Patient centred care: essential but probably not sufficient.

One of the many lessons to emerge from the analysis of the care of children in the cardiac unit at the Bristol Royal Infirmary is the importance of engaging patients in decisions about their health and health care. This is a message that has relevance to all healthcare professionals in all clinical settings. Patient centredness is crucial for good quality care, but achieving genuine patient centred care throughout health services will require transformation of systems as well as attitudes.

Patient safety: a call to action: a consensus statement from the National Quality Forum.

OBJECTIVE: The Institute of Medicine (IOM) and the Presidential Advisory Commission on Consumer Protection and Quality in the Healthcare Industry have both recently highlighted healthcare errors as a serious public health problem. An in-depth review of the issue was conducted by the National Quality Forum (NQF) in preparation for work the federal government has asked the NQF to do. PARTICIPANTS: The membership of the NQF includes a wide array of public and private health agencies, healthcare provider organizations, consumer groups, healthcare purchasers, and research and quality improvement organizations. EVIDENCE: Published literature, including more than 350 journal articles and over 30 books and monographs, were reviewed, and input was solicited from individuals and organizations known to be knowledgeable on the topic, including the Harvard University Executive Session on Medical Error, the VA National Patient Safety Center, the Joint Commission on Accreditation of Healthcare Organizations, the National Patient Safety Foundation, and the IOM. The principal observations and findings were collated; 10 high-priority strategic areas needing action were identified; and specific recommendations for each area were crafted. CONSENSUS PROCESS: A draft statement was prepared and submitted to the NQF membership and Directors, as well as to external reviewers. The statement was revised following subsequent rounds of review and comment, after which it was approved by the NQF Board of Directors. CONCLUSIONS: There is an urgent need to reduce healthcare errors; however, numerous barriers impede progress in this regard, including widespread misunderstanding about why healthcare errors occur, the prevailing culture of "name and blame" surrounding these events, lack of user-friendly error-reporting mechanisms, and fear of litigation if errors are acknowledged and reported. To eliminate these barriers, and to begin to reduce healthcare errors, the NQF recommends that concerted action be taken in the 10 strategic areas identified here.

Establishing health care performance standards in an era of consumerism.

As the US health care system begins to reengineer itself to address the need for quality improvement, it also is being actively reshaped by the expectations of consumers. The confluence of these forces requires a new approach to setting health care performance standards. The National Quality Forum (NQF) has been established as a private, not-for-profit, open membership, public benefit corporation for the purposes of developing consensus about standardized health care performance measures, reporting mechanisms, and a national strategy for health care quality improvement. The NQF has broad representation from all segments of the health care industry and provides an equitable way of addressing the disparate priorities of health care's many stakeholders. Agreement and implementation of standardized health care performance measures and achievement of quality improvement in the emerging era of consumerism will be facilitated by (1) establishing national goals for health care quality; (2) embracing public policy that recognizes the complementary roles of quality improvement, cost control, and improved access; (3) giving greater priority to measuring and reporting the performance of those aspects of the health care system that directly affect consumers; (4) focusing on creating a health care culture of excellence; and (5) promoting the active collaboration of all stakeholders.

Results of a nationwide Veterans Affairs initiative to align graduate medical education and patient care.

CONTEXT: Planning for the US physician workforce is imprecise. Prevailing policy generally advocates more training in primary care specialties. OBJECTIVE: To describe a program to increase primary care graduate medical education (GME) in a large academic health system-the Veterans Health Administration of the Department of Veterans Affairs (VA). DESIGN: In 1995, a VA advisory panel recommended a 3-year plan to eliminate 1000 specialist training positions and add 750 primary care positions. After assessing the impact of the first year of these changes on patient care, the VA implemented modifications aimed at introducing primary care curricula for training of internal medicine subspecialists, neurologists, and psychiatrists. The change in strategy was in response to the call for better alignment of GME with local patient care and training needs to provide coordinated, continuous care for seriously and chronically ill patients. SETTING: The VA health system, including 172 hospitals, 773 ambulatory and community-based clinics, 206 counseling centers, and 132 nursing homes. PARTICIPANTS: A total of 8900 VA residency training positions affiliated with 107 medical schools. MAIN OUTCOME MEASURE: Proportion of residents in primary care training during the 3-year alignment. RESULTS: Over 3 years, primary care training in the VA increased from 38% to 48% of funded positions. Of this total, 39% of the increase was in internal medicine subspecialties, neurology, and psychiatry. CONCLUSION: In this case study of GME realignment, national policy was driven more by local patient care issues than by a perceived national need for primary care or specialty positions.

Physician perceptions of a national formulary.

