Commentary -- October 2000
Symposium on Quality in Health Care
By Josie R. Williams, MD, MMM, Guest editor
Symposium on Quality in Health Care
"Of the many issues now confronting medical professionals, none seems more perplexing than the debate about the quality of care. Although it is understandable that so many physicians have reacted to the debate over the quality of care with anger, skepticism, or simply disinterest, such reactions are a luxury that physicians can no longer afford" (1).
The ability of the medical profession to agree upon an adequate definition and measurement of quality health care also has had its share of beleaguered trials and failed attempts. The amount of controversy regarding whether we can or should measure quality of care is not new. The 1910 Flexner Report stated: "One of the problems of the future is to educate the public itself to appreciate that very seldom, under existing conditions, does a patient receive the best aid which is possible to give him in the present state of medicine" (2).
Dr Earnest Codman, in "A Study in Hospital Efficiency" in 1913, stated, "I am called eccentric for saying in public: that hospitals, if they wish to be sure of improvement, must find out what their results are, must analyze their results, find their strong and weak points, must compare their results with those of other hospitals [and] must care for cases which they are not qualified to care for well . . . must welcome publicity not only for their successes, but for their errors" (3).
Dr Codman was eventually forced to leave the Massachusetts General Hospital staff. He died unheralded and, indeed, was shamed for his "follow-up system."
In a six-part New England Journal of Medicine series on quality of care in 1996, Blumenthal and colleagues outlined many of the issues, principles, and skepticism that physicians face in quality-of-care discussions (1,4-8). The definition of quality they suggested for physicians was "doing the right thing right." The Institute of Medicine (IOM) defines quality as the "degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge" (9).
Blumenthal et al opened the door for the legitimate discussion of quality by addressing five major areas:
- The measurement of care and the limits of such measurement;
- Methods of measurement, ranging from classical, double-blinded randomized control trials to improving and measuring processes imported from industry;
- The issues of financial, scientific, social, and political influence on quality;
- The impact of managed care techniques; and,
- Ethical concerns over capitation's effect on quality care.
A healthy skepticism to the methods of change was suggested (1,4-8). Blumenthal et al concluded the series with this statement to physicians: "A far more useful and constructive strategy is to embrace change and to shape it for positive purposes" (8).
Other issues of concern in the quality debate are the cost of implementing performance measurement and quality improvement programs, confidentiality in an era of widespread sharing and comparing of data, and the liability (or perceived liability) we all face in a litigious society. The challenges to the profession 4 years after the landmark New England Journal of Medicine series was published are virtually unchanged. Payers do not discriminate on the basis of quality in spite of multiple sources showing that quality of care varies.
There is not a physician worth his or her proverbial salt who cannot agree that the goal of medical care is improving patients' health and improving the care delivered to patients in a rational, studied, scientific manner. Yet, the current environment does not lend itself to the study of the quality of that care. Every physician who has survived the chaos in health care during the past decade knows "it ain't what it used to be" in terms of autonomy, patient satisfaction, physician satisfaction, reimbursement, regulation, prestige, and esteem. The industrialization of medicine has become a given. The corporate entrance into medical care has further fragmented an already fragmented "nonsystem" of health care. The realization of the complexities of caring for an increasingly knowledgeable, demanding, and aging consumer has become reality for managed care organizations, resulting in further consolidations, mergers, and restructuring to optimize corporate finances.
The debate over quality health care reemerged with the November 1999 IOM report, To Err is Human . We saw reactions to the sensational headlines from the press, the public, governmental agencies, private health care payers, and health care professionals. More important than the predictable reactions was the IOM's call for changing the health care process to systematic health care learning and improvement. The latter message is one I hope we as a profession have the will to address in the quality debate.
The medical profession owns very little data to rationally defend or rebut the fragmented data of insurance companies and government agencies as buyers of health care services. The quality of care and outcomes measurement in any setting outside of the randomized controlled trials of select patients is only recently evolving as a discipline of inquiry. A physician will likely get multiple "report cards" from hospitals, insurance companies, HMOs, and IPAs -- all of them showing different levels of performance and benchmarks. It is irrational to judge physicians' effectiveness and how they compare to their peers or to the medical literature on the basis of these fragmented individual reports. It is just as foolhardy for physicians to prepare for the future without adequate data that are stored, collected, and analyzed to produce information regarding our own performance and the performance of our system.
