In the national dialogue on healthcare, much attention is paid to ensuring that patients receive the services they need in ways that both the individuals and society as a whole can afford. But another significant issue is drawing equal attention from the government, healthcare providers and patients alike: the quality of care that is delivered. It goes without saying that every patient wants to receive care that is reliably error-free and of the highest quality. But what does that mean? In his role as chief medical officer, J. Thomas Rosenthal, MD – he prefers to simply be called Tom – focuses his attention on quality and safety, which are top priorities for UCLA’s hospitals. He spoke with U Magazine contributing writer Dan Gordon.
How is quality care typically defined?
Dr. Rosenthal: Well, that’s the sixty-four-thousand-dollar question. If you go back 20 years, quality simply meant all of us doing our best. The presumption was that you trained people well, put them in good environments, made sure they were professional and highly motivated, and then you would get good
results. That was quality.
When did that perspective change, and what instigated the shift in thinking?
Dr. Rosenthal: A pair of influential reports by the Institute of Medicine, released beginning in 1999, marked the turning point. Among other things, these reports, To Err is Human and Crossing the Quality Chasm, estimated that there were 100,000 preventable deaths each year in hospitals as a result of medical errors. Beyond the focus on poor care, there was recognition that being highly motivated to do our best was not enough. The complexity of modern medicine demands that we approach it in a more systematic way, and not doing so can cause preventable harm and death to patients. That was the basis for the beginning of the quality movement.
What has characterized that movement? Who is involved, and what are the goals?
Dr. Rosenthal: The first change in a hospital has to be the realization that the old system is insufficient. Then, an investment has to be made in people who can facilitate groups coming together to design processes of care that are more systematic, more reliable and more measurable. This is often referred to as creating a culture of safety. This is the job of everyone in medicine, but the responsibility of leading this effort is given to people like me who have the title chief medical officer and to people who have the title chief safety officer. The second element of the safety movement has been to better define quality by actual measures, to collect the data from hospitals and physicians and to report it publicly. A group of professionals across the country, as well as national organizations and professional societies, has been working diligently to define metrics, determine how to collect the data and bring the data together in productive ways. A number of entities, notably the federal Center for Medicare and Medicaid Services and state governments, including California’s, have required that certain measures be publicly reported. The idea is to provide measurements that will not only be useful for patients as consumers, but also that hospitals and physician groups can use to improve performance. And the evidence is quite compelling that when doctors, nurses and healthcare organi-zations are provided with solid data about their performance, they will be more motivated to make the necessary changes that are required to improve.
What are some of the key areas that are measured, and what is UCLA doing to improve its own performance?
Dr. Rosenthal: We have several areas of priority including medication safety, prevention of hospital-acquired infections and improvement in communication and hand-offs. As an example of our approach to medication safety, we realized that UCLA’s hospitals 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. Transitioning patients to a new medical team is another area where things can go wrong, so we have established communication protocols to be sure that all essential information is passed onto the new team. Many of our processes around structured communication and checklists are borrowed from NASA and the airline industry. For example, we now have a formal “timeout” before a surgery during which the plan is gone over, and each item on the list is checked off – things that must be done every time. We need 100-percent reliability, and to do that, nothing can be taken for granted. It’s not easy. It requires a substantial investment of resources to get from 90-percent reliability to 100-percent reliability. But that is now the expectation, and it’s entirely appropriate.
Obviously, safety is critical but it’s not the only thing to be considered. Beyond not making mistakes, how is quality assessed?
Dr. Rosenthal: Certain areas have been identified as representing the highest standard of care. For example, a facility should give every suspected heart-attack patient aspirin upon arrival. That’s important – everyone wants a highly reliable organization when it comes to healthcare. What patients care most about is whether or not 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.
Can outcomes for every type of case be accurately measured and monitored? Aren’t there conditions that don’t fall so clearly into a category?
