Key points

Introduction to quality improvement

In the past 10 to 15 years, there has been an enormous focus on the quality of health care in the United States. Several major reports placed a spotlight on quality improvement (QI) and threw the gauntlet down for change. Among these were the Institute of Medicine (IOM) National Roundtable on Health Care Quality Report, “The Urgent Need to Improve Health Care Quality,” To Err is Human , and IOM’s Crossing the Quality Chasm . There have been many definitions of quality and operational frameworks. The most highly referenced of these come from the IOM report, Crossing the Quality Chasm , whereby quality is defined as “the degree to which healthcare services increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” The framework to measure quality included 6 dimensions: effectiveness, equity, efficiency, patient-centered, safety, and access.

The US health care system is the most costly in the world, accounting for 17% of the gross domestic product with estimates that percentage will grow to nearly 20% by 2020 (National Healthcare Expenditure Projections, 2010–2020). A recent report from the Robert Wood Johnson Foundation Commission to Build a Healthier America warns that the health in America is worse than other developed nations on more than 100 measures. Furthermore, they report 30 countries having lower infant mortality rates, and people in 26 countries can expect to live longer than Americans. The trend of this latter statistic was of even more concern because life expectancy in the United States ranked 15th among affluent countries in 1980, and by 2009 had slipped to 27th place.

In 2007, the Institute for Healthcare Improvement (IHI) launched the Triple Aim Initiative, which is composed of 3 key goals: improving the patient experience of care, improving the health of populations, and reducing the per capita cost of health care. This broad concept brings the attention to individuals, populations, and cost, along with the necessary integration of systems (health care, social services, public health, community organizations, and school systems). In the US environment, many areas of health reform can be furthered and strengthened by Triple Aim thinking, including accountable care organizations, bundled payments, and other innovative financing approaches; new models of primary care, such as patient-centered medical homes; sanctions for avoidable events, such as hospital readmissions or infections; and the integration of information technology. The following hyperlink to the IHI Web site provides a short video on “design of a triple aim enterprise”: www.IHI.org/TripleAim .

As the emphasis on QI grows in the hospital arena, so does the emphasis in other arenas as well. In government, as policy makers work to increase the incentives for quality in government programs, in the insurance arena, as health plans evaluate providers based on quality indicators, in the provider arena, as hospitals and practices are investing in information technology to improve efficiency and effectiveness of care, and in the consumer arena, patients are seeking transparent information from health care organizations before choosing a physician or hospital for their care. Pediatric hospital medicine (PHM) physicians can play an important role in linking QI activities to these other arenas by way of national QI collaboratives, partnerships and networks, professional organizations, and the federal government via funding sources, such as the Agency for Healthcare Research and Quality (AHRQ), the National Institutes of Health, and the Centers for Medicare and Medicaid Services (CMS).