Patients need to be involved in quality metrics

I recently heard from an aging and respected physician the old adage that “what is good for the doctor is good for the patient.” The room full of physicians of all ages and specialties nodded their heads in agreement. This saddened me, as it represents a physician-centric system that oftentimes leaves the patient’s needs and desires completely out of the equation.

An area of emerging importance in medicine, whose impact should be broadened in order to ensure the patient’s place in the equation, is quality improvement.  “Quality” health care is defined loosely by hundreds of very specific measurements, such as consistent testing for hemoglobin A1C in patients with diabetes mellitus or the timing of antibiotics for surgery, which perpetuate this physician-centric paradigm within our health care system.  Consistent hemoglobin testing and proper timing of antibiotics in surgery are absolutely important for the health of the patient, but may not hold meaning for patients as metrics for choosing a quality physician or hospital. Quality measurements need to be meaningful and understandable to patients if they are to use them to improve their well-being and to select doctors who share their vision of health.

Multiple studies have shown that most patients desire a competent, knowledgeable, and caring physician. They want to know that the advice and care they receive is based on what is best for their health, as opposed to what is best for the physician’s bottom line.  And patients repeatedly say they are most interested in providers they can trust, who have an easy and approachable bedside manner, and who properly communicate with them. But such traits, including empathy, kindness and patience, are not currently considered essential measures of quality by anyone but the patient.

While hospital performance scores are slowly becoming available for potential patients to consider, reliable quality measures on outpatient primary-care providers (PCPs), where there is much greater need and variation, are severely lacking. And because the majority of metrics used to define a quality provider, when they are made available, have little meaning to the average patient, patients often fail to see the importance of seeking out a “qualified” physician or how to do so.

The combination of multiple, provider-centric metrics of quality and the difficulty for individual patients to access and understand this information has led to a sense of confusion among patients and physicians alike as to what quality health care actually is. Most measures do not apply to most patients, and those that do apply typically show that most providers are good at some metrics and poorer at others. But most importantly, the issues that tend to be of most concern to patients, such as the above-mentioned trust and bedside manner, are not included. This provides little help to patients in their search for a quality PCP to assist them in achieving optimal health.

There is legitimate concern that based on current quality measures patients may seek out multiple providers for separate and relatively simple issues. A patient may select one provider who is better with diabetes and another who achieves better scores in hypertension. Or a patient may seek costly care from a specialist over an acceptable PCP for a given condition. This could lead to further degradation of the physician-patient relationship through less continuity of care, while increasing cost and time for patients and providers, even though the “quality” of care will appear improved.

In order to make the measured quality accessible to patients, patients need to be involved in the creation and implementation of quality metrics that have meaning to them. The primary method by which patients participate in the quality process now is via patient satisfaction surveys. Medical practices or independent organizations often solicit patient feedback on what could make things more patient-friendly. These forums, however, are often misleading as they have inherent selection bias of both extremes – either very good or very bad isolated experiences are most commonly shared, with multiple confounders. And in these surveys, patients are reacting to existing constraints as opposed to creating patient-centered experiences. What’s more, feedback from these surveys is typically considered a “patient satisfaction” issue, which is separate from quality. The patient satisfaction survey treats the patient as merely a customer in a business instead of an integral part of the physician-patient relationship. But patients react best when they feel that their provider has their best interests at heart and is not acting out of motivations for improved numbers or increased income, as one would in a business-client relationship. Instead of treating patients as customers, patients should be treated as equal partners in quality improvement for their own health.

Certainly patients should not control every aspect of quality measurement to the exclusion of important health-related factors. Providers should still be expected to take the lead and act as educator and coach. But if it is going to produce any fruitful results, it must be a partnership with patients and not a dictation to them. This concept continues to gain importance as medical practice redesign moves towards patient-centered medical homes (PCMH) and accountable care organizations (ACOs), and their increased emphases on primary care. Patients need to feel that it is their medical home, as opposed to being told what and where their medical home is. Otherwise we can expect patients to continue to seek care from multiple providers, leading to duplicate tests and visits, increased costs, wasted time, and further alienation of patients from the care they want and need.

The emphasis on quality in health care is extremely important, but if we continue to focus only on the physician end of the equation, then we will fail to learn the fundamental lesson of effective medicine: that what is good for the patient is good for the doctor.

Kyle Bradford Jones is a family physician who blogs at Primary Care Progress.

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  • http://www.facebook.com/shirie.leng Shirie Leng

    The “quality measures” are generally things that are easily measured and numerical: do you smoke or not, what is your HbA1c, what number of screening tests did you order, how many people were re-admitted, etc. That’s because quality measures are being used to pay doctors and set policy. I have found they have little relation to real quality. And BTW, pre-operative antibiotics, one of the quality measures in anesthesia, have not really been shown to do anything. Yet our pay is based on it.

  • Nurhusen Ibrahim

    Great article and the patient has to be participated in quality measure. I think it is advantageous for both the patient and the health care provider to know patient’s opinion. The provider will improve thier service based on that and the patient will get a better service!

  • http://twitter.com/tomadamczyk Tom Adamczyk

    Thanks for that interesting point of view and one coming from a physician. I am not a doctor, but I see patients all day long, and I have noticed that over half the patients seem to care less about their health that myself and my co-workers. How do you confront those people who do not actively participate in their health affairs and later on give the facility or the staff a low performance score, based on their experience that is perhaps misplaced?

