Blog | Tuesday, August 7, 2012

What's your druthers for quality?


"As was said in the report Crossing the Quality Chasm [blah blah blah]... "

Every report and article on the topic "health care quality" starts this way, because the Crossing the Quality Chasm report was groundbreaking, laying out the domains that we should aspire to perfect: safety, effectiveness, patient-centeredness, timeliness, efficiency and equity. These domains apply at multiple levels throughout the healthcare system.

But as Don Berwick pointed out, our true lodestone should be the patient's experience. In that case, why don't we ask how people (sorry, "patients") feel about these domains, and what are most important to them?

Of course, it's impossible to achieve all the domains perfectly at once. Everyone could be made perfectly safe if nothing were attempted. Care could be timely if no one ever asked patients' opinions or double checked that errors weren't being made. And so on.

How would you make the tradeoff, if you could?

I asked in a poll, "What is your preferred quality domain, all things being equal?" The answers were (answer, total votes, percent):

--effectiveness, 8, 47%
--patient-centeredness, 4, 24%
--equity, 2, 12%
--safety, 1, 6%
--timeliness, 1, 6%
--efficiency, 1, 6%

It wasn't a big poll, but I find the answers interesting. I asked you what the most important quality domain was. There's nothing statistically significant here, because only 17 of you responded. (If this was just 1 person responding 17 times, let me warn you that the punishment for screwing around is severe and swift. This is a serious blog.)

What catches my eye are the several choices that lost out and ended up at the bottom: safety, timeliness and efficiency. It could be that people didn't really understand what these meant. (Timeliness, that medical care be delivered at the right time, i.e. neither too early nor too late; efficiency, that resources not be wasted, or underutilized, in delivering the care.)

Safety, though, is surely something that everyone understands. Why didn't it get more votes? There's no clear answer from this unscientific effort, but here are some speculative possibilities:

It's something everyone assumes already exists, until they are themselves affected by subpar safety. Who judges an airline or a car by its safety record? Maybe we don't talk about those things because we assumed that someone, somewhere, is ensuring the safety of our airline travel or automobile manufacture. Certain people, by pointing out governmental and private negligence, have forced us to pay attention to things we might not want to notice. The same is true of health care, but maybe that just hasn't registered yet.

Or perhaps, subconsciously at least, the category "effectiveness" already folds in safety. If we are delivered quality care, we already assume that it will be done without errors, certainly without serious error. If our gall bladder were removed without a trace but then we got a blood clot in our leg, we might not consider that an effective cholecystectomy!

However, apart from our individual preferences, the real reason I put up this poll was to illuminate a larger problem. There is precious little research on what patients think is meant by high-quality health care. If we make use of new public reporting mechanisms (or reporting done by private concerns, like Consumer Reports) to tell us which doctors or hospitals are better, we should make sure that we understand and agree with the criteria.

Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews. He is also a poet, journalist and translator in Yiddish and English. This post originally appeared at his blog.