It’s time to support performance measurement in health care

I practiced surgery for many years in a very large hospital.  In the 1980s, 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 them 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.  Health care 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 health care 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 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.  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 the Joint Commission 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 health care 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 health care 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.

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 through 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.

Richard Patterson is a surgeon who blogs at DailyDudley.

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  • Thomas D Guastavino

    Im curious. How exactly would you set up quality and performance measures for healthcare.?

  • Dr. Drake Ramoray

    I will propose the same question to yet another thought leader for performance measurements. My Endocrine practice is in a fairly rural location, is the only practice for at least 50 miles, the next is over 100 miles away, and after that to get my type of specialty you have to leave the state for the nearest care. How are these pay for performance meaures as an outpatient going to account for my demographics of relatively poor, relatively undereducated, and difficult population. Some patients age issues with transportation, a fair number of diabetics struggle with math, and there is a fairly high penetrance of poverty.

    If I stay where I am and continue this current business model (ie don’t move and go concierge) Im going to get paid and graded in the same scale as my colleagues in the affluent suburbs with simple diabetics on oral therapy only. One doctors executive on Metformin monotherapy does not equal my patient living marginally above poverty on U-500 specialty insulin.

    If my practice folds there will be several counties in my state without access to Endocrine specialty services. How are these “performance measurements” not going to hurt access to care?

    • Jess

      It’s probably no consolation, but public school teachers face the same difficulties. It’s easier to be a “good (well-rated) teacher” when your students all come from stable two-parent households, are well-fed, have a quiet place to do homework and a safe place to sleep, and are supported by families who both model and reinforce the importance of education and reading. But when teachers teach in inner cities to children born of entrenched disadvantage, it’s not fair to put down any lack of progress down solely to the teacher. There are so many things that aren’t even in their control!

      • Dr. Drake Ramoray

        I realize that I have te same plight as teachers. They rightfully make a similar case. That bein said Im pretty free to move wherever as my specialty is so under represented. I get about 4 mailings a week about jobs in nice locations. We like where we live and we are close to my spouse’s family. But with the way things are heading in likely moving and staring a concierge practice. The difference is if my practice closes up then there is nobody to take our place.

      • Dr. Drake Ramoray

        I have been wondering as physicians increasingly get pushed into mega corporations and hospitals who don’t always share the same interests if physicians will ever unionize. There are certainly pros and cons to such a decision, and I’m not using this post to advocate it, but the loss of autonomy is not something the majority of doctors expected depending on their age.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    “As health care costs spiraled and apparent benefits did not keep pace…”

    I would think that statements like this (even with the “apparent” qualifier), need to have some measurement, and proper analysis, behind them as well. Right now we know that costs are spiraling because other countries spend less and because relative to other expenditures, the share of health care expenditures has increased. We also have some very ill defined, and sloppily calculated, measures that we keep comparing with other countries in a very selective manner, and proceed to draw preordained conclusions unrelated to those measures.
    For example, by all international measures, we know that Americans use hospitals less, and use doctors less, and have less doctors than other industrialized nations. So what do we do? We have national campaigns to reduce admissions and readmissions and LOS, and reduce the number of physicians per capita.

    Makes absolutely no sense until one realizes that spiraling costs have very little to do with the way medicine is practiced, and everything to do with the way business is conducted. And business, while very good at measuring those it manipulates for profit, holds itself high and above measuring its own motives and actions. Accountability is exclusively for the powerless.

    • Deceased MD

      You are a true thought leader Margalit. For the pts and for the docs it is a sense of being swallowed up for dinner by CorpMed.
      I live near an academic institution that is swallowing up everything around it. Around the corner Johnson and Johnson has taken over office buildings.

    • Deceased MD

      The question I have, is who is allowing so many admins to take control and keep it. The answer always seems to get more admins. Common sense says that this is inefficient. yet no one is challenging this. Only the pennies that PCP makes per medicare visit.

