The Quality Illusion
I practiced surgery for many years in a very large hospital. In the 1980’s, the marketing department launched a campaign with the tagline, “A Leader in World Medicine”. About the same time, two of my colleagues created The Hernia Institute, sensing gold in them thar groins. They placed ads in the sports pages of our local newspaper, right next to those of the topless clubs.
These initiatives had two things in common:
- · They attempted to appeal to patients and referring physicians through an implicit message of high quality care;
- · Their messages, though perhaps rationally defensible, were entirely without supporting data.
The absence of data was symmetrical; the competition had none with which to refute or counter the messages. That’s because no one had any quality data at all. Healthcare had made no substantive attempt at measuring quality, except in research trials and the like. Clinical practice was virtually unexamined, so anyone could make any claim without fear of rebuttal.
It is to our discredit as physicians that we muddled along, practicing what we knew to be “best”, attending the occasional meeting, perhaps reading some professional literature, but never looking in a rigorous way at what we were achieving and what we were missing. We deflected calls for us to do so by asserting that medicine was too complex to be measured.
A fundamental mantra of business students is, “If you cannot measure it, you cannot manage it.” As healthcare costs spiraled and apparent benefits did not keep pace, there was increasing pressure—and rightly so—to manage the resources being consumed, in a way that ensured quality improvement.
That meant quality had to be measured, but we as a profession—again—sat with our hands folded and essentially engaged in a staring contest.
Had one asked doctors and nurses at the time if they felt other peoples’ patients were receiving high quality care, the candid answers would have been unenthusiastic. Outside of the episodic mortality and morbidity conferences and peer review meetings, these issues were not seriously addressed, however. Each hospital staff could have agreed to ask “how are we doing” in one or another clinical circumstance and gathered data that would have been locally informative and useful. For the most part, that didn’t happen.
Nature abhors a vacuum, and into this particular vacuum swept Medicare and The Joint Commission. Having neglected the opportunity to voice and explore locally meaningful questions, we were lassoed into a program of national norms and standards and, ultimately, the public reporting of our performance and financial awards and penalties for it.
It is not that these national “core measures” are without validity and value. It is that in order to achieve consensus and the widest applicability, they must be rather rudimentary and their pertinence will vary from institution to institution. They had one distinguishing attribute, and it was not their clinical importance. They were easily measured.
An anonymous wag’s lampoon of the business mantra is, “If you cannot measure it, measure it anyway.” Faced with the difficulty of defining and measuring “quality”, Medicare and TJC proposed the core measures as surrogates. Given the broad professional recalcitrance in the matter, there was little option if the ball were going to be advanced.
And advancing the ball in terms of quality was the motivating idea, a worthy one. The thinking was that in the course of improving core measure performance, hospitals would learn to apply those lessons to other issues within their walls. I believed that. I really did.
Dr. Robert Wachter is a distinguished clinician and widely read author in the area of healthcare quality. Years ago he warned that by focusing on what might be easily measured, we risked neglecting the more crucial issues. Witness the core measure myopia and credit Dr. Wachter’s prescience.
David Jarrard is CEO of a highly regarded healthcare consulting firm. He has issued a call to the industry to renounce passivity and act to define its own standards, one hospital and medical staff at a time. You can read his comments at http://jarrardinc.com/2013/11/quality-time-change-playing-field/.
The rub is that action requires money and time, and it is the rare executive who can see above the dust cloud of the quarterly balance sheet. Most of the impetus for hospital administrators is to jump the core measure hoops while minimizing overall costs. The enlightened management of the Geisinger and Intermountain systems are regrettably exceptional.
Physicians, nurses, and other professionals should rally around their managers and give them the support and encouragement necessary to identify and correct concerns in their particular environments.