With each issue, Trib+Health brings you an interview with experts on issues related to health care. Here is this week's subject:
Gary Reed is the associate dean for quality, safety and outcomes education at the University of Texas Southwestern Medical Center, as well as headmaster of the Academic Colleges. Reed joined the faculty of UT Southwestern in 1980 and recently served as the chief quality officer for UT Southwestern hospitals and clinics. Reed has an active practice in primary care and hospital medicine and has professional interests in quality improvement education for health professionals, quality improvement methodology and health care delivery redesign.
Editor's note: This interview has been edited for length and clarity.
Trib+Health: When you talk about focusing on quality and safety, what does that actually mean, and how is that a shift from past practice at medical centers across the country?
Gary Reed: In general, I think the focus on quality and safety really started seriously about 10 or 15 years ago in the U.S. when the Institute of Medicine brought it up and started the conversation. In general, what quality means is that people get their care that they need at the right time, and patient safety is a piece of quality and generally refers to the fact that patients should expect that they're not harmed in any way by the care that they receive — that if a patient has a bad outcome it's because of the disease they have and not due to the care that they got. So quality and patient safety are very similar, but I always look at patient safety as being a part of quality.
Trib+Health: Why do you think it took so long for medical centers and medicine to take all these quality and safety measures into account?
Reed: I think the attitude of medicine for centuries has been, "We're trying to help people. We don't try to hurt people." So the assumption, I think, was made that if the things we do are dangerous — it's not normal to do surgery on people or to give drugs to people — that's not something our bodies were built for. When things happened that weren't expected, they tended to be looked at as complications rather than as preventable events. So I think what's happened over the past couple of decades is that people have begun to realize that a lot of these complications can be prevented. They're not always 100 percent preventable, but at least we can have fewer complications than we have seen in the past.
I think that's what happened. I don't think it's because it was ignored because medicine has always had the idea that it wants to get better and better, and every year we have always tried to develop better treatments for the things that we deal with. But I think looking at the safety part of it as its own isolated thing is what's new. I don't think medicine ever ignored quality. Some places like the Mayo Clinic have had quality departments for 50 years. So it was always there; it just never had the big focus that it has now.
And I think the other thing that drives this also has to do with cost, since cost is really considered part of quality. What's happened over the past couple of decades is the realization that medical care has become too expensive in the U.S. is really part of what's driven this. Part of what drives the cost are complications that we have.
Trib+Health: So what are the impacts that these quality and safety measures have on curbing those costs? How effective of a tool is it in making health care less expensive for consumers?
Reed: I think we have to look at the cost of it in two ways. One, anytime there's a complication, especially serious complications, the costs can be enormous. A lot of infections that people develop in the hospital, for example, can cost tens of thousands of dollars of extra cost just for treating an isolated incidence of disease. So the money cost of it is one thing. And then there's the cost of lost work and disability and occasionally the cost of a life because of a complication. All of those things are pieces of the puzzle that we're always trying to figure out to try to decrease these costs.
Trib+Health: You've led a clinical safety and effectiveness program and have trained staff and faculty about all this. What kind of challenges have you and others in your position faced in trying to shift the focus to quality and safety education?
Reed: The challenges that we've had around the education, I think, has been to try to get people to look at quality and safety in a new way. Traditionally, medicine has used what I would consider the traditional biomedical approach to quality and safety, but over the last couple of decades, we're beginning to use engineering approaches to quality and safety that have been used in other industries, which I personally think have brought us forward a lot faster. In the past, for example, we would wait to improve the treatment of an infection until somebody discovered a new antibiotic. Now we try to look at the entire care that the patient gets, not just giving them the antibiotic but realize there's a lot of things we do around fluid management and other things that can actually decrease the chances of them having a complication and not wait for these big discoveries to change things. It's the little things that actually measure the way we take care of patients. It's how often you wash your hands during the day; it's not just how powerful the antibiotics you give people.
Trib+Health: And with the complex health systems that have evolved in hospitals, how much of this is improving communication between sections and departments? Does that play into this conversation at all?
Reed: I think that plays a huge role, especially communications among the teams that are taking care of people. One level of communication is just having the one doctor communicating with the specialists that are taking care of a patient or communicating with a laboratory. But also the communication among the three or four people that are actually caring for a patient at any given minute, to me, is probably more important. So communication in general is a huge thing in quality and safety.
Trib+Health: How do you measure these outcomes and tell whether this stuff is working? Where do you look at to see improvements?
Reed: Traditionally, what we've done is we've just looked at the incidence of the complications. We look at the outcomes as the most important. And so we look at mortality, we look at infection rates, we look at other complication rates like how much blood people have whenever they need certain surgeries. Those have been the traditional things people look at. More recently, we've begun to concentrate more on what are more process measures because I think that's the engineering principles that have been brought into the equation. That means we measure all kinds of process things about the way we deliver care, realizing that if we do the process perfectly, then the outcome is going to be better.
Trib+Health: As dean, you'll be working on the revamp of the medical school curriculum. What kind of changes should people expect to see in terms of quality and safety?
Reed: There will be more specific training around the methodology of quality improvement for both the medical students and the residents doing postgraduate training. That is one thing that's happening all across the country. But specifically in our new curriculum, there will be specific courses they take on how to do quality improvement and how to improve patient safety.
Trib+Health: Are there other things I should include?
Reed: One thing I was about to emphasize to you about our quality program, which I think is a little different in academic medical centers than it may be at the community hospital level. We look at quality as really part of our mission of the medical school of needing to not only improve quality or improve clinical care of the patients we take care of, but also training people on how to do quality improvement and also doing research on patient safety and quality improvement. So at Southwestern what we've done is be sure we hit all of those areas of our mission.
One other thing that I think is important in the quality world now is the idea of transparency of quality data. The federal government at first brought this up several years ago. They have websites now where they publish quality data of all hospitals and health systems. And at Southwestern, we believe that transparency of quality data is very important to the point that we developed our own website a couple of years ago. And I think we were the first, if not one of the first, in the state of Texas where we not only publish on our website our quality data that the federal government publishes, but also we put internal quality data that nobody knows except our quality people. Because we really feel that patients, in order to make good decisions about health care, need to know the quality of the place that they're coming to.
So we put those things on our website so that when we do really well – and we're happy that we do really well in most things — but even if something is not good, we put that on our website.
Trib+Health: Do you see patients using this stuff a lot, or do you point them to this information?
Reed: We monitor how many people look at that website every month. We have about 1,000 people a month look at it. The way we use it generally is that someone looks at Southwestern to consider if they should get their care here. At that point, we use that just as another bit of information. So if you want to come here to get your heart surgery here, obviously you want to know who your heart surgeon is and how good the heart team is that's going to do your heart surgery. But, oh by the way, if you want to look at our quality also then you can go to our website and see what our quality of care in general is in addition to just the heart surgery.