primum non nocere 2500 years ago may have been the earliest reflection of the importance of patient safety, but the Institute of Medicine’s (IOM) 1999 landmark report To Err Is Human truly galvanized the current focus on eliminating preventable harm from health care. Its most quoted statistic, that between 44,000 and 98,000 Americans die every year because of medical error, was based on studies of hospital mortality in Colorado, Utah, and New York, and extrapolated to an annual estimate for the country. The IOM followed up this report with a second publication, Crossing the Quality Chasm, in which they said, “Health care today harms too frequently, and routinely fails to deliver its potential benefits…. Between the health care we have and the care we could have lies not just a gap, but a chasm.” These two reports have served as central elements in an advocacy movement that has engaged stakeholders across the continuum of our health care delivery system and changed the nature of how we think about the quality and safety of the care we provide and receive.

In 1966, Avedis Donabedian wrote a review of the then scant literature on the methods for assessing the quality of medical care. He mentions that “it seems likely that there will never be a single comprehensive criterion by which to measure the quality of patient care. This was recognized by the IOM in the landmark publication Crossing the Quality Chasm, offering an elegant definition of the word “quality” as it applies to health care. They defined six domains of health care quality: (1) SAFE—free from preventable harm; (2) EFFECTIVE—optimal clinical outcomes; doing what we should do, not what we should not do according to the evidence; (3) EFFICIENT—without waste of resources—human, financial, or supplies/equipment; (4) TIMELY—without unnecessary delay; (5) PATIENT/FAMILY CENTERED—according to the wishes and values of patients and their families; and (6) EQUITABLE—eliminating disparities in outcomes between patients of different race, gender, and socioeconomic status.

In the years since these two seminal reports were published, multiple stakeholders who have been concerned about the effectiveness, safety, and cost of health care in the United States and, indeed throughout the world, have accelerated their individual and collective involvement in analyzing and improving care. In the United States, numerous governmental agencies, large employer groups, health insurance plans, consumers/patients, health care providers, and delivery systems are among the key constituencies calling for and working toward better and safer care at lower cost. Similar efforts are occurring internationally. Indeed, the concept of the Triple Aim has been widely accepted as an organizing framework for considering the country’s overall health care improvement goals.