Video Transcript: Defining Quality: Aiming for a Better Health Care System

Donald M. Berwick, MD, MPP, President Emeritus and Senior Fellow at the Institute for Healthcare Improvement and Former Administrator for the Centers for Medicare & Medicaid Services

One of the most important things that happened in that report was that it gave names to the dimensions of quality. If you’re buying a car, there are dimensions of quality: safety, fuel efficiency, comfort, fun in driving, durability, and so-on. We’re used to that. Well, what are the dimensions of goodness in health care? And the Institute of Medicine Crossing the Quality Chasm report gave us six dimensions and said, “These should be the areas for health care to improve on.” It also summarized a lot of the research literature on the current levels of performance for those six areas, and here are the areas:

The first one is safety, [relating] back to the report from a year and a half earlier, To Err is Human. Safety means we’re not harming people with our care. We’re not adding to the burden of illness. So, a safe health care system reduces hazards and risk from the care itself. Safety.

The second dimension they called effectiveness, and that was a term that was meant to mean matching science to care. If science says, “This drug can help in this disease,” then we use that drug, and if science says it can’t help, then we don’t use it. So avoiding overuse of things that don’t help and assuring use of things that do help — avoiding underuse — that’s effectiveness, lining up science with care. There are big problems in effectiveness. The Rand Corporation famously published a study a few years ago, which showed that of the needed effective care that Americans should get, when they tracked 7,000 people over two years, those people — who had all sorts of things ranging from just well care to serious chronic illness — those 7,000 people failed to get 45 percent of the care that would have helped them. So that’s effectiveness.

The third dimension is patient-centeredness, and this is a pretty subversive goal. It means people should be in control of their own care. They should make decisions about what affects them. We say, “Nothing about me without me.” It’s putting the patient in the center of the care system and giving them power and control over their own lives and their own care.

The fourth dimension is timeliness, which means avoiding delays. People are quite familiar with waiting rooms. We wait a long time to get in to see the doctor in the emergency room or waiting for an appointment. In all other industries, timeliness is an important dimension of quality. You don’t want to wait everywhere. Well, nor do you in health care. So timeliness is reduction of needless delay. Some delays are instrumental — you want to wait to see what happens — but there is a lot of non-instrumental, very costly delay.

The fifth dimension is efficiency, which means avoiding waste. We throw out so much in health care: We give things that can’t help, we duplicate procedures and tests, we lose records, we lose the ideas of the workforce by not inviting them to join in invention. So efficiency is a big word. It means stop wasting stuff. We’re very, very wasteful in health care.

The last dimension, which some people think should be the first, is equity, and that means closing the gap in justice and health care basically. Right now, the biggest predictor of your health status in our country remains your race. If you know someone’s race, you know much more about their future in health than almost anything else I could tell you about them. A black baby born in inner city Baltimore this year has a life expectancy of a male that is seven or eight years less than a white baby. That’s a quality dimension, too, equity.

So, safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. Those are the names of dimensions of quality that the Institute of Medicine says we should work on. The Institute for Healthcare Improvement has taken those aims and put them in our mission statement. We exist to improve on those six dimensions. And more and more, thanks to the Institute of Medicine, you’re seeing hospitals and clinics and health care organizations in our country and, by the way, other countries, adopt that same now rather famous list of goals for improving health care.