Quality Improvement in Medical Practice - Need for Balance

The quality improvement movement in medicine has been important and fruitful. Nonetheless, many of us have had reservations. The complaints have ranged from the indisputable fact that P4P results reported to our practices are often inaccurate, to concerns that meeting standards and reporting to authorities is often just busy work, to worries that standards often lead to teaching to the test, to the criticism that practices that treat the lower socioeconomic strata (or, practices that treat non-vaccinators) are penalized by the shortcomings of their patient bases. These are all valid. My own concern has been that with a strict emphasis on the measurable, important aspects of quality that are difficult to measure have been neglected. Let me explain.

Two Methods and Two Types of Objectives

There are two methods we can use to effect both clinical and clerical change in our offices. One could be called Systemic Re-engineering (SR); the other would be Professional Enhancement (PE).

SR builds techniques into the office environment with such devices as checklists, explicit protocols, flow sheets, questionnaires, and computerization. SR solutions are “outside the head” and relieve the clinician or staff of the burden of remembering.

PE, on the other hand, happens inside the head, as in, “Remember to….” PE is very familiar to us from our training. We are educated in basic facts, basic procedures, precepts, attitudes, etc.

Just as there are two ways to effect change, there are two types of objectives. Type one is a Quantifiable Objective (QO); the other would be Non-quantifiable Objective (NO).

A QO is generally related to a stereotypical event, such as vaccinating, or diagnosing and treating streptococcal pharyngitis. QO’s are familiar to us as P4P measurements.

An NO may be a non-stereotypical event. Pursuing a difficult diagnosis would be such an event. There is no current way to measure how a clinician pursues signs and symptoms with his or her own acumen, strategic tests, and referrals.

Other NO’s would be based on the human behavior of the clinician. Caring for patients with empathy and compassion would be such a behavior. Another would be attentiveness to a patient’s communication, and patience in eliciting information. A patient satisfaction survey is far too blunt an instrument to capture these qualities accurately, and we have no other applicable means of measurement.

Matching Methods and Objectives

The two methods and the two objectives tend to pair up, SR with QO, and PE with NO. An example of the SR-QO pair would be the stereotypic case of prescribing controllers for asthma and not relying on rescue medications excessively. The PE approach would be to bank on the attentiveness and memory of the clinician when the refill requests come in (“Remember!”). The preferred SR approach might be to institute an office procedure that forbids albuterol refills, and instead compels the staff to schedule a visit when an albuterol refill request is made, and has a flow sheet in the chart that details all prescriptions. The results of this QI effort would be clearly measurable, as we know.

A clerical example of office functioning would be keeping track of vaccine stock. One could admonish clinicians and staff to remember to bill for every vaccine given (PE – remember!), or one could institute a procedure of daily balancing of stock vs. billing sheets (SR). Clearly, for these stereotypical events, SR would be a more reliable and efficient approach resulting in higher quality and less variation.

I have two favorite examples of the PE-NO pair. The first is the issue of pursuing a difficult diagnosis. Perhaps clinical prompts in an EMR would be helpful, but in general it is difficult to think of an SR approach that would arrange a system to help and encourage a clinician to be smart and persistent in pursuing a diagnosis. Yet it is difficult to think of a more important aspect of quality care than this.

A second favorite example is improving the “caring” function. Imagine a possible SR solution: the placing of a sign on the wall reading “We Care!” Clearly, teaching and encouraging how to care for a patient, how to reduce emotional distance is something that still belongs in the realm of PE.

In both of these issues, the PE approach would seem more apt. I can’t think of any fancy and modernistic approaches, but practice conferences with case presentations and feedback (hopefully positive), and in the case of conferences on caring, the presence of professionals from outside the practice with relevant expertise (social work, psychiatry, clergy), could be of great help.

The key is for the practice as a whole to care about these issues, and to make them part of the practice culture. The fact that the effect is not quantifiable should not deter the practice from emphasizing these very important practice characteristics.

Keeping the Balance

As QI has risen in importance in recent years, QO has been emphasized and NO neglected. Perhaps this has occurred because of our scientific prejudice to pay attention only to the measurable and to distrust the impressionistic. Maybe it has happened because of a perceived need to “prove” quality to insurance companies and payers. Both are understandable.

