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The State of Quality Improvement and Implementation Research: Expert Views, Workshop Summary 1 Persistent Problems with Quality* Persistent problems exist in the quality of health care, preventing it from being as high quality and as effective as it could be. To help illustrate problems in health care and explain why quality improvement and quality improvement research is important in the advancement of health care, two perspectives were presented: value and patient. VALUE PROPOSITION Forum co-chair Paul O’Neill acknowledged that quality of health care can be conceptualized in many ways. Addressing the overuse, misuse, and underuse of clinical care is an important aspect of improving quality in health care, but can be limited in its impact. O’Neill’s perspective of quality in health care considers the value proposition and thus has a broader goal—to improve the way health and medical care is provided so that the right care can be delivered every time. Practicing health care in this manner could reduce the cost of health and medical care by an estimated 50 percent or $1 trillion while making great improvements in patient outcomes. One example O’Neill cited was the adequate stocking of Pyxis * The planning committee’s role was limited to planning the workshop. The workshop summary has been prepared by the workshop rapporteur as a factual summary of what occurred at the workshop.
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The State of Quality Improvement and Implementation Research: Expert Views, Workshop Summary machines, which nurses use to automatically dispense medications. Improper stocking of medications (known as stock outages) leads to wasted time and resources to find medications that should be there. A hospital O’Neill observed had 57 Pyxis machines and incurred 983 stock outages in a single month. In a disaggregated form, these numbers might not mean anything. However, when compared to a perfect health care system without stock outages, the inadequate supply of medications should be viewed as a systems failure, leading to extra work and wasted resources. In another example, an equivalent of 11 full-time nurses was used to look for equipment in a single year, instead of using their knowledge and skills to treat patients, O’Neill said. Many other examples exist that yield similar value propositions that can help improve the value of health and medical care without challenging medical knowledge. PATIENT PERSPECTIVE Denise Dougherty of the Agency for Healthcare Research and Quality (AHRQ) provided the complementary patient perspective of problems with quality during clinical care. To characterize the urgency of the problems, Dougherty provided national snapshots of issues in quality based on data from AHRQ’s National Healthcare Quality and Disparities Reports, which identified many variations in care. Quality and quality improvement rates varied by delivery setting (e.g., hospitals saw more improvement than ambulatory care centers, nursing homes, and home health care) and by state without a good explanation for why these variations occur. For example, the worst performing state admits five times as many children for asthma into its hospitals than the best performing state. Although we know that a proportion of these hospitalizations could be prevented with appropriate and timely ambulatory care, benchmarks are unknown and need to be developed. Through the lens of the IOM’s six aims for quality—safety, effectiveness, timeliness, patient centered, efficient, and equitable—one can easily identify many more deficiencies in care. Based on the data, progress has been made in many areas of health care quality (overall improvement rate was 3.1 percent between 2005 and 20061), but improvement has been slow. Acceleration of improvements and reductions in disparities in quality are necessary to better serve patients and increase the value of health care to patients and payers. 1 This was determined by averaging improvement rates of core measures of the National Healthcare Quality Report.
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