Our Quality Chasm

Posted on | November 30, 2007 | Comments Off on Our Quality Chasm

There is a lot to be said about quality today. It’s a term we hear in almost any conversation about healthcare, and as much as it’s used, it is misunderstood. Ask most any physician or hospital leader and they will tell you that we have, without question, the best quality healthcare in the world. But let’s look at the facts.

We don’t! We have pockets of the highest quality of care that are only available to some. The facts?

The World Health Organization ranked first world countries for quality of care using measures such as infant mortality, immunization rates, etc. USA’s rank: thirty-seventh! If we are spending over $5200 per person every year for health care (the highest in the world; almost twice the next highest amount), why aren’t we number 1?

Elizabeth McGlynn and her colleagues at RAND Health have published a landmark study that showed that whenever any adult seeks care for any problem, the right things – based on evidence, treatment guidelines, etc.- happen only about 56% of the time (McGlynn et al. RAND Health N Engl J Med. 2003;348(26):2635-2645)!

So what is quality? Fleming’s definition of quality is:

Doing the right thing…and only the right thing….at the right time for every single individual.

And therein lays our problem. Let me recount a true story. A 33-year old man came in and told me this fascinating story. About six weeks before this visit he awoke in the middle of the night with sharp pain in his left chest. His wife took him to a local ED where he underwent a remarkable workup, including a CT scan of his chest. The only finding was a calcified nodule in his left anterior neck seen on the periphery of the CT. He was referred, still having the chest pain to a head and neck surgeon – a quality surgeon, who obtained a CT scan of his neck which, indeed showed a calcified nodule that could indicate a non-Hodgkin’s lymphoma and the patient was set up for a biopsy. The nodule turned out to be a calcified carotid bulb. So the young man had 2 CT scan, a scar on his neck, and still had chest pain. He then saw a cardiologist – a quality cardiologist, who did a stress test which was equivocally positive, so he scheduled an angiogram – which was cold normal. So now he had a hole in his groin, a scar on his neck, 2 CT scans, 5 days lost from work, and still the chest pain. I asked what he did, and he told me that he was a civilian employee at our local AFB and that he worked on jet engines. And, that his power scaffold had broken right before this started. When I asked him to show me what he did, he raised his left arm and suddenly reproduced the pain. When I pressed over his anterior axillary fold, he shouted, “That’s it!” Total charges for his experience: over $128,000. When I tell this story in speeches to employer groups, payer groups and government decision makers, they all come to the same conclusion: It is, simply, waste. We all have such examples. No wonder we are in a crisis.

As noted in its landmark report To Err is Human, the IOM states, “The problem is not bad people in health care–it is that good people are working in bad systems that need to be made safer.” (Crossing the Quality Chasm. Committee on Quality of Health Care in America.
Institute of Medicine 2000).

So how do we do systemic change – one system at a time. And a commitment to do the right thing, but only the right thing, at the right time for every patient!