Viewpoint: Achieving Better Care and Learning - Now and in the Future

Donald M. Berwick, MD, MPP, President and Chief Executive Officer Institute for Healthcare Improvement

Picture academic care settings where patients could always expect safe, reliable, timely and evidence-based care. Imagine the benefits for our patients here and now. Even more exciting would be the outlook for patient care in a future where students and residents who have learned in these settings would continually help to improve care wherever their careers take them.

A clear vision for such care was outlined in the Institute of Medicine (IOM) reports Crossing the Quality Chasm: A New Health System for the 21st Century (2001) and To Err is Human: Building a Safer Health System (1999). While medical schools and teaching hospitals enjoy a well-earned reputation for new and innovative biomedical science and technology, it is fair to say that they have been slower to put into practice the innovations reflected in these reports. The reasons are many - cost, competing academic priorities and the shifting practice environment, to name a few.

Nevertheless, a more urgent strategy for change is required. It is important because our patients deserve it. But it is particularly important for academic care settings, since they affect not only today's patients but also future generations of patients. How swiftly academic centers implement such knowledge determines how quickly that knowledge will become the standard for the care students and residents - the stewards of our future health care system - will provide.

The Association of American Medical Colleges (AAMC) and the Institute for Healthcare Improvement (IHI) are committed to accelerating this process. We have embarked on a partnership between the AAMC and IHI that was initiated when David Stevens moved to Boston for this academic year as a George W. Merck Senior Fellow - immersed in the work of the IHI. In addition, the AAMC has established the AAMC Institute for Improving Clinical Care (IICCC) (formerly the Center for Clinical Care Improvement) which will serve as a conduit to constituents for effective strategies and knowledge for improvement. This partnership between IHI and the IICC will launch opportunities for teaching hospitals, medical schools and other stakeholders in academe to implement improvement strategies that have been the hallmark of IHI.

David P. Stevens, MD, Vice President, Clinical Care Improvement, Association of American Medical Colleges

The mission of the IHI, a not-for-profit, educational, consulting and advocacy organization located in Boston, is to develop and spread health car improvement throughout the world. IHI has a culture of collaborative innovation with an aggressive goal to rapidly test and spread these innovations. For instance, 30% of IHI's work at any given time is focused on health care innovations that have been developed in the last 18 months. Many approaches are adapted from non-medical disciplines and industries. An example is open access patient scheduling. Employing "lean thinking"-a concept refined by Toyota-and queuing theory, open access allows patients to schedule appointments with their doctor on the day of their choice. Since 70% of patients who call their doctor have a need for care on the same day, open access enables the system to meet clinical needs when they are recognized by the patient and eliminates the considerable waste that resides in maintaining the "inventory" of weeks of waiting patients. Shouldn't students and residents learn such practices from the beginning of their clinical careers?

The IICC's sole mission is the spread of health care innovation to academic settings. This calls for addressing the academic culture that sometimes makes change difficult in our institutions, as well as the special challenge of implementing redesign where students and residents participate in patient care.

Examples of two early IICC initiatives in the coming academic year will include collaboration with medical schools and teaching hospitals to improve chronic illness care in academic settings and to redesign academic inpatient settings. Both involve radical redesign for both patient care and resident training. Moreover, the IICC is committed to evaluating both clinical and cost outcomes of such redesign. These initial activities will draw on the evidence-based strategies for effective chronic care developed by Dr. Ed Wagner and his colleagues at the MacColl Institute for Healthcare Innovation at Group Health Cooperative in Seattle, Washington and the innovative work on high-performance clinical micro-systems of Dr. Paul Batalden and his associates at Dartmouth.

We have no illusions: innovation of this type in academic settings is difficult, but it is well worth the effort. Many medical schools and teaching hospitals have already responded to the call to close the quality and safety gaps. The health system in the US depends on linking such change to the preparation of our future physicians. The IICC and IHI are committed to supporting these activities.

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