The ongoing quality improvement journey: Next stop, high reliability

Health Affairs

Volumn 30, Issue 4, 2011, Pages 559-568

  Chassin, Mark R ^a   Loeb, Jerod M ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; HEALTH CARE; HEALTH CARE DELIVERY; HEALTH CARE ORGANIZATION; HEALTH CARE QUALITY; HEALTH CARE UTILIZATION; HYGIENE; LEADERSHIP; MEDICAL CARE; PRACTICE GUIDELINE; PROFESSIONAL STANDARD; RELIABILITY; TOTAL QUALITY MANAGEMENT;

HISTORY, 20TH CENTURY; HISTORY, 21ST CENTURY; HOSPITALS; QUALITY ASSURANCE, HEALTH CARE; UNITED STATES;

EID: 79955615675     PISSN: 02782715     EISSN: 15445208     Source Type: Journal    
DOI: 10.1377/hlthaff.2011.0076     Document Type: Article

References (51)

1. Colton D. Quality improvement in health care. Eval Health Prof. 2000;23(1):7-42.
2. Luce JM, Bindman AB, Lee PR. A brief history of health care quality assessment and improvement in the United States. West J Med. 1994; 160(3):263-8.
3. McIntyre D, Rogers L, Heier EJ. Overview, history, and objectives of performance measurement. Health Care Financ Rev. 2001;22(3):7-21.
4. Loeb JM. The current state of performance measurement in health care. Int J Qual Health Care. 2004; 16(Suppl 1):i5-9.
5. Bohmer RMJ. Designing care: aligning the nature and management of health care. Boston (MA): Harvard Business Press; 2009.
6. Roberts JS, Coale JG, Redman RR. A history of the Joint Commission on Accreditation of Hospitals. JAMA. 1987;258(7):936-40.
7. Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q. 1966;44(3 Suppl):166-206.
8. Streptomycin treatment of pulmonary tuberculosis. Br Med J. 1948; 2(4582):769-82.
9. Chassin MR. Is health care ready for Six Sigma quality? Milbank Q. 1998;76(4):565-91, 510.
10. Cochrane Library. Cochrane central register of controlled trials [Internet]. Oxford (UK): The Library; [cited 2011 Jan 6]. Available from: http://www.thecochranelibrary.com/view/0/AboutTheCochraneLibrary.html#CENTRAL.
11. Balas EA, Boren SA. Managing clinical knowledge for health care improvement. In: Bemmel J, McCray AT, editors. Yearbook of medical informatics: patient centered systems. Stuttgart (Germany): Schattauer; 2000. p. 65-70.
12. Nelson AR. Relation between quality assessment and utilization review in a functioning PSRO. N Engl J Med. 1975;292(13):671-5.
13. Starr P. The social transformation of American medicine. New York (NY): Basic Books; 1982.
14. Lohr KN, editor. Medicare: a strategy for quality assurance. Vol. 1. Washington (DC): National Academies Press; 1990.
15. Lohr KN, editor. Medicare: a strategy for quality assurance. Vol. 2, Sources and methods. Washington (DC): National Academies Press; 1990.
16. Chassin MR, Kosecoff J, Winslow CM, Kahn KL, Merrick NJ, Keesey J, et al. Does inappropriate use explain geographic variations in the use of health services? A study of three procedures. JAMA. 1987;258(18): 2533-7.
17. Gray BH, Gusmano MK, Collins S. AHCPR and the changing politics of health services research. Health Aff (Millwood). 2003;22:w3-283-307. DOI: 10.1337/hlthaff.w3.283.
18. Qaseem A, Snow V, Owens DK, Shekelle P. Development of clinical practice guidelines and guidance statements of the American College of Physicians: summary of methods. Ann Intern Med. 2010;153(3):194-9.
19. Pepine CJ, Allen HD, Bashore TM, Brinker JA, Cohn LH, Dillon JC, et al. ACC/AHA guidelines for cardiac catheterization and cardiac cath-eterization laboratories. American College of Cardiology/American Heart Association Ad Hoc Task Force on Cardiac Catheterization. Circulation. 1991;84(5):2213-47.
20. Laffel G, Berwick DM. Quality in health care. JAMA. 1992;268(3): 407-9.
21. Berwick DM. Continuous improvement as an ideal in health care. N Engl J Med. 1989;320(1):53-6.
22. Kritchevsky SB, Simmons BP. Continuous quality improvement: concepts and applications for physician care. JAMA. 1991;266(13):1817-23.
23. O'Leary DS. The Joint Commission looks to the future. JAMA. 1987; 258(7):951-2.
24. Iezzoni LI. Assessing quality using administrative data. Ann Intern Med. 1997;127(8 Pt 2):666-74.
25. Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington (DC): National Academies Press; 2000.
26. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington (DC): National Academies Press; 2001.
27. Kizer KW. Establishing health care performance standards in an era of consumerism. JAMA. 2001;286: 1213-7.
