David Hsia has an editorial in the latest JAMA on the federally-mandated quality-improvement initiative in hospital-based health care.
The Institute of Medicine asserts that medical errors kill more people in the United States each year than motor vehicle crashes. For complex reasons, existing systems of quality assessment, review, and improvement function suboptimally.
A critical issue is whether these errors represent failures of humans or systems. Peer review, malpractice litigation, medical licensing, medical disciplinary actions, insurer audit, governmental investigation, and most other quality assurance systems rely on retrospective review. Examining patient charts assumes that error derives from failure on the part of an incompetent or careless individual. Adverse events therefore identify bad apples for removal. This inspection model (“name, blame, shame”) seeks to improve quality by cutting off one tail of the bell-shaped curve of human performance.
In contrast, Deming’s continuous quality improvement (CQI) model assumes that most adverse events represent system failures and that design of work processes should detect and eliminate the human error that inevitably occurs. Industrial quality control statistically analyzes all outcomes for systems improvement opportunities rather than searching for single events that purportedly demonstrate individual error. The CQI model seeks to improve quality by moving the entire bell curve to the left.
Unfortunately, the CQI initiative has not yet attained full acceptance by the general public. The name-blame-shame model produces readily understandable headlines, but it does not methodically eliminate errors to improve statistical outcomes. Yet even if every worker in a health care system could do his or her job perfectly, most events that are considered to be errors would still occur. Although organizations like the Institute for Healthcare Improvement have led the effort to extend the CQI initiative into health care, the recent survey by Blendon et al makes it clear that neither members of the public nor physicians appreciate that poor systems cause most errors.
Contrast that reasoned tone with the adversarial debates over quality improvement in education. Part of the difference is that the health care industry, and the cluster of professions around it, have enough political muscle to be allowed, more or less, to manage their own affairs. Another part is that doctors admit that there are measurable outcomes in medicine, and that in principle physicians should be held accountable for what happens to their patients.