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Taking the IOM quality challenge

October 1, 2007
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Providers can do a lot to meet the Institute of Medicine's call for improving the quality of healthcare

In 1996, the Institute of Medicine (IOM) began to focus on assessing and improving the quality of the nation's healthcare in several domains. Now in its third phase, the IOM's Quality Chasm series includes a report on improving the quality of healthcare for mental and substance use conditions. Over the years, the influence of the Quality Chasm series has increased among physical and behavioral health policy makers and providers. This article outlines how to build a foundation to implement the IOM's quality recommendations in day-to-day operations, based on the experience of Community Counseling Centers of Chicago (C4). C4 offers a full range of outpatient behavioral health services for adults, children, and families struggling with mental illness, substance use, emotional trauma, and the aftermath of violence at eight locations in Chicago.

The IOM's Perspective

In its 2001 Quality Chasm report, the IOM defines quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” In addition, quality is evaluated based on structure, process, and outcomes:

  • Structure is the opportunity to receive healthcare where available. It is comprised of the organization's physical and staff characteristics.

  • Process is what is done to or with healthcare consumers. It is comprised of both clinical and interpersonal care within the organization.

  • Outcomes are the near-term results of healthcare. They are comprised of the consumer's health status and perceptions.

The IOM's six aims for healthcare include services that are:

  • Safe (emotionally and physically)

  • Effective (evidence based)

  • Person centered (preferences, strengths, and culture)

  • Timely (goal directed)

  • Efficient (optimized access)

  • Equitable (both access and quality)

In addition, the IOM outlines ten “rules” (guidelines for redesigning the system of care) for ensuring increased quality of services:

  • Care based on continuous healing relationships

  • Customization based on patient needs and values

  • The patient as the source of control

  • Shared knowledge and the free flow of information

  • Evidence-based decision making

  • Safety as a system property

  • The need for transparency

  • Anticipation of consumer needs

  • Continuous decrease in waste

  • Cooperation among clinicians

The IOM aims and rules are demanding for most provider organizations. They require the organization to identify areas for improvement (the quality aims) and implement interventions to improve performance (the quality rules). This is a different focus for most state-funded organizations, given the economic and political forces reinforcing processes that maximize the number of people served, possibly at the expense of investments in service quality itself. An organization needs to shift its focus to include and emphasize service quality rather than the number served.

Implementing the IOM Guidelines

Addressing the mission and vision statements. This shift can start with the organization's mission and vision statements. Organizational mission refers to the overall function of an organization, or what gets accomplished. Vision refers to the desired future state for the organization in regard to strategic goals or plans. Both the mission and vision are constraints on what plans are implemented, and they also impact the interpretation or meaning of these plans. By emphasizing quality in either or both statements, all related quality activities become anchored as part of the organization.

Creating a quality management plan. Following changes to the mission and vision statements, an organization needs a quality management plan. The QMP is a policy that provides a platform for the IOM aims and rules to be implemented on a day-to-day basis. The QMP should be specifically designed to assess, evaluate, ensure, and improve services' safety and quality. Within larger organizations such as C4, the QMP uses a measurement system to encourage the development of active, participating consumers, who provide feedback to providers to encourage improvement.

Building an organizational framework for quality. In addition to the essential base of mission, vision, and QMP, a framework for organizational structure and processes that encompasses all organizational functions is useful. This framework can be obtained from a balanced scorecard approach to management. A balanced scorecard enables organizations to clarify their vision and strategy, as well as translate them into job requirements. It is a strategic management approach that views performance improvement as based on a number of domains besides financial. In practice, organizational structure and process can be represented by the organization's functional domains. For example, C4 uses the following domains:

  • Innovation and growth (recognition in community, diverse and culturally competent, recovery and resiliency)

  • Consumer perspective (input into decision making, promote engagement)

  • Operations (data-based decision making, cost-effectiveness)

  • Financial perspective (financial performance, clinical/financial linkage)