OBJECTIVE: To assess the perceptions of US Department of Veterans Affairs (VA) physicians regarding effects of a National Formulary (NF) on patient care, access to drugs, physician workload, and resident training approximately 1 year after it was implemented. STUDY DESIGN: Cross-sectional survey. METHODS: A questionnaire was sent to attending physicians working within the VA healthcare system. Participants included general internists (n = 2824), neurologists (n = 238), psychiatrists (n = 997), general surgeons (n = 429), and urologists (n = 152). The response rate was 45%. RESULTS: Most physicians (63%) thought that they could prescribe needed drugs; 65% agreed that patients could obtain needed nonformulary drugs. One third disagreed that access to prescription pharmaceuticals had increased; 29% stated the NF impinged on providing quality care to their own patients, and 21% thought it did so to patients from other VA facilities. Thirty eight percent of physicians perceived the NF to be more restrictive than private sector formularies; 16% thought that the NF diminished the ability to train residents for managed care. Forty percent thought that the NF added to workload. Generalists more often perceived that the NF improved their ability to provide care compared with neurologists (27% vs 18%, P = .046), psychiatrists (27% vs 22%, P = .027), and internal medicine subspecialists (27% vs 18%, P = .001). Physicians with more clinic time were more likely to perceive that the NF increased workload. CONCLUSION: Although differences of opinions among physicians were noted, most responding VA physicians did not perceive that the NF adversely affected patient care, access to pharmaceuticals, physician workload, or resident training.

Tuberculosis in the veterans healthcare system: a six-year review and evaluation of programme effectiveness.

The Department of Veterans Affairs operates a large, centrally administered health care system consisting of 173 hospitals and 4 free standing outpatient clinics nationwide with approximately 945,115 hospital discharges, 24.2 million outpatient visits, and 2.86 million persons served annually over the time frame of the review. The purpose of the study was to define whether such a system could effect timely change in the incidence of tuberculosis (TB) using centralized programme planning and flexible field implementation. A retrospective review of the number of newly diagnosed cases of active TB treated at veterans health care facilities between 1 October 1990 and 30 September 1997 was determined by using a standardized annual case census. Intervention included implementation of the most current guidelines for the prevention of transmission of TB in the community and hospital setting, including administrative and engineering controls and a change in personal protective equipment. Centrally directed programme guidance, education, and funding were provided for field use in health care facilities of widely varying size and complexity. The numbers of total reported cases of TB decreased significantly (P < 0.001) throughout the veterans health care system (nationally and regionally), with the case rate decreasing at a rate significantly greater than that seen in the USA as a whole (P < 0.0001). TB associated with multi-drug resistance (isoniazid and rifampin) and HIV coinfection also significantly decreased over the study period. Therefore, a large, centrally administered health care system can effectively combat a re-emerging infectious disease and may also demonstrate a successful outcome greater than seen in other, perhaps less organized health care settings.

The Department of Veterans Affairs' role in Federal Emergency Management.

The Veterans Health Administration (VHA) has been increasingly called on to provide disaster relief health care personnel and other emergency assistance since the role of the Department of Veterans Affairs in emergency management was expanded by the Federal Response Plan in 1992. This article briefly reviews the VHA's emergency management functions currently specified by the Federal Response Plan and its present activities in procuring and maintaining antidotes, antibiotics, and other pharmaceutical stockpiles to be used in response to terrorist incidents involving weapons of mass destruction. In view of VHA's national scope and extensive assets, its administration by the government, and its critical role in health professional training, there are several additional ways that VHA could economically augment the federal government's efforts to better support and prepare local jurisdictions for disasters or incidents involving weapons of mass destruction, if the required authorization and funding were provided.

Reinventing VA health care: systematizing quality improvement and quality innovation.

The Veterans Health Administration (VHA) in the US Department of Veterans Affairs (VA) manages the largest fully integrated health care system in the United States. In 1995, the VHA initiated a reinvention effort that included the most radical redesign of VA health care to occur since the veterans health care system was formally established in 1946. The 2 paramount goals of this reinvention effort were to ensure the predictable and consistent provision of high-quality care everywhere in the system and to optimize the value of VA health care. Although still a work in progress, dramatic results have been achieved toward these ends during the past 5 years. This article provides an overview of the veterans health care system, and it highlights selected aspects of the system's reengineering. It also describes various steps that have been taken to better manage performance and to systematize quality improvement and quality innovation. This information provides a global context that should facilitate understanding of the genesis and purposes of the Quality Enhancement Research Initiative that is described in other articles in this issue of Medical Care.

Quality Enhancement Research Initiative (QUERI): A collaboration between research and clinical practice.

