Health care quality can be surprisingly subjective

Round and round and round we go yet again. The system is broken. Do something. Health care reform!

“Pay for performance” morphs into “measure (and pay) for quality.” The big problem is that no one has bothered to actually define the term, maybe because everyone assumes they know what it means — and that everyone else agrees with them. Wrong.

Quality is very much in the eye of the beholder, and can be surprisingly subjective. From my previous post:

Quality is like pornography; you know it when you experience it. But it cannot be measured; only assessed, and then only subjectively.

What does quality really mean in the context of medical care?

Some argue that when you have an operation, the surgeon shouldn’t leave anything inside you that shouldn’t be there. Others would say that everyone taking care of patients should wash their hands before and after every patient contact. Certainly all medical professionals should maintain proper licensure and credentials. I think of those things as basic expectations; more the difference between “acceptable” and “unacceptable”. “Quality” is different from “not unacceptable.”

Enter the idea of looking at outcomes (another meaningless word, also previously addressed by me). To reiterate: Only certain kinds of illness and injuries have measurable outcomes. Fractures (should) heal. Surgically treated illnesses (should) resolve after operation. And so on. It’s generally accepted that there is a direct causal relationship between medical treatment provided and resolution of the condition, though this is not always so. Postoperative complications are not always preventable. Some fractures won’t heal. Cancers sometimes recur. So even the measurement of outcomes as a proxy for quality is fraught with hazard.

What about the relationship between quality and patient satisfaction? Two words: Press Ganey. Short version is that there are times (lots of times) when what people think they want from doctors is not only not what they need, but can be dangerous, useless, and expensive. The patient is not the customer (and even so, the customer is not always right). When you actually look, it seems like the more satisfied people are, the worse their care.

So what does quality mean in the setting of primary care? Me again:

Quality in medical care has more to do with meeting the needs of individual patients and less to do with checking off boxes on a preventive care form. Some patients want detailed explanations of every facet of their medical care. Others prefer a more “Just the facts!” approach.

What does it mean to be a high quality primary care physician? According to me:

The ability to bring more than one style of communication to bear in meeting the needs of a varied patient base.

How do I and other skilled primary care physicians accomplish this? That’s simple (not the same as easy): time. Taking the time to listen, get to know what kind of communication the patient wants and needs from us, and then providing it. That’s quality. Find a way to pay for it (or at least find a way to not penalize it) and stand back while things fall into place.

How to measure it? No one has a clue.

Why not?

Because it can’t be done.

Lucy Hornstein is a family physician who blogs at Musings of a Dinosaur, and is the author of Declarations of a Dinosaur: 10 Laws I’ve Learned as a Family Doctor.

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  • NewMexicoRam

    I agree with this post.
    American healthcare, and it’s outcome measures, have gone mad.

  • Thomas D Guastavino

    Is anyone else suspicious that the VA hospital scandal was brought about by the VA attempting to meet the “quality” metric of seeing patients within two weeks? When it comes out that these “quality” metrics are a part of the ACA then the real fun should begin.

    • LeoHolmMD

      Agree. The VA is likely understaffed and overwhelmed with patients. This exemplifies a larger theme: Those who set quality measures are not the ones who actually have to live up to them. Nor do they have to provide the resources to do so. As a result the metric became more important than actually getting patients seen. That would actually require resources and effort. Quite a bit more than sitting around dreaming about quality. The VA’s next trick will be to cram our nation’s heroes in for same day visits so they can be treated like cattle. The last thing they will do is hire up to the task of treating our veterans with dignity. In the meantime, they will hire a whole bunch of “quality” consultants to see if they can identify where the problems are coming from. Shame!

      • southerndoc1

        Don’t fear, a solution for all the VA’s problems has been found:

        “The Veterans’ Health Administration (VHA) is the largest integrated health system to implement the patient-centered medical home (PCMH) to date. This initiative (implemented 2010-2014) aims to achieve team-based care, improved access, and care management for more than 5 million primary care patients nationwide”

        Team huddles! Pre-visit strategizing! Change management specialists!

  • southerndoc1

    Is there any area of human endeavor and interaction in which “quality” can be objectively measured?

    I wonder what the psychological basis is for the masochism and self-loathing among physicians that causes them to allow the complexity and subtlety of their profession to be reduced to series of check-off boxes.

  • LeoHolmMD

    “The ability to bring more than one style of communication to bear in meeting the needs of a varied patient base.”

    This is extremely close. Time, communication and compassion. Only one of those can be easily measured. The same one that has been savaged the most by our current system.

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