28. Joint Commission. Improving America's hospitals: the Joint Commission's annual report on quality and safety, 2010 [Internet]. Oak-brook Terrace (IL): Joint Commission; 2010 [cited 2011 Jan 6]. Available from: http://www.jointcommission.org/assets/1/18/2010_Annual_Report.pdf.
29. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006:335(26):2725-32.
30. Chassin MR, Hannan EL, DeBuono BA. Benefits and hazards of reporting medical outcomes publicly. N Engl J Med. 1996;334(6):394-8.
31. Robert Wood Johnson Foundation. Aligning forces for quality [Internet]. Princeton (NJ): RWJF; [cited 2011 Mar 3]. Available from: http://www.rwjf.org/qualityequality/af4q/.
32. Wisconsin Collaborative for Healthcare Quality [home page on the Internet]. Middleton (WI): The Col-laborative; [cited 2011 Mar 3]. Available from: http://www.wchq.org/.
33. Leonhardt D. Making health care better. New York Times Magazine.2009 Nov 3.
34. Chassin MR, Becher EC. The wrong patient. N Engl J Med. 2002;136(11): 826-33.
35. Joint Commission. Preventing surgical fires [Internet]. Oakbrook Terrace (IL): Joint Commission; 2003 Jun 24 [cited 2011 Mar 3]. (Sentinel Event Alert, issue 29). Available from: http://www.jointcommission.org/assets/1/18/SEA_29.PDF.
36. Joint Commission. A follow-up report on preventing suicide: focus on medical/surgical units and the emergency department. Oakbrook Terrace (IL): Joint Commission; 2010 Nov 17 [cited 2011 Mar 3]. (Sentinel Event Alert, issue 46). Available from: http://www.jointcommission.org/assets/1/18/SEA_46.pdf.
37. Reason J. Human error: models and management. BMJ. 2000; 320(7237):768-70.
38. Weick KE, Sutcliffe KM. Managing the unexpected: resilient performance in an age of uncertainty. 2nd ed. San Francisco (CA): Jossey-Bass; 2007.
39. Dixon NM, Shofer M. Struggling to invent high-reliability organizations in health care settings: insights from the field. Health Serv Res. 2006; 41(4 Pt 2):1618-32.
40. Fei K, Vlasses FR. Creating a safety culture through the application of reliability science. J Healthc Qual. 2008;30(6):37-43.
41. Frankel AS, Leonard MW, Denham CR. Fair and just culture, team behavior, and leadership engagement: the tools to achieve high reliability. Health Serv Res. 2006; 41(4 Pt 2):1690-709.
42. Reason J, Hobbs A. Managing maintenance error: a practical guide. Aldershot (UK): Ashgate; 2003.
43. Goldberg HI. Continuous quality improvement and controlled trials are not mutually exclusive. Health Serv Res. 2000;35(3):701-5.
44. DelliFraine JL, Langabeer JR, Nembhard IM. Assessing the evidence of Six Sigma and Lean in the health care industry. Qual Manag Health Care. 2010:10(3):211-5.
45. DuPree E, Anderson R, Kathuria N, Redich D, Porter C, Chassin MR. Improving patient satisfaction with pain management using Six Sigma tools. Jt Comm J Qual Patient Saf. 2009;35(7):343-50.
46. Joint Commission Center for Transforming Healthcare. Hand hygiene project: best practices from hospitals participating in the Joint Commission Center for Transforming Healthcare project [Internet]. Oak-brook Terrace (IL): The Center; 2010 Nov [cited 2011 Jan 6]. Available from: http://www.hpoe.org/resources-and-tools/resources/hand-hygiene-project.pdf.
47. For additional information on how causes of poor hand hygiene differed among hospitals, see Joint Commission Center for Transforming Healthcare [storyboard on the Internet]. Oakbrook Terrace (IL): The Center; [cited 2011 Jan 6]. Available from: http://www.centerfortransforminghealthcare.org/UserFiles/file/hand_hygiene_storyboard.pdf.
48. The eight original hospitals that worked on the hand hygiene project with the center were the Cedars-Sinai Health System, in California; Exem-pla Healthcare, in Colorado; Froedtert Hospital, in Wisconsin; the Johns Hopkins Hospital and Health System, in Maryland; Memorial Hermann Healthcare System, in Texas; Trinity Health, in Michigan; Virtua, in New Jersey; and Wake Forest University Baptist Medical Center, in North Carolina.
49. Joint Commission Center for Transforming Healthcare. Targeted solutions tool [Internet]. Oakbrook Terrace (IL): The Center; [cited 2011 Feb 24]. Available from: http://www.centerfortransforminghealthcare.org/tst.aspx-.
50. Carthey J, de Leval MR, Reason J. Institutional resilience in healthcare systems. Qual Health Care. 2001; 10(1):29-32.
51. Agency for Healthcare Research and Quality. Hospital survey on patient safety culture [Internet]. Rockville (MD): AHRQ; 2009 Apr [cited 2011 Jan 6]. Available from: http://www.ahrq.gov/qual/patientsafetyculture/hospsurvindex.htm.