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Quality: A moral primer


Research reports that one in three deaths in the United States is due to medical error, much of which is due to sloppy, hasty, or inept care and care systems. That means that many people are receiving poor care, often in the name of saving money. There is no justification for poor quality of care. We know (and have known since at least 1989) that, as Grajewski writes,“[H]igh quality care costs less than poor quality care. High quality care encompasses the elimination of unnecessary or inappropriate services while providing better clinical outcomes, fewer avoidable complications, and greater patient satisfaction. Poor quality care results in adverse outcomes and patient dissatisfaction, both of which can prove costly to a hospital in a competitive market. Hospitals are developing sophisticated data-bases to monitor the quality of care provided to patients.”

And since the development and implementation of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and value-based purchasing (VBP), it is even more costly in financial terms to provide low quality care than it has been in the past. However, financial incentives and federal regulations aside, the words courtesy, kindness, respect, accuracy, duty, loyalty, commitment, justice, honesty, diligence, compassion, and discipline are at the core of true quality of care.

The nature of error

Medical error has been defined as an unintended act (either of omission or commission) or one that does not achieve its intended outcome, the failure of a planned action to be completed as intended (an error of execution), the use of a wrong plan to achieve an aim (an error of planning), or a deviation from the process of care that may or may not cause harm to the patient. Patient harm from medical error can occur at the individual or system level. The taxonomy of errors is expanding to better categorize preventable factors and events.

Human error is inevitable. Although we cannot eliminate human error, we can better measure the problem to design safer systems mitigating its frequency, visibility, and consequences. Strategies to reduce death from medical care should include three steps:

  1. making errors more visible when they occur so their effects can be intercepted,
  2. having remedies at hand to rescue patients, and
  3. making errors less frequent by following principles that take human limitations into account.

One of the principles that help limit error is ethical concern, and with fully one-third of U.S. deaths attributed to error, this clearly is an area of considerable ethical concern.

Ethics has to do with figuring out what is the right thing to do in a given situation. As quality of care is defined as “doing the right thing (getting the health care services needed), at the right time (when they are needed), in the right way (using the appropriate test or procedure), to achieve the best possible results,” it is not an ethical problem. However, it may be a moral one. Morality or “morals” has to do with what you do about what you think is right. Therefore, providing quality of care may present a moral dilemma, especially if one sees quality of care as antithetical to cutting costs or optimizing profit.

How NOT to cut costs

Healthcare providers are responding to the tremendous pressure to reduce costs, but evidence indicates many of their attempts are actually raising costs and sometimes decreasing the quality of care. Kaplan and Haas reached this conclusion after conducting field research with more than 50 healthcare provider organizations. When looking for ways to cut costs, administrators typically target the line-item expense categories. This may generate immediate results, but the costs rebound—and often double. Why? Because this approach usually does not reflect the optimal mix of resources needed to efficiently deliver excellent care.

The authors describe five common mistakes:

  1. Reducing support staff, which often lowers the productivity of clinicians whose time is far more expensive.
  2. Underinvesting in space and equipment. The costs of these are consistently an order of magnitude smaller than personnel costs, so cuts here are short-sighted if they lower people’s productivity.
  3. Focusing on procurement prices without examining how individual clinicians actually consume supplies.
  4. Maximizing patient throughput. Physicians achieve greater overall productivity by spending more time with fewer
  5. Failing to benchmark and standardize.

Other authors add to the list of cost-cutters’ mistakes, particularly the tendency to cut registered nurses (RNs) and/or replace them with other caregivers. This, despite repeated studies indicating that cutting RNs jeopardizes the safety of care and may only save about 1.5% at best. To quote study authors Blegen and colleagues, “Raising the proportion of nursing hours provided by registered nurses (RNs) without increasing total nursing hours is associated with a net reduction in costs. Increasing nursing hours, with or without increasing the proportion of hours provided by RNs, reduces days, adverse outcomes, and patient deaths, but with a net increase in hospital costs of 1.5 percent or less at the staffing levels modeled. Whether or not staffing should be increased depends on the value patients and payers assign to avoided deaths and complications.” Undoubtedly, such studies led to the rapid adoption of VBP!

Beyond safety to quality

By and large, reasonable people agree that patients should not be harmed by the health care they receive. After that, things get a bit murky—and a lot more complicated. At its simplest, patient safety is freedom from healthcare-associated, preventable harm. To maintain or improve patient safety, error has to be prevented, recovered, or at least minimized. There are three levels of harm (or potential harm):

  1. An adverse event occurrs if a patient was injured by healthcare intervention rather than an underlying condition.
  2. A near miss is any incident that could have led to harm but did not, either by chance or through timely intervention.
  3. A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function.

There are also a bewildering array of tools hospitals can use to define, measure, and justify safe care. For example, the Agency for Healthcare Research and Quality (AHRQ) offers practical, research-based tools and resources to help organizations, providers, and others make care safer in all healthcare settings.

Quality care is anything you provide that is more than safe care. The definition of quality healthcare seems to be reasonably clear, but it ends up being quite complex. For example, quality care has three dimensions: structure, process, and outcome. Structure represents the basic characteristics of physicians, hospitals, other professionals, and other facilities. Process, in general terms, means having the right people and facilities doing the right things. The third dimension, outcome, reflects the end result of care. Did people get better? What was the risk-adjusted mortality rate? Was disease or disability reduced or prevented? Was the patient helped as much as he/she could have been, given what we know is scientifically possible?

And as one may surmise, each dimension of quality is measured in many ways.

