Throwing Away Quality - Redefining Health Care

As the efforts at health care reform accelerate, a barrage of perspectives and concerns related to the “quality” of clinical care delivery will be ever escalating. As was brought up by a physician colleague of mine, this raises a really excellent question – what is “quality”.

An effort to raise this question in a meeting, or forum, or virtual bulletin board will result in a vigorous discussion, multiple variables, and at the end, invariably – some member of the discussion group will conclude that “it doesn’t matter because quality in medicine is, and always will be, highly subjective.”

There is much danger in dismissing efforts at defining quality as wholly “subjective”. As we focus more and more on our medical insurance and reimbursement schemes, the ultimate measure against which cost must be evaluated is quality. To dismiss quality as immeasurable – surrenders the importance of clinical delivery to the whims of the masters of the financial suite. As the old adage goes, medicine is much too important to be left to the accountants.

Rather, a more holistic view of quality would be most helpful. Such a holistic view of quality has existed in the business and marketing world for a couple of decades and has proven most useful.

The clinicians’ view of quality has traditionally related to clinical procedures, inputs and outcomes – infection rates, length of stay, minimalizaiton of repeat invasive procedures, etc. While useful to the management of our current health care systems, the fundemental problem with this historic approach is that it has very limited relevance to the consumer (i.e. patient).

While these measures are important to the “tactics” and the processes of delivering medical care, they do not (except in the most extreme cases) cast a shadow of relevance onto the awareness of the patient (or their families).

There are two important changes in perspective that are necessary to move to a more appropriate and relevant view of quality:

- Quality is measured from the patient’s perspective of “the job that needs to get done”.

- Quality has three components

a). Functional
b). Emotional
c). Social




The Job that Needs to Get Done

We have done a horrendous job of defining quality, even to the point of total lack of awareness, from the perspective of what the “job the patient (or patient’s family) needs to have done”. Our training and our conventional wisdom holds that “the job” is to provide clinical interventions, within appropriately understood protocols, to restore health (or at least slow deterioration). It is this world view on which almost all our current quality measures are based – and it is this world view that is preventing us from meeting the challenges of the current environment in an effective and meaningful way.

Appropriate clinical interventions and protocols may, or may not be the “job” that the patient environment “needs to have done” (although they are mostly likely a pretty good baseline). The “job” the patient may need will certainly vary and may include –

- “Be a participant in a meaningful and understood communication”
- “Help in understanding options for care and access to those options”
- “Pain Relief”
- “Access to appropriate specialties”
- “Reasonable response to requests for service”
- “Appropriate and safe therapy”

Or...other things that we will only know if we seek out the understanding of their true importance. The salient point is that to have a meaningful measurement of quality – that level of quality must derive...

a). From the perspective of the patient, and

b). With respect to the job the patient thinks needs to be done.


The elements of Quality

Clinical caregivers have gotten pretty good at the functional aspect of quality definition. These are the processes, variables, and tasks that can be quantified, measured, and analyzed on a fairly precise and consistent basis. However, it is the absence of the other two components of quality that render our discussions about quality clinical care delivery futile. These are the social and emotional dimensions.

It is important to understand that all of the aspects of Quality are inter-related and co-dependent. How the patient (or family) perceives the “job to be done” directly defines the measures of the functional, social and emotional aspects of the quality perception.

For example, if a family member of a patient is a physician, the social aspects of quality will drive a greater expectation of communication and attending physician access than will be found in other environments. One of the multiple and concurrent “jobs to be done” in the physician family member scenario might become ready access and perhaps greater degrees of concurrence with treatment plans (functional aspect expectations).

In another scenario, a patient may have expectations or needs with respect to wireless internet access to maintain her business (functional aspect). The “job to be done” which is defined as minimizing hospital stay and expediting the patient’s return to daily living activities now enjoys a greater importance in the quality equation.

Does this high degree of variability mean we can’t measure Quality?

Of course not! And herein lies the greatest opportunity to change the way we think, and thus the way we approach quality.

Our first thought about this multiple dimension view of quality leads us to believe that there are just too many variables within the human condition to move our quality efforts toward this patient centered approach. But this is only true if one views this challenge from our conventional perspective of centralized systems and centralized data driving our care delivery processes.

One of the tenants of lean manufacturing is that the first step to solving a complicated problem is to --- simplify the problem. Complexity is usually found around elements of a process chain where centralization occurs. This is because in any process centralization occurs where someone, at some time, had felt that either control or the need to fit two non-modular elements of the process together required the process to come to some choke point for review or approval action.

As a practical example for your consideration. My father suffered a significant stroke which left him aphasic and with no remaining gag reflex. Upon admission to the floor he received the standard admission process visits from housekeeping, labs, and nutrition. Each of these specialties had their standardized processes to meet the needs of their individual specialties, and all dutifully (and literally) checked the boxes after their visits – dutifully meeting the needs of the care delivery system.

Now, please imagine the absurdity of a dietetic technician going through her checklist with an aphasic and swallowless man. Food preferences were just not that high a priority at that moment in time for that patient. The ludicrousness of this is driven by the design of processes around system needs instead of the more proper focus on the “job that needs to be done” from the patient’s perspective.

Problems invariably become simpler (lose their complexity) when they are defined from the product, or the patient, or the part as opposed to the perspective of the system into which they are participating.

How much more effective would the admission (which is the introduction of the patient into your quality system) have been if it was set up around the needs and condition of the individual patient instead of the condition of the hospital sub-systems? What if the needs of the patient drove the contacts and the communication rather than the needs of well meaning caregivers to “check the box”?

An admission (and care process) that identifies specific patient information in not just the clinical (i.e. functional), but social and emotional realms would allow a quality process that defines (at least initially) the “job that needs to be done”. This data, which follows the patient, provides a framework for which metrics to utilize in quantifying these multiple quality dimensions. More importantly, it allows for the continual development and utilization of additional metrics and the contribution of the data to a whole new set of knowledge more relevant and meaningful to the care giving experience.

As noted above, this is quickly becoming a need beyond the issues of patient care and comfort. These issues of perception are becoming the balancing point for the most significant financial discussion in health care in 50 years. It is a critical dimension that cannot be surrendered to those whose interests (while legitimate) do not represent the complete, accurate or – taken in isolation – appropriate view of the delivery of health care in our country.

Let’s no longer throw our hands up in the air and deem quality as merely subjective noise. Let’s use this environment to re-think the way we view quality, and in so doing, redefine the way we approach our jobs, our patients, and our lives.