Search

Despite some impressive recent gains, improving the glaring deficiencies in health care quality is proving to be very hard. Improvement is local, rather than system-wide, and is sustained with difficulty, rather than becoming an intrinsic feature of care. My right knee will probably need to be replaced soon. This has given me the opportunity to define, in very personal terms, 5 specific dimensions of "total quality" that I will require from the medical institution that does my surgery and that every patient has the right to require of their encounters with the health care system. Don't kill me (no needless deaths). Do help me, and don't hurt me (no needless pain). Don't make me feel helpless. Don't keep me waiting. And don't waste resources, mine or anyone else's. Given my requirements, it is not clear that any health care institution in the United States will want to take me on as a patient. Although at this point individual institutions can meet some of these requirements, no single institution can deliver on all of them. Generating the energy, insight, and courage we need to get to "total quality" may require those of us who work in health care to get much better at seeing images of ourselves in the people we help. As Gandhi said, "You must be the change you wish to see in the world." [ABSTRACT FROM AUTHOR]

Most people in developed countries will live with a serious, eventually fatal, chronic condition for months or years before dying; yet, the delivery of health care services has only just recently begun adapting to this reality. Quality improvement methods have been effective in helping clinical services to make substantial changes quickly. Quality improvement requires stating an aim, measuring success, and testing possible improvements. The testing of changes requires a clinical team to Plan, Do, Study, and Act on new insights (the "PDSA cycle"). Repeated PDSA cycles generate deep understanding of complex systems and make sustainable improvements rapidly. This paper discusses a composite case study in a nursing home setting, which builds on experience with multisite collaborative efforts and introduces quality improvement methods in the context of end-of-life care. [ABSTRACT FROM AUTHOR]

BACKGROUND: Almost one million cesarean operations are performed each year in the United States. The objective of this project was to test the hypothesis that a structured collaborative effort can help participating health care organizations to reduce their cesarean delivery rates safely. METHODS: Experts associated with the collaborative helped participant organizations to explore several categories of change concepts and to develop action plans for safely reducing their cesarean delivery rates. Over the course of one year participants attended three two-day learning sessions. In the interval between these sessions, collaborative participants communicated by weekly conference calls and a dedicated Internet site. RESULTS: Of 28 participating organizations, 15 percent achieved cesarean delivery rate reductions of 30 percent or more during the 12-month period of active collaborative work. An additional 50 percent achieved reductions between 10 and 30 percent. CONCLUSIONS: The Healthy People 2000 goal of a cesarean delivery rate below 15 percent by the year 2000 is attainable. Clinical leadership from doctors and nurses toward the achievement of that goal is timely, ethical, and in the best interests of childbearing women in the United States. [ABSTRACT FROM AUTHOR]

New patient safety standards from JCAHO that require hospitals to disclose to patients all unexpected outcomes of care took effect 1 July 2001. In an early 2002 survey of risk managers at a nationally representative sample of hospitals, the vast majority reported that their hospital's practice was to disclose harm at least some of the time, although only one-third of hospitals actually had board-approved policies in place. More than half of respondents reported that they would always disclose a death or serious injury, but when presented with actual clinical scenarios, respondents were much less likely to disclose preventable harms than to disclose nonpreventable harms of comparable severity. Reluctance to disclose preventable harms was twice as likely to occur at hospitals having major concerns about the malpractice implications of disclosure. [ABSTRACT FROM AUTHOR]

To mark the 30th anniversary of The American Journal of Managed Care (AJMC), each issue in 2025 includes reflections from a thought leader on what has changed over the past 3 decades and what's next for managed care. The February issue features a retrospective by Richard J. Gilfillan, MD, former director of the Center for Medicare and Medicaid Innovation; and Donald M. Berwick, MD, MPP, former administrator of CMS.

Health care in the United States is among the most technologically advanced in the world, but it is largely failing to meet the needs of the nation. The US can claim international excellence in important areas of care, such as cancer treatment, and it leads the world in biomedical innovation and building a well-prepared and dedicated clinical workforce. The Affordable Care Act was a major step forward in expanding access to health care in the US. However, Americans are faced with staggering health costs, inadequate access to care, pervasive health inequities, and lagging life expectancy compared with other developed nations. In this article, part of the National Academy of Medicine's Vital Directions for Health and Health Care: Priorities for 2025 initiative, we present a partial road map for transforming the US health care system. We propose bold national goals: affordable and equitable care for all, an additional decade of healthy birthdays after retirement, elimination of racial and ethnic disparities in health, substantial reduction in health care expenditures, and, most important, improved health outcomes. To achieve these goals, we recommend changes to ensure coverage for all, invest in primary care and social determinants of health, create financing to incentivize population health, and improve transparency and accountability. Major systemic transformation of the US health care system is not just required; it is a moral and economic imperative.

How to deliver best care in various clinical settings remains a vexing problem. All pertinent healthcare-related questions have not, cannot, and will not be addressable with costly time- and resource-consuming controlled clinical trials. At present, evidence-based guidelines can address only a small fraction of the types of care that clinicians deliver. Furthermore, underserved areas rarely can access state-of-the-art evidence-based guidelines in real-time, and often lack the wherewithal to implement advanced guidelines. Care providers in such settings frequently do not have sufficient training to undertake advanced guideline implementation. Nevertheless, in advanced modern healthcare delivery environments, use of eActions (validated clinical decision support systems) could help overcome the cognitive limitations of overburdened clinicians. Widespread use of eActions will require surmounting current healthcare technical and cultural barriers and installing clinical evidence/data curation systems. The authors expect that increased numbers of evidence-based guidelines will result from future comparative effectiveness clinical research carried out during routine healthcare delivery within learning healthcare systems., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Competing Interests: DM Berwick served as the Administrator of the Centers for Medicare & Medicaid Services in 2010 and 2011. AS Miller and SA Stearns have no potential conflicts to disclose.

The International Health Regulations-State Party Annual Reporting (IHR-SPAR) index and the Global Health Security Index (GHSI) have been developed to aid in strengthening national capacities for pandemic preparedness. We examined the relationship between country-level rankings on these two indices, along with two additional indices (the Universal Health Coverage Service Coverage Index and World Bank Worldwide Governance Indicator (n = 195)) and compared them to the country-level reported coronavirus disease (COVID-19) cases and deaths (Johns Hopkins University COVID-19 Dashboard) through 17 June 2020. Ordinary least squares regression models were used to compare weekly reported COVID-19 cases and death rates per million in the first 12 weeks of the pandemic between countries classified as low, middle and high ranking on each index while controlling for country socio-demographic information. Countries with higher GHSI and IHR-SPAR index scores experienced fewer reported COVID-19 cases and deaths but only for the first 8 weeks after the country's first case. For the GHSI, this association was further limited to countries with populations below 69.4 million. For both the GHSI and IHR-SPAR, countries with a higher sub-index score in human resources for pandemic preparedness reported fewer COVID-19 cases and deaths in the first 8 weeks after the country's first reported case. The Universal Health Coverage Service Coverage Index and Worldwide Governance Indicator country-level rankings were not associated with COVID-19 outcomes. The associations between GHSI and IHR-SPAR scores and COVID-19 outcomes observed in this study demonstrate that these two indices, although imperfect, may have value, especially in countries with a population under 69.4 million people for the GHSI. Preparedness indices may have value; however, they should continue to be evaluated as policy makers seek to better prepare for future global public health crises., (© The Author(s) 2021. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)