The future in the debate over quality of care depends on the will of physicians to carefully evaluate the performance evaluation skills and tools that are being imported from other disciplines, such as business, economics, social sciences, statistics, and marketing, in addition to time-honored scientific principles. We must adopt techniques and tools that improve our patients' outcomes.
The challenge to Texan physicians is to measure ourselves in a common professional endeavor, compare that measurement with the literature, and respond to our own systems according to the measurement. I believe the most powerful tool physicians have to offer in the quality-of-care debate is accurate information based on reliable and valid data from the outcomes of the systems of care we practice in, both individually and collectively .
Can you imagine a system in which we collectively raise our voices to the American public with well-developed, accurate outcomes information, including data regarding not only physical outcomes, but satisfaction, quality of life, functional outcomes, and resource outcomes, that is developed in a manner that forces value-based purchasing of our services rather than a cost-based purchase? The tools for performance measurement outcomes of patient care and systems are available today. They will improve only as we critically use them and improve them as we do any other tool.
Many physicians are wary of so-called "cookbook medicine." Dr Jordan Cohen, president of the Association of American Medical Colleges, suggests that "those who resist such help may well be accused of denying their patients care of optimal quality" (10).
Modern medicine truly is the best medical system in the world for those who have access. However, it can be improved, with our commitment to our patients and our profession. Texas Medical Foundation improvement studies have shown significant opportunities for Texas physicians to improve. Reputable literature sources suggest, however, that we, as a group, are quite slow to change our practices to conform to evidence-based literature.
I prefer to believe we can perform in arational evidence-based system such as the one Dr Staker outlines in this symposium. We as physicians must lead if we are to improve patient outcomes in all outcomes classes. It is clear to me that we must have the will to change when change is appropriate. We also should be willing to define appropriate use, overuse, underuse, appropriate variation, and outcome.
This Texas Medicine Symposium on Quality in Health Care has been both stimulating and challenging to produce. I want to thank the many authors who have taken the time to share with you their perspectives on quality-of-care issues. Our goal was to share with you the thoughts of national quality leaders, governmental and accreditation agencies' expectations related to quality of care, the tools being discussed in the quality-of-care debate, and some experiences in those arenas. I believe you will find the articles informative and intellectually stimulating.
Dr Williams is clinical director of the Texas Health Quality Alliance in Austin.
- Blumenthal D. Part 1. Quality of care: what is it? N Engl J Med. 1996;335(12):891-894.
- Millenson ML. Demanding Medical Excellence . Chicago, Ill: University of Chicago Press; 1999:30.
- Codman E. A Study in Hospital Efficiency. Oakbrook, Ill: Joint Commission on Accreditation of Healthcare Organizations; 1996. Report from a 1917 reprint.
- Brook RH, McGlynn EA, Cleary PD. Quality of health care, part 2: measuring quality of care. N Engl J Med. 1996;335(13):966-970.
- Chassin MR. Quality of health care, part 3: improving the quality of care. N Engl J Med. 1996;335(14):1060-1063.
- Blumenthal D. Quality of health care, part 5: the origins of the quality-of-care debate. N Engl J Med. 1996;335(15):1146-1149.
- Berwick DM. Quality of health care, part 5: payment by capitation and the quality of care. N Engl J Med. 1996;335(16):1227-1231.
- Blumenthal D, Epstein NM. Quality of health care, part 6: the role of physicians in the future of quality management. N Engl J Med. 1996;335(17):1328-1331.
- Lohr KN, Donaldson MS, Harris-Wehling J. Medicare: a strategy for quality assurance, V: quality of care in a changing health care environment. QRB Qual Rev Bull. 1992;18(4):120-126.
- Cohen JJ. Higher quality at lower cost: maybe there is a way. Acad Med. 1998;73(4):414.
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