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Journal for Healthcare Quality Vol. 30, No. 1, pp. 25–29 © 2008 National Association for Healthcare Quality

On January 1, 2008, Mark R. Chassin, MD MPP MPH, assumed the presidency of the Joint Commission. He has an extensive background in quality improvement and has served as commissioner of the New York State Department of Health, senior project director at the RAND Corporation, senior vice president and cofounder of Value Health Sciences, and deputy director and medical director of the Office of Professional Standards Review Organizations of the Health Care Financing Administration. A member of the Institute of Medicine, he coauthored To Err is Human and Crossing the Quality Chasm. Chassin is transitioning to the Joint Commission from his posts as executive vice president for excellence in patient care at Mount Sinai Medical Center and Edmond A. Guggenheim Professor of Health Policy and chair of the department of health policy at Mount Sinai School of Medicine, New York, NY.

Interview with a Quality Leader: Mark Chassin, New President of the Joint CommissionLinda Harrington and Susan V. White, Interviewers

QWhat are three issues facing health-care that must be addressed in the next few years, and what specific

challenges do they pose to hospitals and other healthcare providers?

AI see three broad challenges facing healthcare in the United States and, to a varying degree, other developed

countries: quality, access, and cost.In the quality arena, especially in hospitals

(where the risk for problems and errors end-ing in preventable complications is greatest), we need to make more substantial progress toward achieving much higher levels of safety and quality than we have in recent years.

We also have very serious access problems. I am hopeful that we in the United States are approaching another opportunity to engage in a serious national discussion about achieving universal health insurance. Another dimen-sion to access that presents a serious challenge is racial and ethnic disparities in health and healthcare, which we have begun to tentatively address, but not systematically enough in my opinion.

The third challenge is cost. We cannot sus-tain current healthcare programs, particularly the federal programs, at the rate at which the cost of healthcare is increasing. We need to find a solution to the cost problem that does not impede accomplishing the other two goals. Taken together, these are formidable challenges.

QHow will these major issues affect hospitals trying to build high-quality organizations?

AHospitals are at the forefront of advancing the national quality and safety agenda, although other ven-

ues, such as nursing homes, ambulatory practices, and office-based and multispecialty-group practices, are also engaged. We are just

beginning to understand how hospitals can learn from organizations in other sectors of our society that deal with similar levels of risk but manage to have many fewer adverse events. We’ve started to learn how to adapt lessons from these “high-reliability” organi-zations (a term borrowed from organizational and sociological literature) to hospitals and healthcare, but we need to facilitate learning and help spread information much more rap-idly and effectively than we have thus far.

Hospitals will be challenged to step up the pace of safety and quality improvement activi-ties while also continuing to manage the stress of staff turnover, shortages in some specialty areas, and financial pressures from public and private payers. I recognize that discretionary funding for this kind of work is not plentiful, but the public pressure for increased safety and quality is unquestionably only going to intensify. As a healthcare family, we need to take this message to heart more than we have to date and increase our efforts to get in front of the wave.

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QIn an August 2007 article in Modern Healthcare, you are quoted as saying that one of your ambitions is to accel-

erate quality improvement by more widely and aggressively disseminating proven meth-odologies (“Shaking Up the Joint,” 2007). Could you discuss how this effort might change or create new expectations for health-care organizations?

AWhen undertaking a specific quality improvement project that focuses on a specific goal, you can’t go to a library

and pull from the shelf—virtual or other-wise—information or a set of tools that will describe in operational and usable detail how to actually achieve the goal. It is also difficult to find information about others’ experiences achieving the same goal. How do you avoid the potholes, and how do you get onto the on-ramp without having to build the road yourself?

I am very mindful that for hospitals and other organizations—but particularly hospi-tals—quality improvement resources are very scarce: we have to be very judicious about what we demand of those organizations. It would be most efficient to figure out what really improves specific targeted areas, such as pain management, and what doesn’t work—with respect to both the specific approaches and the specific tools that support those approaches.

We need to disseminate proven strategies and get knowledge-based learning into the hands of quality improvement professionals who are using reliable and proven measures—not just anecdotal ones—that allow healthcare organizations to move much more quickly than if they were starting from scratch.

Another problem that my colleagues and I have grappled with is that even if you actually find an intervention that works and produces some improvement, embedding that interven-tion into routine work is a big challenge. It is difficult for an intervention to continue produc-ing the same level of improvement that it did when the assembled project team was paying attention to a shared goal. Improvement ini-tiatives need to continue to produce the same benefit they did when they were brand-new. Sustaining successful improvements is a major challenge. It is important to recognize that the “special-project approach” we often use is not really designed to produce long-term sustain-able change.

Organizations can be assisted with the last phase of the improvement cycle in a variety of ways, but again, hospitals’ quality improve-ment resources are finite. We don’t want to squander resources by having hospitals work to produce interventions that don’t get sus-tained after we have moved on to the next problem.

QCan you share an example of a tool or method from your work that has been successful?

ASince roughly 1999 we have been using Six Sigma quality improvement tools and strategies, including Lean and

value stream mapping, to create institutional change while sustaining individual projects. We have had a lot of experience figuring out how to adapt those tools and methods to healthcare from their origins in industry.

