Monday, June 25, 2012

Guest Post: On Quality

David Fleeger, MD

Many of us remember the ill-fated crew of Apollo I, whose cabin was consumed by an electrical fire in a pure oxygen environment in a matter of seconds. Thanks to Hollywood, most are aware of the near-tragedy faced by Apollo 13 when an explosion caused by a fault in the oxygen tank damaged the service module. In more recent years, the leaking rocket booster of Challenger or the foam-punctured wing of Columbia elicit similar memories. Not long after the initial shock of these disasters wore off, the finger-pointing began. The press, the public, and politicians were quick to point out “obvious” design flaws, “poorly tested” systems, “unproven” contractors, flawed organizational communications, and a “culture” of unwarranted risk taking. For the billions of dollars America spent on its space program, perfection was not only expected but also demanded. Yet, the reality of space travel is far different. It is naturally dangerous. The systems are complex. The variables never end. The slightest error can lead to the largest of disasters. Perfection is impossible. Sound familiar?

My medical profession knows well the pressure of high public expectations, and yet we work in the reality of a strained medical care system on a daily basis.

Many are quick to point fingers and complain about poor quality and high costs. The drum beat of criticism of our medical system (and consequently the medical profession) is loud, constant, and unfortunately, full of half-truths. Recently, in both press and film, we have been compared unfavorably with other nations with socialized medical systems. Yet none of these nations even pretend to offer the range of services to as many patients as quickly as we do. Others point to the U.S. life span being 36th among nations and consider this a condemnation of our medical care system. In truth, life span reflects the health of a nation and medical care is only one factor at work. In a nation of unparalleled wealth and free choice (where poor choice is possible), society’s problems such as obesity, tobacco, alcohol, drugs, and crime need to be solved before we see significant increases in life span. Nevertheless, many see perception as reality and have decided that the cause of our “failing” system is a lack of quality and value for the dollars we spend.

Quality has become a buzz word. After all, who can argue against improved quality in patient care? Who can deny that high-quality care does not always exist, resulting in patient injury or death? Isn’t there always room for improvement? The answer, of course, is “yes.” As a profession, we are dedicated to doing everything possible to improve the health of our patients. I don’t know any physicians who feel otherwise. The problem lies in the true motivations of those who are not doctors and who use “quality” to advance their own agendas, such as saving money or taking away control of the medical system from physicians. The recent adoption of quality grading systems by health insurance companies is well documented. But grading systems based on billing data and secret formulas are a poor substitute for grades based on how well the individual patient did. These systems measure dollars, not quality.

The excesses of the insurance companies pale in comparison with our friends in the government. The Agency for Healthcare Research and Quality (AHRQ) reported that $29 billion could be saved on hospitalizations per year “by avoiding the need to hospitalize patients for health problems that in most cases, can be prevented ... by high-quality care in physicians’ offices.” The list of conditions includes diabetes, heart disease, lung disease, and their complications as well as dehydration and urinary tract infections. Apparently the people at AHRQ think we can control the lifestyle choices of our patients and get every patient to follow every one of our recommendations.

Worse was the decision that the Centers for Medicare & Medicaid Services (CMS) would no longer pay hospitals for some complications acquired in the hospital. The list does contain some serious and quite avoidable complications. Granted, significant improvements can be made to lower the frequency of each of these complications. But in what parallel universe can they be prevented 100 percent of the time?

These are just two recent examples of government actions with common trends: poor understanding of the science, impractical expectations of an underfunded medical system, a willingness to punish marginal physicians and hospitals (even though often they are the ones serving those in greatest need), weak evidence that these programs improve quality or save money, failure to deal with the consequences of poor patient choice, and an unbending catalog of rules that don’t take into account differences among individual patients.

Physicians, like the engineers of the space program, are to some degree the victims of our own success. Our society has come to expect the medical miracles that they read about and watch on television. There is an expectation that everything will work right every time and that unlimited resources can be used on every problem. As a profession, we aim for this high ideal of quality. We understand that we will always fall short. But our profession must play a part in the creation of quality standards. We must design systems that truly measure improved patient care while allowing for differences in practices and poor patient choice. We must help collect and analyze this quality data to protect doctors and patients from the misrepresentations of others. Only in this way can we truly improve the quality of medical care and thus the health of our patients.

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