Making quality improvement a priority.

Health care errors have received a great deal of press lately, which is no surprise given that 784,000 deaths per year are attributed to medical injuries. It follows that quality assurance in health care is a hot topic these days as well, and that's a good thing, but change needs to be about more than quality assurance--it needs to be about quality improvement.

An inspection of quality issues in health care reveals a number of common themes associated with medical errors. For example, in many cases it is not a single error but a convergence of multiple errors that occurs. Inconsistent processes, a lack of process metrics, tremendous variations in practice, and tolerance of mediocrity also emerge as common themes in the setting of medical error.

Quality improvement, therefore, is the science of process management and strives to promote reduction in practice variations, adherence to evidence-based guidelines, optimization of patient safety, enhanced quality of care, practice efficiency, and reduction of health care costs.

The quality improvement process begins with the Plan-Do-Check-Act cycle. Plan: Begin by identifying a priority process requiring change. Ask yourself: "What are we trying to accomplish, improve, or change?" Do: Establish baseline metrics of the process to be measured, which includes distinguishing between normal variations and important trends. Ask yourself: "How will we know that a change is an improvement?" Check: Summarize data and develop interventions. Ask yourself: "What changes can we make that will result in improvement?" Act: Introduce the interventions, and reassess metrics to measure improvements.

A few "golden rules" of quality improvement should be kept in mind:

* Quality improvement requires leadership and ownership by everyone involved.

* Quality improvement is not about name, blame, and shame, but about working together to achieve a common goal of improving health care quality,

* Quality improvement is transparent.

* Quality improvement is continuous.

A good example of a successful quality improvement program at M.D. Anderson Cancer Center, Houston, was an initiative to reduce Mohs surgery duration and the number of late surgical cases (beyond 5 p.m.). This was a priority process that directly affected health care quality. Longer-than-necessary surgery increases complications and patient fatigue, exhausts staff, and reduces revenue.

A Mohs surgical flowchart was constructed to identify breakdowns in the process. Baseline metrics were established, including the number of patients discharged after 5 p.m. in the previous 4 months, time in and time out of every surgical patient on the days patients were discharged late, surgical schedules on the days of the delayed cases, and a host of other related factors. Our baseline metrics demonstrated that nearly 13% of Mohs cases extended beyond 5 p.m.

Factors affecting late cases included tumor complexity, scheduling of complex cases, and patient education (informed consent, wound care, and so on). Interventions introduced included staggered scheduling with more complex cases scheduled later rather than earlier to allow simpler cases to be completed and discharged in a timely manner and to permit staff availability for multiple-stage surgeries, and an informed consent and wound care video to facilitate patient education.

The improvements were dramatic, with "late" cases dropping from 13% to 5%. In addition to improving patient satisfaction, the program improved team morale and participation in the quality improvement process, promoted development of a culture of transparency in assessing process failure rather than individual failure, and emphasized continuous improvement and staff empowerment to effect change.

This quality improvement training is so pivotal that I now require all procedural dermatology fellows to complete a quality improvement program as part of their training. Our current fellow is on her third quality improvement project. Her efforts have resulted in elimination of voice mail (a friendly human voice answers every patient phone call), improvement of chart documentation for patient calls from 0% to 90%, and a 50% reduction in patient call volume.

To err is human. Acceptance of this fact and a continuous commitment to develop error-reduction processes is the essence of quality improvement. Embracing this passion early and fully, as evidenced by our fellow's successes, will create synonyms of "quality" and "health care." Imagine what would happen if each fellow and resident were required to complete a quality improvement project before graduation--and if all of us took it upon ourselves to make quality improvement a priority.

DR. NGUYEN is an associate professor of dermatology and director of Mobs micrographic and dermatologic surgery at the University of Texas M.D. Anderson Cancer Center, Houston.

BY TRI H. NGUYEN, M.D.