  • Tiredoc

    The problem with “measure anyway” is that the act of measurement changes the outcome. The current quality measurement metrics don’t measure something absolute, like death, but something falsifiable.

    When quality metrics first came to inpatient rehabilitation, they looked at the rates of urinary tract infections and bedsores. I instructed the nurses to remove all Foley catheters on admission, check a UA and document all bedsores, so we wouldn’t get dinged for something that happened at the referring facility.

    This was not popular for the referring facilities, particularly the parent hospital that housed my inpatient rehabilitation unit. So, Foley catheters were removed, but no UA. Bedsores were documented without specifying severity.

    In the end, the quality of the referring facility improves on paper, but not in reality. “You can’t find a fever if you don’t take a temperature.”

  • Deceased MD

    I don’t think that we need to evaluate the physician so much as the system they work under. The question to me, is how do all these admins keep their jobs?

  • Thomas D Guastavino

    Specifics please.

  • Thomas D Guastavino

    What do we do with the patient who won’t follow our recomendations?

    • rbthe4th2

      I would say it works both ways. I have had docs who recommend against what are considered standards of care. I’m probably a bit more comfortable not following them. Find out why they don’t follow the recommends. That will help you to understand why they don’t. Had a few of my docs asked, they would have realized the simple, common sense answer …

      • Thomas D Guastavino

        That certainly may be true but the question at hand here is if a patient will not follow my recomendations how can I be held responsible for the outcome?

        • rbthe4th2

          Which is more important: the patient or you? If the patient can’t follow you because you didn’t explain something, or they don’t have the money for a pill, or there are other methods that accomplish the same goal that the patient wants, would you want to keep them? Otherwise we’re expendable service revenues and you can always get another. Keep only those who adhere to your plan. You can always dump the “non compliant”.
          Are patients allowed to participate in their care plan with you?
          One last question: you said ‘recommendations’. If they are “recommendations” and not “orders”, then what do you want to do?

          • Thomas D Guastavino

            Did I read you correctly? Are saying that is OK for me to dump my “non-compliant” patients?

          • rbthe4th2

            I see and hear about patients getting dumped (blamed for non compliance whether they were or not) all the time. That’s why I say what I did, about us being expendable. I’m not saying its ok, just that its what is done in practice. I think it should be a sit down chat without a computer and go over with the patient what the story is first. However, I see docs who don’t want any one who doesn’t do what they’re told or don’t like them so they get rid of them and blame the patient.

          • Thomas D Guastavino

            So , if I as a physician is going to be judjed by a performance standard, and I have a patient who by non compliance is going to negatively effect my “score” is it not true that the application of the performance standard by itself is going to make worse the very problem you are so concerned about?

          • rbthe4th2

            Yes but that no longer matters. That’s what I’m saying. I’ve already seen docs and other places, they’ll drop you in a NY second. Its the way docs can keep the grips over the population.
            What kind of score are you looking at? If a patient has high blood pressure, diabetes, is overweight, you mark & they sign something that says I have X, Y, Z and if I don’t exercise starting with 15 min. a day, with a diet that I log of X calories or less, my problems will get worse, and they don’t do that, when your score comes up, you have proof that they knew the consequences and they can drop that from your score.
            Besides, I’ve seen docs do that – one lady, couldn’t pay for the exams, so they dropped them because it was going to count against them, and they called them non compliant to get rid of them.
            Where are you guys at, I see it a lot in my area. Hear of it too. I’ve had one guy mess up someone, and another person knew about it. Coughing blood and all, they weren’t about to go to the specialist after what they did to that first patient. Also, this same doc’s practice “fixed” the problems in at least 3 others and then dismissed the patients. That way they could claim they were just mad if they said anything against the doctor.

          • Thomas D Guastavino

            So, do you like the idea of performance standards, or are you acknowledging the fact that performance standards encourage physicians to “dump” non-compliant patients? Its sound from your post it is the latter.

