Speaker 1: Healthcare providers and institutions seek to continually improve the care they provide. Research describes the process healthcare systems and providers use to improve the quality of their care. The Institute of Medicine's 2001 report, Crossing the Quality Chasm, defines six dimensions of healthcare quality. This report and subsequent work highlights the complex nature of quality and also underscores the notion that quality can be defined, measured, and improved upon. Each of the six dimensions is distinct and none is more important than the others. Given these characteristics, any course on the foundations of healthcare quality should focus on specific topics and scholarly fields within each of the six dimensions rather than quality as a composite measure. So let's go over each of our six dimensions. First, safety. Safety is the first thing most people think of when they hear about quality improvement. And for good reason. Safety is fundamental for providing healthcare. Safety refers to making sure that the treatment given in a healthcare setting does not harm patients. Safety is easy to spot. If a patient has an adverse reaction because they were given the wrong dosage of medication, that's a safety issue. While it's easy to see once harm has occurred, addressing the root cause of safety issues is not always straightforward. Safety highlights the system's nature of healthcare quality. When we take the system's perspective in regards to safety, we can catch the near-misses, potential gaps in safety noticed before an adverse event occurs. Quality improvement and a culture of safety arise only when we all use systems thinking. Effectiveness is how well treatments are carried out compared to how they were designed. Effectiveness looks at the potential gap between how things were intended to happen and how they're actually being done. For example, if researchers conduct a clinical trial and find out that drug B works statistically better at treating diabetes than drug A, they might publish their findings and hope physicians everywhere start using drug B. But some healthcare providers might not have read the publications, or they might start giving drug B to all their diabetes patients, even when the published research focused on a narrow population of diabetes patients. This is an effectiveness issue. Effectiveness is also related to the development and implementation of evidence-based guidelines, as well as the recent advent of performance measures. These innovations of evidence-based guidelines and performance measures can improve effectiveness, but sometimes to the detriment of the other quality dimensions. Equity is all about fairness. Although everyone should be treated the same, historically we know that some groups systematically receive better healthcare than others. Research that explores the dimension of equity might compare how treatments and outcomes differ among groups of patients. National data can be used to compare the rates of treatments and outcomes by race or gender, such as how quickly a patient in the emergency department is treated for heart attack symptoms. Sometimes these differences among groups may be warranted or even advantageous. One area of scholarship on equity relates to the heterogeneity of treatment effects among different groups of patients. For example, some types of blood pressure medications are more effective for certain racial or ethnic groups compared with the general population. Scholarship and efficiency explores the sources of waste. Waste arises when resources are used without having added benefits. Waste is a driving factor in excessive healthcare costs. Research in this area tries to discover when expensive procedures create better health outcomes and when outcomes are the same, regardless of whether the expensive procedure is done. Does a patient with X disease do better with a two-day inpatient hospital stay than an outpatient procedure? Efficiency is all about getting the best outcome with the fewest amounts of inputs. But as Robin Hentville, head of the VA National Center for Patient Safety, recently described at the 2015 VA Quality Scholars Summer Institute, there could be a tension between safety and efficiency. Timeliness is made up of two parts, access and system responsiveness. First, can the patient access the care she needs at the moment she needs that care? Are there financial, social, or other barriers to her accessing care? Second, does the hospital or medical system get the treatment to the patients fast enough? If long waits in the emergency department cause an unnecessary delay in an urgent surgery, this would be a timeliness gap. Neither problems accessing care nor time delays in receiving treatment should result in a negative patient outcome. These are timeliness concerns. Timeliness is a dimension that can be evaluated using objective and subjective assessments. These two types of measures are likely to generate different but equally valuable types of information related to timeliness. Patient-centeredness. Health care should be centered on the patient. More often than not, treatment plans involve options. Allowing the patient to explore the options available and choose a treatment plan that works best for them is essential. Ultimately, all care must be aligned to the values and goals of patients and their family members. In a terminal cancer patient, quality of life may be more important than the length of life, or vice versa. Putting the patient at the center of care is a vital dimension of quality. Attention to the people's experiences of receiving health care and of being a patient, i.e., the patient experience, is another key facet of patient-centeredness. In modern health care, the ends do not always justify the means and patients' experiences involve excessive pain, suffering, and alienation. Subjectively reported measures are often the best way of measuring and defining patient-centeredness. So there you have it, the six dimensions of quality. Safety, effectiveness, equity, efficiency, timeliness, and patient-centeredness. Together, these dimensions help ensure that the care we provide keeps our nation healthy.