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Monday, December 2, 2013

Quality over quantity: The only surprise is that it took so long for health care

Over the last couple of years, we have been witnessing the start of a seismic shift in health care philosophy. For far too long, the system has been totally focused on rewarding quantity: The more patients seen, tests performed, procedures completed—the higher the incentives.

Now, instead of rewarding health care providers for quantity in the “fee-for-service” model, we are moving towards a system that rightly focuses on the quality of care that is actually being delivered. This is one of the basic tenets of health care reform, and a change that’s long needed. It fits in completely with today’s 21st century society, where we place a high emphasis on quality and customer satisfaction for all of our products and services. From the consumer goods we buy, to the restaurants and hotels we frequent, most organizations will only flourish by maintaining the highest possible standards.

In my career, I’ve encountered colleagues in health care (and to be fair, it’s the minority) who take pride in being able to churn through large numbers of patients in a short amount of time. “I can see 20 patients in one hour!”, or “I can operate on 10 patients in a single morning session”! Whenever I hear something like this, I always think to myself: Is this really something to be proud of?

I like to draw an analogy of a painter that you call over to your house for an estimate, who tells you with a big smile on his face that he can paint your whole house in under an hour. What would your reaction be? If you’re like most proud homeowners, you’d probably be a little horrified, and promptly show the painter the way out. “Sorry, but I want a painter who will do a good and thorough job”. Imagine then that if we take so much care of our homes, how important it is to apply the same principle to health care. If we would be so alarmed with someone painting our house with such haste and doing a low-quality job, wouldn’t we be even more concerned with a doctor who only has a few rushed minutes with a patient, to deal with a complex and life-threatening illness? Doctors and nurses spending inadequate amounts of time with their patients not only lowers quality, but it is also dangerous. In an occupation where someone’s life is in your hands, there can be no other way but a mentality of “no stone left unturned” thoroughness.

But while most of us may agree that quality is important, the 800-pound gorilla in the room is the debate about who pays for this higher quality health care? Speaking as someone who has worked in both public and privatized systems in Western countries, this issue is complicated and at times convoluted. As a rule with other industries, it’s usually the private for-profit marketplace that delivers the highest quality products and services. But health care is very different, because it isn’t conducive to the usual free-market competition that exists in other industries. Who has time to shop around when faced with an emergency? The fee-for-service model simply hasn’t produced many of the desirable high-quality outcomes.

On the other side of the coin, it’s actually the public systems that often tend to see more patients in less time! An extreme example would be what happens in developing countries, where hospital units containing dozens of beds lined up in a single room is the norm, and high quality cannot be delivered due to a critical lack of resources. In terms of quantity, the U.S. doesn’t even come close to such extremes. Ironically, it may also have partly been the medico-legal environment in the United States that has driven standards upwards.

Whichever method we use to finance the health care system, shifting away from incentivizing quantity doesn’t necessarily have negative financial implications for hospitals and providers. It shouldn’t work that way. When we get the reimbursement model right, the system will reap rewards on the good performers appropriately, much like our society does for other brand names.

There are of course certain challenges that are unique to the industry. For example, a hospital which serves disadvantaged populations may struggle if judged by the same standards as a hospital in a comfortable suburb. There is also the patient compliance concern. Doctors and hospitals can only go so far in striving for high quality, but in the end it’s also the patient (and society) who has to be compliant in doing all that they can to stay healthy. Factors such as these must be taken into account when allocating resources.

Some of the quality measures currently being used to judge hospitals include:
• better outcomes on metrics such as length of stay and readmission rates,
• commitment towards customer service and patient satisfaction, and
• a safer medical environment with lower risks of complications and hospital acquired infections

The ideal health care system of the future will judge success by lack of illness. Organizations should be striving for high standards, evidence-based practices, putting patients first, and a philosophy of zero harm. Good medical care will be defined as patients recovering quickly, avoiding complications, and receiving excellent service. Whatever the intricacies of the policies that get us there, one thing is certain: dedication to quality is the only way to advance health care.Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
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.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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