Blog | Tuesday, June 10, 2014

What is quality?


One of my long-time favorite bloggers, the Dinosaur, had a wonderful post on KevinMD yesterday. I have gone to her original post for the link: Words That Don’t Mean What You Think They Mean: “Quality”

In this wonderful post, she makes a point that this blog has featured often, that quality has multidimensionality. This multidimensionality makes metrics virtually impossible. We too often measure those things that lend themselves to metrics. When using metrics we focus on more common problems, because metrics do not work unless we have an adequate denominator.

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

[T]he 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.

In her post she rails against Press Ganey. Many patients want what they want, not what they need (pardon me if the Rolling Stones are singing in my head). Physicians have a responsibility to not order unnecessary tests, prescribe expensive medications when a less expensive choices works as well, and not prescribe opiates “willy nilly”, yet some patients want those things.

When a patient has a cold and insists on a Z-pack, what should we do. When we refuse, our Press Ganey score could suffer. When we refuse to prescribe more Lortab, or order an unnecessary MRI (because my daughter wants me to have it), then what?

And quality has so many more dimensions. When I treat the wrong diagnosis perfectly, does the patient benefit? When I fail to ask the right questions and miss the diagnosis what happens? When my care is not patient-centered have I fulfilled my social contract with the patient? Not all patients want the performance measurement goal achieved. We should tailor our treatment to the patient.

The Dinosaur and I and many others would like to ban the use of quality to imply a measurable attribute. I hope we all aspire to high quality, but I suspect we cannot measure it, rather we know it when we provide it.

For those who say we have to measure something, I say let’s measure safety issues, PICC line infections, central line infections, unnecessary Foley catheters, giving the wrong medication, ignoring lab or imaging results. But do not call that quality, rather patient safety.

Thanks great to the Dinosaur for stimulating my ranting.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.