Raising the Bar: Achieving Dramatically Better Results

In 2002, 13 health care organizations, seven US and six European organizations, set out to "pursue perfection," with funding for the seven US organizations from The Robert Wood Johnson Foundation. As part of the Pursuing Perfection initiative, their aim is to raise the bar — dramatically improve results for patients beyond the best known in health care today. This ambitious goal, when achieved, will show just how much better health care can be for patients, for providers, and for the community. The lessons are valuable for all health care organizations. Identifying the best known performance — the bar — and then improving care to exceed this, is the challenge.
Raising the Bar has five steps:
    1. Establish the will to go beyond “we are doing OK” performance
    2. Set aims that raise the bar, reaching beyond what has been achieved in health care thus far
    3. Measure performance at this higher level
    4. Develop and test the type of changes that can bring an organization to a new level of performance
    5. Learn from the changes in ways that benefit the entire organization
The Pursuing Perfection organizations have maintained a high level of will to accomplish the overall mission of the program — raising the bar of health care performance. However, when the focus became a particular health care service or process, we had difficulty knowing what performance would raise the bar. Like most organizations engaged in quality improvement they could determine the level of performance that would raise the bar in their organization. But in Pursuing Perfection the performance target was the best anywhere in the world, or at least the best in the organization’s country. This made setting aims and recognizing when new levels of performance had been achieved very difficult.
Aims for Raising the Bar
Through review of the literature, study of performance on system issues such as delays and safety in and outside of health care, and inquiries to health care experts around the world the Pursuing Perfection project has developed a template consisting of nine generic aims and the Institute of Medicine (IOM) dimensions to which they relate [in brackets]:
    1. 10-1 to 10-2 reliability for tens of thousands [Effective, Safe]
    2. 10-2 to 10-3 reliability for hundreds [Effective, Safe]
    3. Hospital Standardized Mortality Rate (HSMR) of less than 75 or a reduction of 20 points [Effective, Safe]
    4. Same-day access for primary care and 7 calendar day access to specialist for greater than 20 practices [Timely]
    5. Turns per bed per year (adjusted for case mix) of greater than 90 while maintaining or improving quality of care and work life [Efficient, Timely]
    6. (Value added time) ÷ (Total time cycle) of greater than 10 percent [Efficient, Timely]
    7. Cost reductions of 1 to 3 percent of expenses or $1 million (whichever is greater) while maintaining or improving quality of care and work life (certified by the finance department) [Efficient]
    8. Patterns of variation, 80 percent of which are explained by preferences of patients [Patient-Centered, Equitable]
    9. Scale-up and spread of improvements to an entire community [All six dimensions: Safe, Effective, Patient-Centered, Timely, Efficient, Equitable]

These templates can be used as a guide for developing raise-the-bar aims for specific improvement initiatives. By using these templates, we as a learning community can recognize where the performance bar is and how to raise it.
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