We have learned that Six Sigma should be taught as a systematic approach to problem solving and process improvement that estab-lishes specific stages of an improvement cycle and ensures that you don’t skip important steps. For example, a few years ago we were working on a project to improve the timely return of routine laboratory results to clini-cians. Our team came up with a specific goal: to have routine results reported within 3 hours. Any lab results report delayed more than 3 hours was considered a bad outcome. We mea-sured the process of reporting routine results and found that 31% of the reports came back more than 3 hours after the patients’ blood was drawn. The next step after measurement was to identify the source of the problem. (Admittedly, the challenge of measurement is significant; once we decide what the most important measure of quality is for a particular process, we frequently don’t have the data we really need at our fingertips.)

The critical point about not skipping steps is that when we know the magnitude of the problem, we tend to think we know the answer to the problem or the source of the problem. People end up sitting around the table point-ing fingers at each other and at the process. At this point, you need to stop and say, “Wait a second. We really need to measure the sources of the problem in our place, not the story that someone remembers from 2 years ago or the story that someone heard from a friend in a different place. Let’s figure out what causes this

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problem here and now so that we can intervene effectively.” This approach will lead to very tar-geted and focused interventions. If you search for causes correctly, the interventions have a much higher chance of working than when you just pick somebody else’s solution off the shelf without looking at what is causing the problem in your own location.

The last part of this process is embedding the solution into routine work and sustaining the gains. I’ve given a very quick overview of a successful intervention strategy here. This sys-tematic approach to solving critically important problems is one of the lessons we have learned that might be much more broadly applicable across healthcare organizations.

To summarize, hospitals need to use a vari-ety of proven tools and methods (such as Six Sigma and Lean strategies), to design and deploy effective interventions and use system-atic approaches to embed those improvements into routine work processes.

QGiven that healthcare is extremely complex, fast paced, and rapidly changing, what suggestions can you

offer for helping organizations adopt the ideas you have discussed?

AOne of the challenges we are all going to have—the Joint Commission as well as other organizations that are placing

demands on healthcare providers—is to be sure that the demands we make are the most appropriate and relevant for healthcare orga-nizations. We need to be sure that if hospitals achieve the goals we set, patient outcomes are really going to improve.

So we need to take a close look at these demands. The time may be right to prune this garden a little and encourage growth that is focused in the most appropriate and relevant directions. We can lighten the load of the demands we’re making on healthcare organiza-tions so that the efforts of quality improvement professionals will have the greatest effect on healthcare outcomes. That is really our goal.

QYou’ve discussed what you think needs to happen to improve quality and safety. What competencies do our

quality improvement leaders need if they are to make these changes at the pace you are proposing?

AHospitals need to develop a very robust capacity for process improvement. I’ve talked about some of the characteristics

of that capacity. It is not a consultant-based central utility that goes out and fixes things for internal customers in the organization—that is not the most effective competency or capacity. Process improvement really works best when it becomes a part of the institution’s daily operation and life, when competency is spread throughout the organization and facili-tated by a small central group of experts.

But the real work is done by people in the important divisions within hospitals and other care delivery sites whose jobs range from house-keeping and transport to laboratory services and radiology—and all of the direct patient care areas (such as nursing and physician ser-vices across all specialties). Process improve-ment doesn’t work very well if an organization has to rely on an internal team, and it certainly doesn’t work if you rely on outside consultants. It is an institution’s responsibility to develop the capacity to approach process improvement systematically and deploy this approach to tar-get the institution’s strategic goals. Quality and safety objectives should be among the goals that have the very highest priority.

QIs there an organization or a model, either in this country or abroad, that should be studied or adapted by our

healthcare organizations?

AThat’s a really good question, and I’m not really prepared to answer it fully yet. Some organizations are further

along in this development task than others. I will single out one that is particularly far along: Intermountain Healthcare, headquar-tered in Salt Lake City, Utah. Under Brent James’s leadership during the last 5–8 years, Intermountain Healthcare has come as close as any organization has to developing a com-prehensive approach to process improvement that puts quality and safety at the top of the list and has become an integral part of the institution’s strategic planning, goal setting, and daily work.

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QWhat do you, as a researcher, believe is the future role of research in quality improvement?

AResearch will play a vital role in the future, and it is a shame that we as a nation have not invested more in devel-

oping quality improvement science. We have done a poor job of identifying and developing this science as a research priority. That said, although the research agenda is somewhat separate and perhaps parallel to the quality improvement agenda, operational, clinical, and other process improvement programs can learn significant lessons from research.

The systematic approach to quality improvement that I described earlier is essen-tially research based—it is driven primarily by really good data. The approach depends on thinking very carefully about what the most important parts of a process are for producing the desired outcome. Careful measurement is essential, as is an understanding of the limits of the measures used to collect the data and to determine how precise and reliable the tools are. Rigorous standards are needed for how much information must be collected to deter-mine whether you have made a significant improvement. We do need some statistical learning and also attention to the design of the interventions to know whether an interven-tion has made a difference or not.

