Over the past two decades, health care quality improvement has moved from a fringe activity within hospital management to a key national priority. No organization has been more responsible for that transition than the Institute for Healthcare Improvement (IHI). Known for its highly attended national quality forums, the 100,000 Lives Campaign, and countless other initiatives to drive clinical quality improvement, IHI is at the nexus of work to improve care and reduce costs.

I spoke recently with Maureen Bisognano, IHI's President and Chief Executive Officer. A nurse by training, Ms. Bisognano is an elected member of the Institute of Medicine and the Commonwealth Fund's Commission on a High Performance Health System. Ms. Bisognano advises health care leaders around the world, is a frequent speaker at major health care conferences on quality improvement, and is a tireless advocate for change. She serves on the boards of the Commonwealth Fund, ThedaCare Center for Healthcare Value, and Mayo Clinic Health System in Eau Claire. Prior to joining IHI, she served as CEO of the Massachusetts Respiratory Hospital and Senior Vice President of The Juran Institute.

For decades now, IHI has helped to set the national health care quality agenda. What kinds of changes have you seen in our approach to health care improvement?
We've moved from focusing on individual interactions and episodes of care to improving care across the entire continuum and controlling costs. We've moved from excellence on process and outcome measures (which are, of course, still very important) to creating an excellent and comprehensive experience of care for patients.

What do you presently see as the key pieces of the national health care agenda?
The Affordable Care Act (ACA) has opened up a trove of new ways for citizens to access health care. The changes in access create new challenges — primarily, optimizing the health care delivery system to accommodate new patients and ensure their health. One of the central questions for us is how do we invite more patients into the system and continue the pace of improving quality and controlling costs? We need to focus on improving care and health for the 5 percent of the population who account for 50 percent of health care costs, and simultaneously plan for the care for the 50 percent of the population who currently only account for 3 percent of health care costs. All of this requires new models and a culture of innovation. The ACA fosters this culture and spirit of innovation through its specific provisions, and also through the invaluable Center for Medicare and Medicaid Innovation.

What do you see as the major quality issues in the cardiovascular (CV) health domain? What kind of initiatives is the IHI pursuing to improve CV health outcomes?
Our work in CV health has shifted somewhat — from a focus on process measures, like door-to-balloon time, to an expanded view of quality across the entire continuum. When you think about the true determinants of health (especially heart health), health care is but one, small driver. Behavior and social contexts are more directly related to health, and this again requires a change for physicians. Not only must they think about the patient as a whole person whose care extends well beyond the walls of a hospital or doctor's office, but they also have to find new ways to interact with patients since the "touch time" of a traditional visit just isn't enough. Physicians need to think about crucial issues like medication adherence; as many as 50 percent of patients don't follow their medication prescriptions. Thinking about care in this way helps physicians reduce what my friend Victor Montori, a physician leader at the Mayo Clinic, calls the "burden of treatment."

How has the passage of health care reform affected the national quality movement? Has it accelerated efforts or detracted from them?
I think health care reform has dramatically accelerated improvement efforts and, as I said earlier, created a newly invigorated culture of innovation. The changes in access and the extension of coverage to millions force us all to look for new models and new strategies, and I think that's fantastic and much needed.

What practical advice would you give to cardiologists interested in pursuing quality improvement in their practices?
Think about more than just process improvements and look for ways to increase and deepen interactions with patients. Improving CV health takes vigilance, both by the patients and by the physicians. I would recommend looking for new ways to leverage resources and interact with patients, such as nutrition clinics, nurse-led group counseling, a focus on patient education, and new ways to see patients, like e-visits and phone consults. Of course, this requires a substantial redesign of the way office-based practices are organized and run, but the need for redesign is a theme that shows up in every area of care improvement.

What are the key resources that IHI can offer the cardiology community?
IHI's website (www.ihi.org) has a wealth of free resources for cardiologists interested in improvement. We have a series of more than 25 white papers, several clear and concise "how-to" guides, and a broad compendium of improvement literature. IHI's leaders, faculty and staff also have a unique expertise on redesign and, as I've repeatedly emphasized, redesign is crucially important.

We also have a unique resource in the IHI Open School. The Open School's online courses in quality improvement, patient safety, leadership, and health care operations are as good a source of improvement knowledge as exists anywhere. Students, residents, and career professionals are all finding it an engaging and effective way to learn improvement methods and theory.

And there are, of course, our traditional offerings, notably our annual National Forum and Office Practice Summit. These meetings, along with our seminars and professional development programs, continue to bring people together and create a global community of improvers. Cardiologists have always been generous sources of expertise and learning as well as curious and devoted students of improvement. I would encourage anyone interested in improvement to contact us or explore our website.

Disclaimer: Dr. Jain now serves as chief medical information officer at Merck. This column was written and submitted prior to his accepting this position. The fact that this column is published in CardioSource WorldNews is not meant to imply endorsement or approval of Merck products or initiatives by the ACC, the ACCF, or the editors of CardioSource WorldNews.

Sachin H. Jain, MD, MBA, is chief medical information and innovation officer at Merck and Co. He previously served as an advisor in the Obama Administration, where he helped launch the Centers for Medicare and Medicaid Innovation and the HITECH Act's Meaningful Use provisions.

Keywords: Medication Adherence, Quality Improvement, Health Care Reform, Delivery of Health Care, Medicaid, Health Care Costs, Patient Safety, Medicare

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