When 100 Percent Reliability Is Required Nothing Is Taken for Granted

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It should go without saying that we all want the highest-quality healthcare. But what does that mean? UCLA Health has made quality and safety the top priority, and has joined with leading hospitals, physician groups, employers, health-insurance associations and others to focus on monitoring and improving healthcare quality and efficiency through national evidence-based measures of evaluating, standardizing and comparing the performance of hospitals, physicians and other providers. Thomas Rosenthal, MD, chief medical officer for UCLA Health, discusses the quality movement and how UCLA has responded.

How do you define quality?

Well that’s the $64,000 question. If you go back 20 years, quality simply meant all of us doing our best. The presumption was that if you trained people well, put them in good environments, made sure they were professional and highly motivated, and got good results, that was quality. But a pair of influential reports by the Institute of Medicine, released beginning in 1999, concluded that that was not enough — that if you didn’t approach hospital care in a more systematic way, you could cause preventable harm and death to patients. That was the basis for the beginning of the quality movement.

What has characterized that movement?

The goal over the last 15 years has been to better define quality by actual measures, to collect the data from hospitals and to report it publicly. The idea is not only to measure quality, but also to use those measurements to improve performance.

What are some of the key areas that are measured, and what is UCLA doing to improve its own performance?

There is a great deal of underreporting and it starts with patient safety. In Ronald Reagan UCLA Medical Center we give 6-million doses of medications to patients per year. That’s a lot of opportunities to make a mistake, so we institute automated processes and checks to take the element of human error out of the picture. Hospitals are also places where there is a risk of infection, and we institute steps to ensure that our patients aren’t exposed to that risk. We borrowed structured communication and checklists from NASA and the airline industry. For example, we now have a formal “timeout” before a surgery where the plan is gone over and each item on the list is checked off — things that need to be done every time. We need 100 percent reliability, and to

do that nothing can be taken for granted.

Beyond not making mistakes, how is quality assessed?

There are some national standards — for example, a facility should reliably give every heart attack patient aspirin upon arrival. What patients care most about, of course, is whether they survive the heart attack. So the next level of measurements involves outcomes. This includes survival rates for conditions such as heart attack, congestive heart failure and stroke, taking into account patients’ risk factors. Transplant outcomes are also reported for each hospital. But outcomes for some diseases are not as easily captured. So we are in the process of engaging all of our departments in an effort to define what perfect care looks like. Obviously safety is essential, but it’s also explaining treatment options in a way that helps patients make informed decisions; having the treatment carried out with the highest possible technical expertise with minimal or no complications; and treating patients with compassion.

In other words, quality encompasses not just medical outcomes but also what patients think of the hospital experience?

Absolutely. Clearly, when we talk about delivering perfect care, it’s what the patient believes is perfect. Patients expect not to be harmed; patients expect technically expert care; and patients expect to be treated with dignity and compassion. That’s a critical part of their expectation of high-quality medical care, so we need to measure that and hold ourselves accountable in that area as well. Seven years ago we introduced the CICARE program to create a standard process for our interactions with patients and families. Now we have 8,000 employees who come to work each day with a desire to go the extra mile in treating patients the way they would want their own family member treated.

There are also groups that rank or give hospitals grades based on quality measures. How useful are these rankings?

I don’t think those are entirely helpful in the medical sphere. For one thing, these rankings are fraught with methodological problems, and if they are done badly it can create misperceptions on the part of the public. Hospitals and doctors end up spending a lot of time arguing over what went into the rankings — energy that should be spent on improvements. Transparency is important: If people are coming to me as a surgeon, they should have access to as much information as possible about my experience and performance. But they should interpret that information carefully and talk to their doctor about it.


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