Question

Identify two or three issues for each aim. care that is Safe- Effective- Efficient- Equitable- Timely- Patient centered-

Answer 1

Safe: Avoiding harm to patients from the care that is intended to help them.

The health care environment should be safe for all patients, in all of its processes, all the time. This standard of safety implies that organizations should not have different, lower standards of care on nights and weekends or during times of organizational change. In a safe system, patients need to tell caregivers something only once. To be safe, care must be seamless—supporting the ability of interdependent people and technologies to perform as a unified whole, especially at points of transition between and among caregivers, across sites of care, and through time. It is in inadequate handoffs that safety often fails first. Specifically, in a safe system, information is not lost, inaccessible, or forgotten in transitions. Knowledge about patients—such as their allergies, their medications, their diagnostic and treatment plans, and their specific needs—is available, with appropriate assurances of confidentiality, to all who need to know it, regardless of where and when they become involved in the process of giving care.

Effective: Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and misuse, respectively).

Effective care should ensure the use of the available, relevant science base. Evidence comes from four main types of research: laboratory experiments, clinical trials, epidemiological research, and outcomes research, including analyses of systematically acquired and properly studied case reports involving one or a population of patients (Agency for Healthcare Research and Quality, 2000). Laboratory experiments—usually on cells or tissues in laboratory animals—are conducted to determine the cause of a disease or how a drug or treatment works. Randomized clinical trials compare outcomes among patients who are randomly assigned to control or treatment groups; other clinical trials compare populations that may be assigned by nonrandom methods. Epidemiological research examines the natural course of disease in particular groups of people; the relationships between people and their health habits, lifestyles, and environment; and risk factors for certain diseases. Outcomes research uses information about how well treatments work in everyday practice settings. The findings of this research sometimes serve as the basis for clinical practice guidelines.

Patient-centered: Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.

Many patients have expressed frustration with their inability to participate in decision making, to obtain the information they need, to be heard, and to participate in systems of care that are responsive to their needs. The Picker Institute in Boston, Massachusetts, has been tracking patients' experiences in hospitals, clinics, and other settings since 1988 (Cleary et al., 1991; Picker Institute and American Hospital Association, 1996). In a 1999 report, patients said that, for the most part, doctors, nurses, and medical staff were courteous, and that as patients they were treated with respect and received attention to their basic physical needs. They also reported, however, that hospital discharge often meant an abrupt transition without information on how they should care for themselves, when to resume activities, what side effects of medications should be monitored, or how to have their questions answered. Above all, patients cited difficulty in obtaining the information they wanted, whether in hospitals, clinics, or doctors' offices. In the scenario presented earlier, little consideration was given to satisfying Ms. Martinez' preferences or to ensure that she had sufficient information to make informed decisions.

Timely: Reducing waits and sometimes harmful delays for both those who receive and those who give care.

Any high-quality process should flow smoothly. Delays should occur rarely. Waiting times should be continually reduced for both patients and those who give care. Much waiting today appears to result from the presumption that certain kinds of face-to-face encounters are required for patients to receive the help or interaction they require. Health systems must develop multiple ways of responding to patients' needs beyond patient visits, including the use of the Internet. Reducing waiting time does not have to increase expense. Experience has shown repeatedly that in many areas, improving access reduces costs in health care (Barry-Walker, 2000; Cohn et al., 1997; Fuss et al., 1998; Stewart et al., 1997; Tidikis and Strasen, 1994; Tunick et al., 1997) and in other industries (Heskett et al., 1997). Promising work in health care has begun to result in reduced delays by decreasing cycle time and by applying lessons from other industries on continuous rather than batch production

Efficient: Avoiding waste, including waste of equipment, supplies, ideas, and energy.

Not all but many types of quality improvements result in lower resource use. This is true for improvements in effectiveness that result from reductions in overuse. It is also true for most improvements in safety, which result in fewer injuries. Quality waste from both overuse (see Appendix A) and errors (Institute of Medicine, 2000b) is abundant in health care and contributes to excess costs.

Equitable: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.

With regard to equity in care giving, all individuals rightly expect to be treated fairly by social institutions, including health care organizations. The availability of care and quality of services should be based on individuals' particular needs and not on personal characteristics unrelated to the patient's condition or to the reason for seeking care. In particular, the quality of care should not differ because of such characteristics as gender, race, age, ethnicity, income, education, disability, sexual orientation, or location of residence (Ayanian et al., 1999; Canto et al., 2000; Fiscella et al., 2000; Freeman and Payne, 2000; Kahn et al., 1994; Pearson et al., 1992; Philbin and DiSalvo, 1998; Ross et al., 2000; Yergan et al., 1987).