This article provides an overview of the Quality Enhancement Research Initiative (QUERI), an ambitious attempt to develop a data-driven national quality-improvement program for the Veterans Health Administration (VHA) that is fully integrated within VHA's Strategic Framework for Quality Management, as discussed elsewhere in this supplement. QUERI is designed to ensure the systematic translation of findings and products (quality tools that promote use of research findings) to promote optimal patient outcomes and system-wide improvements. In developing QUERI, a framework was created to integrate structural elements (organizational characteristics) and process considerations (those actions and action sequences associated with positive change) with outcomes (both at the patient level and at the systems level). In developing this framework, a process for translation of evidence into action was born. The QUERI process depends on having or discovering accurate information about what services are needed, who needs them, how they should be provided, and relevant outcomes and costs. This article describes the 6-step QUERI process and presents an overview of relevant programmatic details, including QUERI's rigorous review process, and VHA's unique qualifications for establishing a national model for quality improvement.

Promoting innovative nursing practice during radical health system change.

Between 1995 and 1999, the United States veterans healthcare system underwent a radical transformation. The reinvention effort remains a work in progress, but the results have documented improved access to care, significantly higher service satisfaction, and substantially higher quality of care, while reducing per patient costs by 25%. Although turbulent at times, the changes instituted during this period created a dynamic milieu for nursing that has provided fertile ground for innovation and unprecedented opportunities to improve patient care.

Lessons learned in public health emergency management: personal reflections.

Multiple environmental, ecological, and socio-political forces are converging to increase the occurrence of both natural and technological disasters. Ten forces are of most concern in this regard. These are: 1) global warming, with its consequent weather extremes and climate changes; 2) continued rapid human population growth and concomitant increased urbanization; 3) decreased bio-diversity and consequent ecological fragility; 4) deforestation and loss of natural habitat for animal species, with resultant greater overlap of human and animal habitats, human exposure to animal pathogens, and other ecological perturbations; 5) increased technological development throughout the world (especially in developing countries with their typically immature safety programs); 6) globalization and increased population mobility; 7) sub-national religious and ethnic conflicts, and their potential for conflict escalation and large scale displacement of populations; 8) the collapse of several major countries and consequent unraveling of national identity and social order; 9) the rise of terrorism; and 10) dramatic advances in the science and technology of computing, communications, biotechnology, and genomics. This paper describes 10 lessons learned relative to the public health aspects of emergency management, especially as they pertain to disasters. 1) Planning pays; 2) A bad situation can be made worse by inappropriate responses; 3) Most life saving interventions will occur before the disaster happens and immediately afterwards by local action; 4) Public health emergency management is not a democratic process; 5) Psychological impacts are usually greater than anticipated; 6) Communications and information management are vital, but often are the weak link in the response chain; 7) Collaboration and partnerships are essential; 8) Unsolicited volunteers and aid are inevitable and must be planned for and managed; 9) Never assume anything, and always expect the unexpected; and 10) Post-event evaluation is important, and must be coordinated. The paramount lesson learned from past emergencies is that the untoward impact of these events can be anticipated and significantly ameliorated by appropriate planning and preparation. On the other hand, preparation for emergency events has deteriorated because of health-care financial constraints, and resources to support planning and needed infrastructure have diminished. Given these realities, the major unresolved challenge is how to ensure that planning for the common good is supported and, in fact, gets done.

Kenneth W. Kizer on a national quality strategy. Interview by Lori Blades and Patricia A. Cholewka.

Kenneth W. Kizer, MD MPH, is president and chief executive officer (CEO) of the National Forum for Health Care Quality Measurement and Reporting (National Quality Forum [NQF]), a not-for-profit membership organization created to develop and implement a national strategy for measuring and reporting healthcare quality. Dr. Kizer previously served as Under Secretary for Health in the U.S. Department of Veterans Affairs (VA) and is widely credited as being the chief architect of and driving force behind the greatest transformation of VA healthcare since its creation in 1946. NQF is a public-private partnership designed to involve all segments of the nation's healthcare system. The organization was proposed as part of the findings of the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry (1998). Since the release of those findings, leaders from consumer, purchaser, provider, health plan, and health services research organizations, as well as from government, have met to define the mission, structure, and financing of NQF, and staff support has been provided by the United Hospital Fund of New York. NQF is primarily a membership dues- and grant-financed organization and has received significant public and private funding from foundation and corporate grants, including a $2.5-million founding grant from the Robert-Wood Johnson Foundation and a $1-million founding grant from the California Healthcare Foundation. NQF also received initial financial support from The Commonwealth Fund and United Hospital Fund.