May 2014, VOLUME133 /ISSUE 5

Revisiting the Quality Chasm

  1. Richard J. Brilli, MD, FAAPa,b,
  2. Steve Allen, MD, MBAa,c, and
  3. J. Terrance Davis, MDa,d
  1. aNationwide Children’s Hospital, Columbus, Ohio; and
  2. Departments of bPediatrics,
  3. cAnesthesiology, and
  4. dClinical Surgery, The Ohio State University College of Medicine, Columbus, Ohio
  • strategic plan
  • patient-family centeredness
  • Institute of Medicine quality domains
  • quality improvement
  • patient safety
  • patient harm
  • efficient care
  • equitable care
  • pediatrics
  • Abbreviation:
    Institute of Medicine
  • Strategic plans provide the roadmap by which organizations achieve their vision. To effectively serve as that roadmap, strategic plans must have certain essential characteristics. These include the ability to inspire and motivate while remaining action-oriented and understandable to all personnel. More than a decade ago, in Crossing the Quality Chasm,1 the Institute of Medicine (IOM) suggested organizing transformational efforts in 6 domains: Safety, Effectiveness, Patient-Family Centeredness, Timeliness, Efficiency, and Equity. Recently 2 additional domains have been added: Access and Care Coordination. Since that time, many quality and safety efforts and hospital strategic plans have been built around those domains. Although the IOM structure is succinct, the domains important, and the strategic vision thorough, it did not inspire or motivate our staff sufficiently to be the framework for change in our hospital. Therefore, Nationwide Children’s Hospital developed a strategic plan, organized entirely from the point of view of the patient and family. We believe this quality and safety strategic plan is readily understandable by all, more motivational because of its direct link to the patient, and offers an effective alternative to the IOM domains of transformative strategic thinking (Table 1).

    TABLE 1

    IOM Domains Compared With National Children’s Hospital Quality and Safety Strategic Plan Domains

    The plan has 5 pillars/domains: (1) Do not harm me, (2) Cure me, (3) Treat me with respect, (4) Navigate my care, and (5) Keep us well. This language is understandable at all levels in the organization—from front line staff to the board of directors. Although the IOM terminology articulates the intellectual content of the domains (“the head”), our terminology evokes those same concepts from the more compelling point of view of the patient (“the heart”). Our experience with this strategic planning approach has been positive and well received by our hospital staff.

    Do Not Harm Me

    The central pillar of the plan is patient safety and was launched in 2008 with a publically declared goal to eliminate preventable harm.2 All employees received training in high-reliability principles, and multiple reinforcing techniques ensured that the culture change became just the way business gets done. In addition, a significant increase in the quality improvement infrastructure allowed the simultaneous launching of scores of quality improvement projects led by multidisciplinary teams targeting the problems causing patient harm. The primary outcome metric for “Do not harm me” is the Preventable Harm Index, which is the sum of harm events occurring each month.2 Clinically relevant and statistically significant decreases in all metrics of patient safety have been obtained and sustained. Examples include an 83% reduction in the Serious Safety Event rate (P < .001) and a 53% reduction in preventable harm events compared with peak (P < .01).3

    Cure Me

    This domain focuses on clinical outcomes. All 30 clinical service lines in the hospital will pursue a transformative clinically important goal/outcome for a specific disease within their purview. Specific examples include a reduction in total hospital days during the first year after hybrid repair of hypoplastic left heart syndrome, reduction in bronchopulmonary dysplasia rates in neonates, and increasing remission rates for patients with inflammatory bowel disease.4 A key emphasis in this domain has been identifying and reliably implementing best care practices (eg, care bundles) and measuring practice compliance, not necessarily focusing on discovering the next new drug or gene therapy.

    Treat Me With Respect

    This domain involves transforming the entire patient and family inpatient/outpatient experience by partnering with them in all aspects of their journey toward wellness. Families are included and provide advice at nearly every hospital level, including having a family member with full voting privileges on the Quality Committee of the Hospital Board of Directors. Outcome metrics for “Treat me with respect” include increasing the percentage of total respondents to a postdischarge survey who give the hospital the top rating (“5”), and reducing the number of filed patient and family grievances. This domain also aligns fully with the Nationwide Children’s Hospital mission to treat all patients equally without regard to ability to pay.

    Navigate My Care

    Addressing the ability of patients to move easily and seamlessly through the health care system is the focus of this domain. Examples of issues in this pillar include wait times for new clinic appointments, improved care coordination for complex patients, and time spent in the emergency department. Our initial focus has been on complex care patients such as those with cerebral palsy, and the primary outcome metric is reducing total annual inpatient hospital days for this cohort of patients.

    Keep Us Well

    For this pillar, population health is the focus, and the goal is to keep children from becoming patients while helping them achieve their full potential. Inpatient and outpatient disease management of conditions such as diabetes and asthma are high priorities, as are projects related to improving immunization rates, enhancing dental care, and obesity prevention. Our hospital is partnering with local adult providers to prevent premature births, thus reducing the need to treat the complications of prematurity. This pillar also focuses on the wellness needs of an entire geographic region immediately contiguous to our hospital by addressing not only acute illnesses but also the social determinants of health, such as poverty, unemployment, and education.


    Transformational change requires more than solid, evidence-based information regarding how best to care for patients. Many evidence-based practices for both acute and chronic conditions have been slowly or incompletely adopted, even after many years.5,6 Clinical practice changes or new concepts must be sold to the people who carry out that care. We believe the strategic plan organizational framework we have outlined has facilitated the adoption of change better than if we had used the more abstract IOM domains and terminology because it addresses both the head and heart of our staff. The plan encompasses and links to the IOM concepts (Table 1) but in language and context that staff can relate to and embrace.

    Migration from our previous strategic plan, in which quality and safety were centered on the IOM domains, was remarkably easy, and no obstacles were encountered because the new strategic plan aligned entirely with our mission, vision, and values—only from the point of view of the family. The plan was developed with input from multiple working groups including families, front-line managers, and community representatives and was ultimately reviewed and approved by the Strategic Planning Committee of the Board of Directors.

    Implementation of high-reliability principles and a significantly enhanced quality improvement infrastructure has served as the platform from which all the domains or pillars of the strategic plan were launched. As new initiatives begin, we emphasize that this is not a new flavor or project of the month but rather something that contributes to fulfilling our patient-centered strategic plan. Furthermore, this plan helps prevent scope creep by denying projects that do not advance ≥1 of the pillars.


    As hospitals strive to “cross the quality chasm,” we believe a quality and safety strategic plan organized entirely from the patient’s perspective can provide a compelling roadmap that inspires and motivates staff through its understandable simplicity and focus on what drives clinicians: the mission to improve the health and well-being of patients and their families. This approach is applicable in adult and pediatric health care organizations alike, and we recommend this organizational framework to others.


      • Accepted October 23, 2013.
    • Address correspondence to Richard J. Brilli, MD, 7th Floor Administration, Nationwide Children’s Hospital, 700 Children’s Dr, Columbus, OH 43205. E-mail: rbrilli{at}
    • Dr Brilli conceptualized the framework and served as leader of the quality and safety strategic program implementation, codrafted the initial manuscript, and revised subsequent drafts; Dr Allen helped conceptualize the framework and reviewed and revised the manuscript; Dr Davis conceptualized the framework and actively helped implement multiple aspects of the quality and safety program in his role as Co-Medical Director for Patient Safety at Nationwide Children’s Hopsital, codrafted with Dr Brilli version 1 of the manuscript, and revised subsequent drafts; all authors approved the final manuscript as submitted.

    • FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

    • FUNDING: No external funding.

    • POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.


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