Quality is Control

Like an anthem, a holy grail, the word appears in every journal, every proposal and every health strategic plan.  “Quality.”  We say, read and hear it so often we are developing “quality fatigue.”  Like “iterative” hackneyed phrases such as “out-of-the-box”, “deep-dive” and perhaps even “Personalized Medicine,” quality has begun to feel like water-torture and risks being deprived of flavor or meaning.  However, do not so fooled or bludgeoned that you lose focus.  Quality is another word for absolute control and power.

For too long quality meant, “work hard, do a good job, care about the patient.”  Every provider was a “quality provider.”  Have you ever met a doctor who did not believe they practiced “high quality” medicine?

Quality was measured at the front end by basic research, whether a medicine or therapy might improve human life, and on the back end by the marketplace.  If patients and doctors liked an idea, it would flourish.  If not, then it would gradually fade away.  In between the only enforcement of quality was the individual motivation, experience and judgment of physicians, the “art” of medicine, the occasional headline grabbing disaster, and coarse insurance oversight and denial; all nailed together by the gavel of medical-legal confrontation.

Today quality means is data.  Big data.  Giant data.  The ability to monitor, measure and modify, in real time, the impact of every medical event and intervention.  Not the average hospital length-of-stay last year, but the specific moment by moment actions which delay the discharge of a specific patient or patient type, today.  Not how many vaccines are distributed, but to whom, with what result and, most importantly, who is not vaccinated and why?

Does a therapy work to save lives in the real world, and at what cost? Is compliance an issue?  What known and unknown complications are occurring and what is their root cause.  Which clinicians need new training?  How fast does a critical advance get to the bedside and are physicians incorporating the technology; what is the net effect?  Big quality uses the entire healthcare system as a laboratory and all of us, all our patients, every community, are subjects and benefactors of the grand experiment.

Quality will control the future of healthcare.  Those individuals or institutions that wait to get their “quality metric” report back from their local friendly insurance carrier or from CMS, who rely on billing data to measure outcomes, or patient satisfaction surveys as a final measure of “how well we are doing,” are doomed.

Investing in a “culture of quality,” means not just “doing our best,” but fully investing in the analysis and improvement of every step, from the moment a person rolls out of bed, turns on their smart-phone, parks in the lot, walks into the office, uses a surgicenter, enters a hospital, purchases at a pharmacy, gets rehab, is admitted to a nursing facility or spends their last day in hospice. Those institutions that understand and optimize total quality will dictate tomorrow.

Quality; hard clear defined big data, is power. Doctors must seize the quality mantra and use it to design, direct and define the practice of medicine and the future health of populations.  Only when we have achieved that goal, can we say we are tired of the word and rest.



  • meyati
    Quality and power depends on how you use it. You are looking at the long term goals that quality brings, but the individual is affected by what happens to them. My cancer clinic is trying to have traveling 6 week sessions for cancer patients. This has yogavagelists-I don't want to convert at all, PTs OT, dietitians. I get along with the weight lifters that show how to control lymphedema , These people are doing a good thing, I was asked to go, but I didn't sign any contract, and I wish that they understood that I'm just going to see what they have. I'm thinking of going to PT again for a leg problem, but I know that I will avoid these ladies. Quality gives power, but petty power ruins quality.
  • D Someya Reed
    Curious post. So who will do the data analysis for doctors when they seize the quality mantra? Will these analysts have a fiduciary interest in the doctors or the patients? Or, in someone else? I'm shocked that you stated that those "who rely on billing data to measure outcomes, or patient satisfaction surveys as a final measure of “how well we are doing,” are doomed." Really? This is exactly how the hospice industry measures their success. Unfortunately, they have (and use) the power to abuse it by selecting who will get a survey or who won't. Which responses they will keep and report and which they will discard. Nothing about the satisfaction survey or its distribution is mandatory or regulated in any way. And what about relying on faulty data? A simple example...The NHPCO, for years, has reported annual statistics on hospice usage showing a modest but steady increase year by year. Their numbers are supposed to be based on the CDC's final annual U.S. death totals (but don't always agree) along with their own "estimated estimate" of patients served (largely due to poor, "voluntary only" reporting practices by hospices) expressed as a percentage. In 2012's report, NHPCO made a glaring error. They reported 1,059,000 patients served and 2,513,000 U.S. deaths (again not what CDC had) as 44.6%...a significant jump over 2011's 41.9%. Unfortunately, the actual calculation results in 42.1%...an increase over 2011's, but much smaller. I called the NHPCO to advise them of the error. NHPCO's response was that "If an error is found, we will reissue the report." I stated that a calculator would show the error in seconds. I was told they do not have calculators. The report has never been changed. Why? Maybe because the average person will look at 44.6% and think "Wow, that's almost 50%" (not so with 42.1%) and be persuaded to sign up? However, what happens when the 2012 totals are released by the CDC (they haven't been yet) and the new calculation does not exceed 44.6%? How will they (or do they want to) explain the dip in usage after showing years of steady increase? I explained this situation but they neither cared nor offered any appreciation for bringing this to their attention. So, if you are saying that hospice is doomed if they don't stop using Medicare billing data, family satisfaction surveys and their own particular "estimate" spin on the results, then I cannot agree with you more. Overall, though, I'm not sure if this post promotes medical evangelism or medical megalomania (in the form of a power grab).
  • D Someya Reed
    Another thought...Why is it that when a patient wants to maintain (or gain) control of their care it is equated with denial but when a doctor wants control it is likened to saving the world as is represented in this post? I just attended a pathology seminar led by a doctor from a prestigious institution. I cannot tell you how many times he stated some form of "We just don't know" or "That was proven wrong." Now, as you stated, medicine is an "art form" and an inexact science. So did he. There has always been and will always be exceptions to exceptions to exceptions. But data is just a numbers game. The standard of care will be defined by who has the biggest (therefore "best") numbers AND, as you stated, how many doctors agree with them. You included patients but I feel that's a "not so much" variable in that most doctors don't usually consult their patients on their opinions of the viability of a medical procedure...most doctors really don't want the patient's opinion (see your own past posts referring to patients getting info off the internet, for instance). The cornerstone of science fact is the reproducible event which doesn't lend itself well to medicine. Medicine may truly never be understood (and disease controllable) unless we can unlock the secrets to life itself. Disease is also life just life that disagrees with us and ultimately itself by killing the host or breeding organism. Unfortunately, it commonly has dormancy, self-preservation features that we don't. Data, big or small, will do nothing to change this if it is inaccurate or misinterpreted. How do we ensure that? Garbage in/garbage out still applies and only provides a false sense of control. And none of this remotely resembles quality. Medicine represents a partnership between patient and doctor with a common goal that, in all honesty, is far more personal and important to the patient than the doctor. Aren't patients routinely told that there is so much they can do themselves to cut their risks of disease and improve their overall health based upon the accepted notion(s) of the moment? Aren't patients routinely chastised for not following their doctor's orders (that's control or attempted control, too). Why can't we cut patients (the true lab rat in this scenario, though you said it nicer) a little slack rather than promote the "I need control but you can't have it" mentality? Please reread some of your past posts about denial, from a need for control perspective, as in this post, and see if you don't come away with an even slightly changed opinion.

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