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Crossing the Quality Chasm: A New Health System for the 21st Century
The availability of systematic reviews and the resulting clinical guidelines for practicing clinicians (O’Connor et al., 1999) is an essential adjunct to practice. A growing body of evidence demonstrates that the use of clinical practice guidelines with other supportive tools, such as reminder systems, can improve patient care (Cabana et al., 1999; East et al., 1999; Morris, 1993; Thomsen et al., 1994; Wells et al., 2000). Despite the best of intentions, clinicians cannot be expected to process unaided all the details, strengths, and limitations of scientific evidence under normal conditions of practice in which the number of variables to be considered is great, but resources, including time, are severely limited (Weed, 1999).
The commitment to standardizing to excellence—using the best available information—does not begin with a slavish adherence to simplistic practice guidelines. With today’s information systems, protocols can incorporate variations based on the individual patient’s condition, such as kidney function and the presence of other chronic problems. An example is adult respiratory distress symptom, an extremely serious condition that in the late 1970s resulted in death for nearly 90 percent of intensive care unit (ICU) patients for whom it was diagnosed. A group of investigators at LDS Hospital in Salt Lake City was able to generate computer-generated guidelines for concurrent management of the many complex physiological parameters involved in treating this illness, which had resulted in several thousand separate instructions (Thomsen et al., 1994). The new system of computer-generated protocols adapted continuously to the patient’s condition. ICU staff were required to take actions in response to the guidelines, accepting or rejecting the instructions on the basis of their judgment. With use, the instructions become more accurate, and the ICU staff came to trust them more. As a result, in 1991 the ICU reported an unprecedented survival rate for the disease of 45 percent (Suchyta et al., 1991). More recently, other investigators have reported using such clinical algorithms to achieve survival rates as high as 75 percent (East et al., 1999; Lewandowski et al., 1997).
A commitment to evidence-based practice may appear to conflict with Rule 3, according to which patient values should drive variability. A simplistic way of stating the tension between the two is: The patient is always right, but sometimes the doctor knows best. When a patient seeks inappropriate health care services, the challenge for clinicians is to find ways of reducing this conflict and, to the extent possible, resolving it, guided always by efforts to understand and respond to patient needs. If a conflict cannot be resolved through counseling, the clinician should refuse to provide nonbeneficial services. If a patient decides not to accept services that are likely be beneficial, the clinician needs to ensure that the patient understands the implications of his or her choice and support the patient in that choice.