Quality improvement programs can be enhanced by learning from research how to pro-duce valid information about effectiveness. This is why it is important to investigate whether the exemplary stories we hear about places that invest a lot in quality improvement—time, effort, money—are internally valid, that is, whether we have convincing evidence that an intervention worked in that institution. Then we can start addressing the questions of how generalizable those lessons are to other places. Without infor-mation about whether the program produced internally valid evidence of improvement, you cannot move to dissemination—the final step of the quality improvement process.

I am certainly not advocating that every quality improvement project be a research study; however, important lessons can be learned from research regarding the construc-tion of measures and the way interventions are designed and evaluated.

QSome recent Institute of Medicine (IOM) reports describe our healthcare system as broken. Could you discuss

your role in those reports and some of the findings that are related to the Committee on Quality of Health Care in America?

AI cochaired the first IOM activity—the National Roundtable on Healthcare Quality—in its recent history of

involvement in quality of care. The roundtable included representatives from business, aca-demia, private practice, and a variety of other constituencies. The cochair was Bob Galvin of Motorola, who ran Motorola for many years and was one of the developers of Six Sigma in industry. The roundtable produced a broad-ly accepted consensus statement about the nature of our healthcare quality problems. The consensus statement, “The Urgent Need to Improve Health Care Quality,” was published in 1998 in the Journal of the American Medical Association (Chassin & Galvin, 1998). We com-missioned literature reviews to document the substantial quality problems being faced in three dimensions: overuse, underuse, and misuse. Our conclusion was that we really didn’t have any good role models.

During the roundtable discussions, it was David Lawrence, then CEO of Kaiser Permanente, who said that the basic chassis we’ve been driving healthcare on all these years is not sturdy enough to withstand much higher levels of quality and safety. That really set the stage for the series of reports produced by the Committee on Quality of Health Care in America. I was on the committee that pro-duced the first two reports, To Err Is Human (IOM, 2000) and Crossing the Quality Chasm (IOM, 2001). I believe that the committee’s initial activities in 1998–2000 coalesced con-sensus about the problems not only within the healthcare industry but outside as well. During the past 50 years, an enormous amount of our national treasure has been spent on National Institutes of Health–funded research to pro-duce some very important advances that, if applied appropriately, would tremendously improve the health and function of those served by the U.S. healthcare system.

We now know that we don’t use this research when we should, which has resulted in a mas-sive underuse of healthcare—almost 50% of

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Americans who could benefit from an effec-tive intervention don’t get it. In addition, we have overuse—the use of health services when risk exceeds benefit. And finally, we have the safety problem of misuse—when we pick the right thing to do but do it badly, exposing patients to the risk of preventable complications.

The IOM initiatives have been immensely valuable in creating agreement among many stakeholder groups that a large number of quality and safety problems do exist and need to be identified and addressed. The next round of work must focus on specific, concrete, and practical solutions that can be developed, assessed, and proven effective. Rather than relying on long-term research studies, efforts must be more local, improvement driven, and widely disseminated. I don’t think this work can be accomplished through national processes. It will happen one institution at a time, with each one finding solutions, apply-ing principles, and facilitating implementa-tion. I hope we receive better federal funding for this work—on both the research side and the improvement and dissemination side—so that we can maximize the spread of the learning that should accompany a successful intervention. That will be the next generation of improvement.

QDo you have a final message to share with JHQ readers?

AIn the coming years, healthcare qual-ity professionals will be among the most valued resources that hospitals

and other healthcare organizations have. The most effective organizations will invest in the development of these professionals, place them in central roles in the organizations, and equip them with appropriate resources for achieving their most critical strategic goals in safety and quality. As the tide of demand for improved safety and quality continues to rise on all sides—government, private sector, con-sumers—healthcare quality professionals will be lifted by that tide. So my word of advice would be “Get ready for that tsunami.”

ReferencesChassin, M. R., & Galvin, R. W. (1998). The urgent need

to improve health care quality. Institute of Medicine Roundtable on Health Care Quality. Journal of the American Medical Association, 280(11), 1000–1005.

Institute of Medicine, Committee on Quality of Health Care in America. (2000). To err is human: Building a safer health system (L. T. Kohn, J. M. Corrigan, & M. S. Donaldson, Eds.). Washington, DC: National Academies Press.

Institute of Medicine, Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: A new health system for the 21st century (J. M. Corrigan, M. S. Donaldson, L. T. Kohn, S. K. Maguire, & K. C. Pike, Eds.). Washington, DC: National Academies Press.

Shaking up the Joint? When Mark Chassin takes over as president of the Joint Commission next year, sources say, don’t expect business as usual. (2007, August 6). Modern Healthcare, p. 6.

Linda Harrington, PhD RN CNS CPHQ, is associate pro-fessor at Texas Christian University, Fort Worth, TX, and nurse researcher at Presbyterian Hospital of Plano, TX.

Susan V. White, PhD RN CNAA CPHQ FNAHQ, is the associate chief nurse for quality improvement at the James A. Haley Veterans’ Hospital, Tampa, FL.