    • http://www.bryantsstatisticalconsulting.com Donald Tex Bryant

      Being patient-centered, according to the definition frequently quoted from “Crossing the Quality Chasm”, means that the patient is involved in decision making in his or her care. If he or she is involved in the decision making process, then the patient is also responsible for the decisions made and responsible for the success of treatment along with the physician or caregiver.

    • Droma Jemmico

      I work in HIV project in Arua, Uganda – East Africa. Many have understood the stigma in a mention of HIV. In today’s world, the success of health delivery is centered on all involved and provider initiated. Yes patients may not reveal their health problems, but you as the provider you change that around through dialogue with patients and making them feel more responsible. If we don’t involve patients as stake holders we shall not be successful our service delivery. In the end we shall be beating bottom of the drum.

  • Docbart

    Unfortunately, the paradigm is shifting to what is good for the payers and healthcare organizations, and what is good for patients and doctors is becoming just an embellishment. Payers are the fish and everyone is the parsley, no matter how much we are being told otherwise.

  • http://www.facebook.com/fadi.m.asfoor Fadi M. Asfoor

    Thanks for sharing your perspective. The quality metrics you speak of that would include patient input would be a great way to improve the quality of care in the US. I would be interested to see what those metrics would look like coming from a patient

    I quote you by saying,

    “Consistent hemoglobin testing and proper timing of antibiotics in surgery are absolutely important for the health of the patient, but may not hold meaning for patients as metrics for choosing a quality physician or hospital. Quality measurements need to be meaningful and understandable to patients if they are to use them to improve their well-being and to select doctors who share their vision of health”

    I agree with this statement. If I follow your logic, the question still stands, how will patients be able to be seen by a physician “who share their vision of health” and who live 100 miles away? I like the concept but this will not be possible without the use of technology to enhance the patient physician relationship. As for geriatric patients, your point is well taken due to the fact that long term facilities for geriatric population is on the rise. These are great facilities to allow for the implementation of patient satisfaction surveys to be administered. For the younger generation, they have a tougher time choosing doctors because many of them have not experienced an ailment or disease that has hijacked their life nor do they have a good sense of optimal health.

    Instead of enhancing the patient physician relationship I would challenge physicians to be better at educating their patients and working with the entire health care team (pharmacists and nurses) to ensure a better quality of care. Pharmacists have a huge role in the coming years to provide medication therapy management services and nurses currently spend more time with patients than doctors. The entire team of health care providers will need to work together to enhance the “physician patient relationship” you speak of. Patient centered care in the coming years will evolve into the “Health Team Patient Relationship.” Patient satisfaction surveys must not only be administered by physicians, but also by pharmacist and nurses.

  • http://twitter.com/FerkhamPasha Ferkham pasha

    Great article

  • S A Manikandan

    Patient always come out with a feeling that Doctor should have paid little more attention to his Queries & Doctor feels that Patient always has the tendency to ask more & more Questions which is not Relevant. There must be System where Both the ends Meet to Care & Cure the Patient in a holistic manner.Counsellors could Play the role by Discussing with the Patient Before Meeting the Doctor & send the Case History & after meeting Also to give reassurance.

  • Gvozden

    I will feel free to add couple of comments regarding one very important sentence in this article : ‘Multiple studies have shown that most patients desire a competent, knowledgeable, and caring physician’.
    For a physician to have above mentioned qualities there is one huge opsticle in healthcare – money.Today we have Doctors from various fields employed by percentage which is devastating for institution where they are working.
    How to make more income when you are employed by percentage?
    1.Finish with patient fast,so you can take another?
    2.Explain to patient how he need to come for his own good more than couple of times on sessions even if he maybe don’t need to.
    3.Find another condition on patient even if he is ok and double the number of visits?
    4.Send him on additional tests like MRI,X-RAY,Laboratory analysis but only on place from which you will get commission for adding a patient on another schedule?
    5.When employer finds out that employee is still not making enough money because they have deal at least 50%-50% than just go up with fees for single session so patient just need to pay more for them to be satisfied?
    I can continue this for a long time but there is no point.
    Solution for this that no one likes is to have Medical Staff employees salary based and all mentioned above is voided.Only than Medical Staff that want to take care of the patient will stay on this field and they will commit working hours to patient,not to money.
    We will never be super rich but Health Care will become what it suppose to be,and anyone who is not satisfied will find for himself other area of interest.Maybe in sales,politics or marketing…
    Salary based Medical Staff employes will always make enough for decent life,enough for Hospital or Clinic where they are working, committing them self’s to patients and excellent performance,building they own and Hospital / Clinic reputation.

  • http://www.bryantsstatisticalconsulting.com Donald Tex Bryant

    Recently the New England Journal of Medicine website posted a study on patient satisfaction; the study focused primarily on HCAHPS. A similar survey will be used for physicians treating Medicare patients in 2015. The authors stated that the HCAHPS survey accurately reflects several dimensions of the quality of care delivered and provides suggestions of designing good surveys to measure quality of care. I was so impressed with the article that I reviewed it and several other patient-centered topics in my most recent newsletter. You can find the NEJM article at http://www.nejm.org/doi/full/10.1056/NEJMp1211775.

  • Nondoc

    Good viewpoint and well written. I wish there were more hard examples provided or sources. You talk about studies and misleading surveys but I see no evidence. Would just be great to hear more detail so we, the reader, can do our own research into it as well.

  • http://www.facebook.com/estuckel Elizabeth A. Stuckel

    Over 2 decades ago, I suffered 2 strokes during 7 brain surgeries! The ‘Power from Within’ can change any medical statistics, and I am the perfect example of that!