But the imbalance is regrettable. What can be more important than pursuing difficult diagnoses? What can be more important than the caring function? Yet, because they are not easily measurable practices are not paid to excel in these functions. The measurable has pushed out the unmeasurable.

Still, although we are influenced by QI professionals and organizations, and by financial incentives, in the final analysis our practices are ours to shape. If we take steps to improve our practices in these very important but non-quantifiable aspects, we ourselves will feel the richer for it, and it is quite possible our patients will benefit from it. The key is "Not everything that counts can be counted, and not everything that can be counted counts.” (William Bruce Cameron.)

Budd Shenkin

Steve Jobs and My Credit Card Woes

I think it’s time for a few smaller blog posts. I can’t be hamstrung by trying to make every one better than the last. Even at the risk of triviality. But after all, some of my favorite writers – Dave Barry, say – dwell in that region and thrive.

So, I just read Walter Isaacson’s Steve Jobs biography, which is well worth reading, sports fans. Great story and Isaacson is in a class with David McCullough and Michael Lewis and Alan Furst– you can’t go wrong reading what they write. Steve’s wife, Laurene Powell, said he’s a great man, but great men are not great at everything. So personal relations and being nice to others weren’t his strengths.

But he was frank. There were a lot of gadgets, devices, architecture, a lot of things that he pronounced as shit. The whole music industry didn’t get it as their business went kerplunk. It took Itunes to get it right and save them, and it was an outside agency that did it, not they themselves. Sony had everything together to do an Ipod and they didn’t do it – why? Because they were divided into divisions and the divisions didn’t and couldn’t work together. So an outsider, Jobs, did it.

BTW, this invention is an example of the incorrectness of the description of innovation as “find a need and fill it.” Instead, he visited Toshiba, I think it was, and they said, we invented this 1.8 inch hard drive and we can’t figure out what to do with it. Jobs thought, I can do something with this, and brought together technology, his love of music, and his identification with the general consumer to think, Ipod. The technology advanced and he found the use for it. This is generally what happens – like the telephone, recording devices, the computer itself.

Anyway, let me be inspired by Jobs’ ready indictment of the ignorance of others. About three years ago I made a mid-year’s resolution. I was leaving my credit card behind at too many restaurants, and in my car I was pulling out of my lane without looking too often (all the time, actually). So my resolution was to stop forgetting my credit card, and to look before I pulled out.

Perspective: whenever there is improvement to be made, there are two ways to do it, personal improvement or systematic re-engineering. When I want to make an improvement at Bayside, that’s the choice I have – ask people to try to remember, or build it into the system. Sometimes one strategy is appropriate, sometimes the other. In the case of my credit care forgetfulness woes and my driving woes, since I’m just an individual, only the individual strategy is open to me – be aware, remind myself at the table and at the wheel, take the card and look first.

Jobs was in the position that he could look at a device, how much a customer needed to remember to use it, and say, This is ridiculous, and make a better, more intuitive device. In the Apple stores he realized how inefficient it was for a customer (the customer’s view!) to have to line up to pay for a purchase. Reminds me of the old Soviet stores where you lined up to look at something, lined up again to get the item, and lined up again to pay for it. So Jobs had the employees have those little devices that paid for the item right on the floor – just as in Europe as they do in restaurants.

But what do they do in restaurants here at home? Here, they take your card away, bring it back, and then they HIDE THE CARD INSIDE THE CUSTOMER’S RECEIPT! How many of us want that receipt, for God’s sake? The way they do it now, I have to prompt myself to take the hidden card out and put it in my wallet. It’s just not going to work all the time, but this is the way they keep doing it. Ridiculous. Where is Steve Jobs when I need him?

So, I’m here in Hawaii and the other night I left my card behind again – got it later, but what a pain. This is a stupid system and they’re all doing the same damn thing, hiding the card! At least I can rant and recognize that this is what Jobs was a specialist at, ranting about the idiocy of others. I’m in good company.

Oh, and one more thing – in my new car, an Infinity, there is a little light by the door that lights up when there is a car in my blind spot. All I have to do is remember to look at it. What they need is a bell that goes off when my wheels start to turn and the light is lit.

I read the Steve Jobs book, I understand the power of being right – No More Mr. Nice Guy!

Budd Shenkin