  • Structure indicators assess the characteristics of a care setting, including facilities, personnel, and/or policies related to care delivery. For example, does an intensive care unit (ICU) have an intensivist available at all times? Sufficient staffing with certified ICU nurses? A respiratory therapist available to the ICU at all times?
  • Process indicators measure things like timeliness and baseline practices.
  • Outcome indicators are measured in numerous ways (such as mortality rates, infection rates, and complication rates). An overall quality measure is derived from medical information from patient records converted into a rate or percentage that shows how well hospitals care for their patients. For example, one quality indicator is the percentage of heart attack patients who are prescribed aspirin at discharge.

The National Healthcare Quality Report tracks the healthcare system through quality measures, such as what proportion of heart attack patients received recommended care when they reached the hospital, or what percentage of children received recommended vaccinations. The Report is based on a framework established by the Institute of Medicine and developed by an interagency working group within the Department of Health and Human Services (HHS). It avoids the tens of thousands of possible interventions and focuses on slightly more than 100 measures culled from a wide-range of existing public- and private-sector data collection efforts.

Quality measurement can be useful information for CEOs, CFOs, and CNOs for preventing the overuse, underuse, and misuse of healthcare services and ensuring patient safety. It helps improve health care overall by:

  • identifying what works in health care—and what doesn’t—to drive improvement
  • holding health insurance plans and healthcare providers accountable for providing high-quality care
  • measuring and addressing disparities in how care is delivered and in health outcomes
  • helping consumers make informed choices about their care.

What patients think affects reimbursement

But we do not stop there. We also now measure patients’ experiences of hospital care. The Centers for Medicare & Medicaid Services (CMS) requires hospitals to use a third party to conduct the HCAPS survey of patients. Survey results are tied to reimbursement (30% of a hospital’s Medicare reimbursement rate is determined by the survey), and the results are made public and compared to those of other hospitals; patients are the ones doing the assessing.

In 2016, the Affordable Care Act withholds 1.75% of total Medicare reimbursements—over $1.25 billion—from all hospitals. The percentage withheld will increase to 2% in 2017. Each year, only hospitals with high patient-satisfaction scores and a measure of certain basic care standards will earn that money back, and the top performers will receive bonus money from the pool. The poor performers get nothing back and may even be penalized further by an annual payment update (APU) reduction.

Health reform continues to expand

Today, participating hospitals are paid for inpatient acute care services based on the quality of the care, not just quantity of the services they provide. Congress authorized Inpatient Hospital VBP in Section 3001(a) of the Affordable Care Act. The program uses the hospital quality data reporting infrastructure developed for the Hospital Inpatient Quality Reporting (IQR) Program, which was authorized by Section 501(b) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

Amid the reform-driven shift to outcomes-focused, VBP, and reimbursement systems, numerous countries are instituting reform-driven drug price controls. Drug manufacturers will continue to be pressured to justify the cost of their products based on, among other things, the product’s comparative effectiveness against similar offerings. In addition, there exists the perception of predatory pricing by some drug companies, which recently are increasing prices of older yet essential generic drugs by orders of magnitude. Such practices may accelerate governmental regulation of the pharmaceutical industry!

“Quality” describes a characteristic that belongs to a thing’s essential nature. If care is not “quality care” then it’s not care at all. It’s neglect—of persons, of duty, and of self-respect. So, perhaps we should be saying that it is human neglect rather than human error that is causing one in three deaths in the United States today. As Null and colleagues note, “Human error is inevitable. Although we cannot eliminate human error, we can better measure the problem to design safer systems mitigating its frequency, visibility, and consequences. Strategies to reduce death from medical care should include three steps: making errors more visible when they occur so their effects can be intercepted; having remedies at hand to rescue patients; and making errors less frequent by following principles that take human limitations into account.”

At any rate, any organization serious about delivering quality care today would do well to remember these old fashioned things.

Selected references

Aiken LH, Clarke SP, Sloane DM, et al. Nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;228(16):1987-93.

Batchelor GJ, Esmond TH Jr. Maintaining high quality patient care while controlling costs. Healthc Financ Manage. 1989;43(2):21-22, 26-27.

Blegen MA, Goode CJ, Spetz J, et al. Nurse staffing effects on patient outcomes. Med Care. 2011;49(4):406-14.

Grajewski B. Why are hospitals cutting costs? Becker’s Hospital CFO. May 12, 2015.

Grober ED, Bohnen JM. Defining medical error. Can J Surg. 2005;48(1):39-44.

Kane RL, Shamliyan TA, Mueller C, et al. The association of registered nurse staffing levels and patient outcomes: Systematic review and meta-analysis. Med Care. 2007;45(12):1195-1204.

Kaplan RS, Haas DA. How not to cut health care costs. Harv Bus Rev. November 2014.

Leape LL. Error in medicine. JAMA. 1994;272(23):1851-7.

Makary M, Daniel M. Medical error—the third leading cause of death in the US. BMJ. 2016;353:i2139.

Needleman J, Buerhaus PI, Stewart M, et al. Nurse staffing in hospitals: is there a business case for quality. Health Aff. 2006;25(1):1204-11.

Null G, Feldman M, Rasio D, et al. Death By Medicine. Edinburg, VA: Axios Press; 2011.

Reason J. Human Error. New York, NY: Cambridge University Press; 1990.

Reason JT. Understanding adverse events: The human factor. In: Vincent C, ed. Clinical Risk Management: Enhancing Patient Safety, 2nd ed. London: BMJ Books; 2001.

Saxena A. 6 ways to save money on labour costs without sacrificing care. Becker’s Hospital Review. Feb. 2, 2015.

Saxena A. CFOs cite layoffs as one way of offsetting healthcare costs next year. Becker’s Hospital CFO. Dec. 8, 2014.

TriStar Horizon Medical Center. What does quality in health care mean? Dec. 17, 2010.

Leah Curtin is Executive Editor, Professional Outreach for American Nurse Today and a consultant with CGFNS International in Philadelphia, Pennsylvania.


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