Quality in Veterinary Medicine: the ultimate goal
“What is perhaps most disturbing is the absence of real progress toward restructuring health care systems to address both quality and cost concerns, or toward applying advances in information technology to improve administrative and clinical processes. Despite the efforts of many talented leaders and dedicated professionals, the last quarter of the 20th century might best be described as the “era of Brownian motion in health care.” Mergers, acquisitions, and affiliations have been commonplace within the health plan, hospital, and physician practice sectors (Colby, 1997). Yet all this organizational turmoil has resulted in little change in the way health care is delivered.” – From Crossing the Quality Chasm , 2001
I’ve spent most of my blog so far talking about ownership and community. The reason I care so much about ownership is because my ultimate goal is to help continuously improve the quality of veterinary medicine. The sentiments expressed above by the Institutes of Medicine about human healthcare in 2001 apply very much to where veterinary medicine sits today: too much Brownian motion, not enough forward momentum to truly improve care and outcomes for pets and their people.
The wakeup call on the human side occurred in early 1990s when a series of articles was published, documenting the number of deaths occurring due to preventable adverse events in hospitalized patients http://www.nejm.org/doi/full/10.1056/NEJM199102073240604, http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(98)24009-8/fulltext. The Institutes of Medicine formed the Committee on the Quality of Health Care in America in 1998. The committee was charged with developing a ten-year strategy to substantially improve the quality of health care. The committee performed a detailed review of quality of care literature, which used workshops to identify strategies for raising the awareness of the public and key stakeholders. They also identified environmental forces that influenced efforts to improve quality; developed strategies for fostering greater quality accountability; and identified important future areas of research.
In 2000, the committee published some of their findings in To Err is Human: Building a Safer Health System . They confirmed the huge toll of medication mistakes and estimated that between 44,000 and 98,000 Americans died each year as result of these errors. Their research showed that faulty systems, not faulty humans, needed to be addressed in order to decrease the incidence of mistakes.
Their second publication in 2001 was Crossing the Quality Chasm: A new health system for the 21st Century In this , they made specific recommendations to begin addressing not only safety but also other quality concerns in medicine. They recommended that true quality care should to be judged on six key metrics recognized by the acronym STEEEP:
- SAFE – no harm to patients in hospitals
- TIMELY – ER care and test results should not be delayed
- EFFECTIVE – people need the right treatment for the right disease, with evidence-based recommendations put into practice quickly
- EFFICIENT – systems need to avoid duplication of testing and need to aim for the right diagnosis quickly
- EQUITABLE –all people no matter their class or race should be cared for equally
- PATIENT – CENTERED –the patient’s needs and wants should be always at the forefront
All of these can and should be used to develop a road map for quality in the veterinary field as well. However, instead of our industry being PATIENT-CENTERED, I would argue that we must be PET FAMILY CENTERED.
My definition of quality veterinary medicine is: safe, reliable, and effective healthcare that puts pets and their families first.
The Tax Relief and Health Care Act of 2006 requires that all hospitals accepting Medicare payment report the incidence of severe adverse events. This law, and the above mentioned publications have led to concerted efforts to find ways to prevent errors and to catch mistakes. Work over the last 10 years has led to overall system improvements in human healthcare. From 2010 to 2013, there was a 17% reduction in hospital acquired conditions. In addition, it is now possible for customers to find published data on outcome from common diseases at different hospitals.This is crucial as improvements in outcomes have not been consistent across hospitals so prognosis varies widely by which hospital you go to. Detailed studies comparing hospitals has shown that those with the best outcomes were the most likely to have cultures that emphasized communication, interdepartmental coordination, continuous learning, and overall engagement in quality improvement.
No large studies have been done in veterinary medicine but we all know that mistakes do happen, with medications, with equipment, with secondary infections, and with a variety of things that no one might expect. In 2008, our hospital decided to pursue AAHA specialty accreditation. One of the criteria was tracking adverse events and we instituted reporting in our hospital. The value of tracking and then discussing even minor errors was that we discovered SYSTEMS that needed to be fixed. As we learned how to discuss errors without blame, we learned how to engage all of our staff in our journey toward quality.
To truly change the trajectory of veterinary medicine, we need to rise above the “Brownian motion,” and start really looking at the care we provide. We need to work together, universities and large private practices, to define and publish appropriate outcome statistics so we can use evidence to choose the best treatment plans. We need to recognize common medical errors, talk about them openly, and look for SYSTEM changes to prevent them. We need to become a profession that understands improvement science and embraces it.
In the coming weeks, I hope to not only continue the conversation on ownership and community but also to continue providing thoughts and ideas on how we can use what we’ve learned on the human side to improve the care we all provide to pets and their families.