Jean Slepian has been a community hospital librarian in the Northeastern United States for 37 years, with special interests in health policy and advocacy
I have been a medical librarian for nearly 40 years, and in that time we have seen a 180 degree turn-about in regard to healthcare “quality”. In the old days we never questioned the quality of medical care. In fact, such blasphemy might get a person fired. In the late 1990s we were shocked out of our oblivion by a scorching report on medical errors from the National Academies Institute of Medicine, To Err is Human.[1] Thus began the long and arduous journey toward healthcare quality. Today we measure quality with objective indicators, such as the number of readmissions after acute care hospitalization and whether patients receive appropriate discharge instructions. Have we made progress?
On the road to quality nirvana we have encountered several gurus…the first was W. Edwards Deming, the “father” of total quality management. Largely credited with the revitalization of industry in post-WW II Japan, Deming had a 14 point plan to achieve quality. Point 10 is to “Eliminate slogans and exhortations.” One of our more recent quality gurus, Quinton Studer, has lots of catchy slogans and mnemonics to inspire quality, and I tend to favor Deming’s approach. He also said, “It is wrong to suppose that if you can’t measure it, you can’t manage it – a costly myth.”[2]
In the past year several controversial studies have been published that seem to suggest that we may not be measuring what we think we’re measuring with objective quality indicators. In the Journal of the American Medical Association (JAMA) last February a study was published that found no difference in inpatient complications and mortality between hospitals that participate in the National Surgical Quality Improvement Project, and hospitals that don’t participate.[3] Another study published in the same issue[4] found no difference in outcomes or expenditures for Medicare beneficiaries between hospitals that participate in NSQIP and those that don’t.
A study by Howell[5] published in JAMA in October 2014 found no correlation between two obstetric quality indicators and maternal/neonatal morbidity. In the same issue, a study by Neuman[6] of Medicare beneficiaries released to skilled nursing facilities after acute care hospitalization found no consistent association between skilled nursing facility quality indicators, and readmission or death.
In the “softer” medical literature I detect a growing dissatisfaction with the objectification of quality, and the depersonalization of patient contact with use of the electronic medical record.
Chi and Verghese [7] refer to the”iPatient” and state, ” …the abundance of dropdown menus on the EHR and the compulsion to leave no box unchecked often creates a neat construct of a patient that can be a meta-fiction. This construct is often at odds with the real patient…not always accurate in the sense of the patient’s story or the manifestations of illness on the patient’s body.” Wu[8] sadly characterizes himself as a “kind of virtual doctor”, prizing “efficiency over human contact, computerized data over stories, virtual reality over authentic life.” Patel[9] painfully relates an experience in the ER when he overlooked a patient in frank respiratory failure because of his pre-occupation with her electronic history.
Dr. Charlotte Yeh relates her experience[10] after being hit by a car when emergency department providers put quality metrics before her actual needs. Dr. Patricia Gabow, a former healthcare executive and chief medical officer[11], found that when her mother was injured in a fall, the standardized care she had always advocated was not appropriate.
In the medical library business these days, “quality” seems to equate to the number of online resources we make available to our patrons, but do we really know if patient outcomes are better when providers have instantaneous access to the medical literature, or is that just a logical yet possibly erroneous assumption?
Indeed, sometimes it seems that in our quest for the perfect data driven measure, we have devolved to the point where “quality” and “compassion” are mutually exclusive concepts.
However, I believe that we can manage quality without objectifying it into tiny measurable bites. I believe that there is someone out there who is smart enough to do it – please let us hear from you!
References
- Committee on Quality of Healthcare in America: To Err is Human; Building a Safer Health System. Washington, D.C.: National Academies Press, 2000.
- Deming, WE. The New Economics; Cambridge, Ma: MIT Press, 2nd ed, 2000.
- Etzioni DA, et al. Association of hospital participation in a surgical outcomes monitoring program with inpatient complications and mortality. JAMA 2015 Feb 3; 313(5): 505-511 .
- Osborne NH, et al. Association of hospital participation in a quality reporting program with surgical outcomes and expenditures for Medicare beneficiaries. JAMA 2015 Feb 3;313(5):496-504.
- Howell EA , et a. Association between hospital–level obstetric quality indicators and maternal and neonatal morbidity. JAMA 2014 Oct 15;312(15):1531-41.
- Neuman MD, et al. Association between Skilled Nursing Facility quality indicators and hospital re-admissions. JAMA 2014 Oct 15;312(15):1542-51.
- Chi J, Verghese A. Clinical education and the electronic health record: The Flipped patient. JAMA 2014 Dec 10; 312(22):2331-2.
- Wu D. Virtual grief. JAMA 2012 Nov 28;308(20):2095-6.
- Patel JJ. Writing the wrong. JAMA 2015 Aug 18;314(7):671-2.
- Yeh C. ‘Nothing is Broken’: For an injured doctor, quality–focused care misses the mark. Health Aff (Milwood) 2014 Jun :33(6);1094–7.
- Gabow P. The Fall: Aligning the best care with standards of care at the end of life. Health Aff (Milwood) 2015 Jun 34(5):871-4.