Consumer/Quality Insider: Understanding Health Care Quality

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Rand: This is Healthcare 411 for the week of October 15, 2005.

Debra: Healthcare 411 is produced by AHRQ, the Agency for Healthcare Research and Quality, part of the U.S. Department of Health and Human Services. I’m Debra James.

Rand: And I’m Rand Gardner.

Debra: The Agency for Healthcare Research & Quality has published a new consumer booklet entitled “Guide to Health Care Quality - How to Know it When You See it.” AHRQ Director, Dr. Carolyn Clancy, sat down with Rand Gardner to discuss what health care quality is and how you can use this booklet to become better informed and more involved in your own health care.

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Rand: Dr. Clancy, how would you describe health care quality?

Dr. Clancy: Health care quality means getting the right care for your problem at the right time. So in your doctors office this means when you go in with a specific problem they tell you and make recommendations about what to do based on the best medical evidence. Now, sometimes the right care for you can be pretty complicated. As science is advanced there are, often times, many different treatment options for a particular problem and that’s where it is very important to rely on the latest scientific evidence. Many individuals believe that how nice the doctors and nurses are to you is a very important part of quality - and that is important. But, if your problem doesn’t get fixed then you haven’t received high quality care. It’s not unlike going to a car mechanic. The people in the shop can be really nice, but if your car still has that rattle when you go home, you haven’t gotten quality service.

Rand: What about preventive care? Isn’t it important for my doctor to keep me from getting sick in the first place?

Dr. Clancy: It’s very important for your doctor to help you identity what you can do either to prevent diseases altogether or to diagnose those diseases early when it makes a difference. By that I mean detecting disease early when early treatment can actually alter the course of the disease. So for example, high blood pressure is something that millions of Americans aren’t aware that they have. Treating it early can ultimately mean lowering your risk of heart attacks, strokes, kidney disease and so forth. So, preventive care is very important. Now, not all care that we call prevention is necessarily important. It’s very important to know what is the scientific evidence underlying prevention.

Rand: What about medical errors? How big of a problem is it? And does it mean that there are lots of bad doctors and nurses out there?

Dr. Clancy: We’ve learned as a result of a groundbreaking report from the Institute of Medicine that up to 98,000 people a year die as a result of medical errors. And many, many people believe that that’s an under-estimate. The reason they think it may actually be a low figure is because that only includes estimates for problems that occur in the hospital. Our knowledge about what happens in outpatient settings such as doctors offices, nursing homes, rehab facilities and so forth is just now developing. One of the key messages from that report is that this is not about bad doctors or bad nurses or bad pharmacists or bad institutions, it’s really that we have not designed health care organizations to provide safe care. By that I mean, any time a pilot goes in to fly a plane all of the controls look exactly the same. That doesn’t happen in health care at all. Another example might be going to Starbucks for a coffee. If you order your favorite latte, the person repeats it back to you and then they write it on the cup, just to make sure that they don’t make a mistake. Most interactions in health care don’t have that level of backup and confirmation. So there’s a lot that we can do and are beginning to do now in health care. Verbal read back of orders, just like the example of Starbucks is one, bar coding and the use of information technology to make sure that the right patient gets the right medications. A lot of very exciting work in progress right now, but we have a long way to go.

Rand: Can you talk a little more about what is being done to stop medical errors?

Dr. Clancy: Since the Institute of Medicine report was published, there’s been enormous momentum and interest across health care in this country to make health care safer. So doctors organizations, the organizations that train doctors, hospitals are all very much about trying to figure out how they can avoid medical errors. Having said that, it’s very difficult. One of the difficult aspects is that an important source of errors is poor flow of information. So you go in to have knee surgery and all of the information is in the doctor’s office, which is 45 minutes away from the facility where they are actually doing the knee surgery. Many patients think that this information is just flowing seamlessly. Unfortunately it’s often in a manila folder so there’s no way for it to flow. For that reason, many of our efforts as well as the efforts of others are now relying on greater use of health information technology. That is to say doctors writing orders online rather than actually with a pen and paper. This decreases errors due to poor handwriting. It also makes sure that orders get transmitted more quickly and the ultimate goal is that your information is available wherever a doctor or nurse needs it to take care of you.

Rand: So, what can I do to make sure that I’m getting quality care?

Dr. Clancy: There are a number of steps that individuals can take to make sure they’re getting safe high quality care. The first is to ask questions if you have any problems or concerns. That may sound a little bit silly but the truth is that researchers have found that on average patients ask 1.4 questions per encounter and that includes questions about parking. Often times people leave after a doctors visit - they have questions and don’t even know where to go to get answers. Very, very important to ask questions. The second thing you can do is to make sure that you understand what medicines that you are taking. One of the common problems we see a lot is that people are admitted to the hospital - they don’t know what medicines they are taking or they do know and their medicines have to be changed while they’re in the hospital. And they get discharged home on a different set and they have the same old medicines at home in their medicine cabinets and they don’t actually match them up very closely and they may end up double dosing or taking drugs that interact with each other in a bad way. Very, very important. Your medication list ought to be like your driver’s license or your social security number: you have to have it with you. A third and very important step that people can take is to make sure that you get the results of any tests that you have done, whether that is a lab test or an x-ray or some other kind of procedure. You cannot simple expect that the doctor will contact you or that no news is good news. Not because people don’t want to send you the information but because sometimes it gets lost in transition. For example people who are admitted to the hospital for a very short stay, sometimes the results don’t get back to the chart until the patient is discharged in which case important information can be lost, diagnoses can be missed and so forth. If you have a test done, make sure you get the results. A fourth thing that you can do is to make sure that you know what kind of procedure you are going to have done - if you are having surgery or similar type of procedure. Many, many patients that I see have no idea what kind of operation that they had. So I ask them, Gee, you had a hysterectomy, do you still have ovaries? They don’t know, no idea. Very, very important to know. If you have surgery or some other type of procedure recommended, you should be asking the doctor.. Are there other options? Is this the only treatment? What else might I do? What’s the evidence for the kind of option I am having? This is not to say that individuals or patients are responsible for medical errors. But that they have a very important opportunity to make sure that errors don’t happen. Many people are well aware that our health care system often has problems delivering quality care. In response, over the past few years there are more and more resources to help people understand various dimensions of quality of care. For example, there are now report cards on hospitals, there are report cards on nursing homes. And many states and communities have very specific efforts as well. This is all good news. Sometimes though that information is not easy to understand or the information you find on one particular Web site or one particular publication does not necessarily address the question you have. So we produced a new booklet called “Guide to Health Care Quality - How to Know it When You See it.” The book contains a great deal of information about resources that are available on the Web, resources that are available from many agencies, and will help you become a better informed and more involved health care consumer.

Rand: Thank you Dr. Clancy. Copies of the booklet are available on the AHRQ Web site at www.ahrq.gov/consumer. It’s also available by calling the AHRQ Publications Clearinghouse at 1-800-358-9295 or by sending an email to ahrqpubs@ahrq.gov.

Debra: That’s it for this week. Healthcare 411 is produced by AHRQ, the Agency for Healthcare Research and Quality, part of the U.S. Department of Health and Human Services. For Rand Gardner, I’m Debra James. Please join us for the next edition of Healthcare 411.