          • rbthe4th2

            I like the idea of performance standards and I’m saying that dumping patients whether or not they’re non compliant already happens any way. Besides, I’ve seen where if you’re liked or whatever as a doctor, risk management or admin will blow over everything any way. There’s no real action ever taken by JC, the state boards, or lawyers. You might have an occasional something but lets face it when someone gets away with “affluenza”, the chances of real consequences are about nil.

          • Thomas D Guastavino

            Sorry, you can’t have it both ways. The application of performance standards worsens the problem of patient dumping. No way around it.

  • Tiredoc

    So, the only way to change the system is to measure the system. The only way to measure the system is empiricise every confounding variable and integrate care into a massive relational database with massively competing interests (payment and medical services) so as to provide the desired metrics.

    Isn’t there a shorter way to say this? Like, the only way o change the system is to measure the system. The only way to measure the system is to change the system. But I guess then anyone would recognize it as a circular argument.

    You are advocating for a massive reorganization of the health care system with ample evidence to suggest that this reorganization multiplies errors of fact and does nothing to improve any aspect of care other than reimbursement and auditing.

    When will all of you Napoleons learn to do the little things instead of trying to change the world?

    • hadhag

      medical billing and record software operates at a level which is 3 decades behind business software. This isn’t rocket science.

  • Thomas D Guastavino

    It seems that your problem is with physicians who do not take your complaints seriously. How is adding performance standards going to help?

    • rbthe4th2

      1) Is the issue the patient can’t follow you (needs further explanation, money, etc.) or won’t follow you and do you find out why? There is a difference between dumping someone who can’t follow your instructions vs. won’t. I’m sure they will make allowances for that: if not at first, it will be.

      2) Patients are already treated as expendable. This only makes it more “legit”. Yes, I’ve seen a number of these things happen. Its a fact.

      3) If patients want to drop doctors, then doctors should be able to do that also (given discrimination laws).

      4) How can the problem be made any worse? As I said, people are already dropped or even blamed when the problem may not be the patient.

      5) Performance standards will encourage those doctors who believe in the Hippocratic Oath that the patient comes first before the wallet. If the eyes are on the wallet, then they’ll dump those patients. Maybe this will encourage medicine to change some of the medical school standards and not get tested on things that don’t count and on things that do.

      6) Performance standards are needed because the medical profession didn’t police itself well enough. There are too many issues that came to light, people who simply tested just to test, gamed the system, or who just went round and round with a patient and they didn’t get better. Part of the issue I see and hear about is (not just me) having to go to doctor after doctor to get diagnosed (or not at all), when frankly we’ve been able to figure out what our diagnoses are. In my case, thousands of dollars has been spent when if the most recent round of testing had been done first, a simple OTC fix for a couple of things would have been done without having to fix all the problems that came after. I was the one who said given my history, this is the problem. Sure enough, that’s been it all along. Thousands of dollars will be spent trying to fix what should have been done a long time ago. Remember one of the axoms: the patient will tell you the diagnosis. Many of us aren’t the enemy you make us out to be. We just want you to help us as the experts. If you don’t show us you are those experts, we’re going to go elsewhere (hence the multi billion dollar alt med industry). When we implode, it is the experts who get the blame.

      7) If docs start taking complaints seriously, then they’ll have to start investigating the complaints and figuring out a diagnosis, and treat. Not just its nothing, all in your head, or the pain can’t be that bad, or your pain isn’t due to this (but if the treatment doesn’t work, that means the treatment/diagnosis is wrong) so don’t think about it. It might also force doctors to listen when you do have savvy patients. Not all of us care that you have an advanced degree. Just because we’re not practicing MD’s doesn’t mean we didn’t arrive at the correct dx.

      Randy

      • Thomas D Guastavino

        At least we can agree that freedom of choice, for both patients and physicians, must be maintained. Ultimately freedom of choice has, and always will be, the best defense against abuse.
        Good luck in the future and I hope that someday you can find a physician you can trust.

        • rbthe4th2

          Thanks. For many, there is no freedom of choice.
          I wish you the best also. I’ve found a couple but still looking in one area.