Dr. Rosenthal: That’s right. Outcomes for some diseases are not as easily captured, and/or there is no national data. If you have prostate cancer, you would have to conduct a fairly sophisticated literature search to determine what treatment-complication rate is considered good, and even that’s problematic, because typically the only people who publish their results in peer-reviewed literature are those who have good outcomes. To help fill this void, we are in the process of engaging all of our departments in an effort to define what perfect care looks like. We say we’re UCLA, we believe we’re the best – and probably in many instances we are the best – but we have to demonstrate it and make sure we’re continuously finding ways to improve. Patients and their families expect their care to be perfect or as close to perfect as is humanly possible.
What are the components of perfect care that would cut across all departments and conditions?
Dr. Rosenthal: Safety is essential, but perfect care also involves explaining treatment options in a way that helps the patient make informed decisions; having the treatment carried out with the highest possible technical expertise, and with minimal or no complications; having it done efficiently, which means the patient doesn’t have to wait six months for a surgery or an hour-and-a-half every time he or she comes to the office; and treating the patient with compassion.
In other words, quality encompasses not just medical outcomes but also what patients think of the hospital experience?
Dr. Rosenthal: Absolutely. Clearly, when we talk about delivering perfect care, it’s what the patient believes is perfect that matters most. And patients expect to be treated with dignity and compassion. There are some experts who believe patient satisfaction is just about amenities that have little to do with outcomes and that it shouldn’t be considered in quality assessments. That’s not our view. We believe issues of emotional support and communication are deeply embedded in the ability to achieve high-quality medical outcomes. And because these are critical components of patients’ expectations of high-quality medical care, we need to measure that and hold ourselves accountable in that area as well.
UCLA Health’s patient-satisfaction ratings have risen dramatically in recent years. What has changed?
Dr. Rosenthal: Seven years ago, we introduced the CI-CARE program to create a standardized process for interactions with patients and families. Before that, many of us would receive feedback from patients and their families that went something like this: “I came to UCLA and you treated my life-threatening illness. I was going to die and now I have returned to a normal life … but I would never go back to UCLA for care or recommend UCLA to a friend or family member because you didn’t take into account my emotional needs or sufficiently communicate what was going on.” That was a powerful wake-up call – that you could save a patient’s life and yet he or she was left very unsatisfied. Patients expect more than just good technical outcomes. And now, thanks to CI-CARE, we have 8,000 employees who come to work each day with a desire and the professional requirement to go the extra mile in treating patients the way they would want their own family members treated.
In what other ways does UCLA assess its own quality and work to make improvements?
Dr. Rosenthal: We certainly measure ourselves against all of the nationally reported data to determine where we need to focus our improvement efforts. We have also set up an infrastructure that includes people who work with our healthcare professionals to collect data, present it and facilitate teams working together to improve quality. These teams are an important part of the continuous improvement process. They are represented by multiple disciplines – physicians, nurses, pharmacists and others – who are knowledgeable about a particular problem, and we help facilitate their efforts to collect and analyze data, hold meetings and carry out any action steps.
How useful are the rankings of organizations that grade hospitals based on quality measures?
Dr. Rosenthal: I don’t think they are entirely helpful. These rankings often are fraught with methodological problems, and if they are done badly, it can create misperceptions on the part of the public. There is a belief on the part of some of these rating entities that public embarrassment will change hospital and physician performance, whether the data is accurate or not. That’s probably true when the data is accurate. But when it’s not, hospitals and doctors end up spending a lot of time arguing over what went into the rankings – energy that should be spent on improvements.
So accountability and transparency are not problematic as long as the information is accurate and can be properly interpreted?
Dr. Rosenthal: Absolutely. Transparency is crucial. 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. Where there are accurate ways of measuring, we are completely in favor of that, and we have no problem being held accountable publicly. It’s our task as leaders to identify those areas where we’re not doing as well as we could and fix them. Meanwhile, we must continue to put processes in place that will work toward our goal of delivering perfect care – defined as safe, effective, compassionate and efficient. That’s what patients expect, and that’s our professional duty.