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Fixin' Healthcare

Friday, February 10, 2006

The Lifestyle Chronicles - What is Quality?

Make no mistake about it, we are going to hear a lot about quality in the near future and it won't be the version used by marketing. This time around quality will be linked with other concepts like outcomes, evidence based medicine and pay for performance. There will be change and some good will come of it, although each of us will disagree as to which parts are good. But, quality is a word ladened with value judgements. Much like beauty, quality is in the eyes of the beholder.

Traditionally, health care has been a process oriented activity. The process of gathering information about a health problem and health status to reach a conclusion or diagnosis is second nature to health care providers. It is a process designed, taught and practiced to avoid, as much as possible, mistakes and oversights. Treatments are based upon the diagnosis plus judgements about the condition of the patient. Adjustments to treatment are based upon the reponse of the patient and any other new information. So far, so good.

Humans beings are complex biological creatures. Even when the diagnosis and treatment are correct the expected outcome may not be achieved. Also, it is not uncommon to achieve the expected outcome based upon valid experience and have that differ from the patient's expected ouitcome. This happens even when there is good communication between the provider and the patient.

A factor often overlooked by the provider and ignored by the patient is that the majority of Americans lead unhealthy lifestyles. Health care is burdened by the perception that years of unhealthy lifestyle can be reversed in a brief period. This is in spite of no change in lifestyle. And, there is the issue of non-compliance by the patient. Where is the quality in this puzzle?

The rapid development and deployment of technology has expanded the scope and range for diagnosis and therapy. The amount and refinement of information is achieved more quickly and with less discomfort to the patient. Diagnosis can be more accurate and therapy more effective. It should not be unexpected that technology has changed the health care system and the perception of quality.

Deployment of technology in health care is a complex and tricky undertaking. Demand to use the newest technology is based upon the opinion that it improves quality. Yet, there is a learning curve for any new technology and the mad rush to utilization may result in a period of less quality for efficiency and effectiveness of care. Additional pressure comes from the business need (business quality?) to recoup the investment in an expensive new technology. Is it any wonder that marketing praises the availability of new technology for competitive advantage? And, providers can generate more income with use of technology whether or not they own it.

Meanwhile, marketing being marketing, competition being competition and human nature being human nature there is pressure to produce the next new technology. It is not surprising the next new thing is a varient of the previous thing and produces the same information and results. True breakthroughs are not common and analysis of paradigm shifts find they have occured in small steps over a long period of time.

Can any of us fault the hope and trust of a cancer patient who choses a clinical trial over an established therapy or flies across the country to a cancer center with more technology? This process can lead to the perception and sometimes the reality of improved quality but most often the outcome is the same. Occassionally, this pursuit can lead to some remote site in the desert receiving injections of extract from who knows what.

Health care providers frequently view quality from the perspective of training and credentialing. Where did you go to school? Where did you do your residency? Are you lisenced to practice? Are you certified by a speciality or subspecialty board? It is a reliable process, but we all know the limitations. I have not been involved for some time with the JCAH (Joint Commission for Accrediting Hospitals) but recall a lot of wasted time and effort in the process. This may have been revised since then.

In addition to technology and specialty care, hospitals stress the hotel aspects of their business. Private rooms, parking, carpet, wood paneling, etc. Comfort and marketing are the key ingredients. There is a tendency for the rich to get richer and the level of amenities to rise higher. At some point, and it is lower than many think, the level of amenities have no bearing on the quality of the health care process or outcomes but the perception may be otherwise.

Quality in health care will continue to attract attention. Several references have appeared to a book entitled "Redefining Health Care" written by Michael Porter from Harvard and Elizabeth Olmsted from The Univerity of Virginia. The book is not due out until May but it is reported to argue that the real problem in health care is a lack of good information on quality and outcomes. The government is encouraged to take the lead in measuring health care quality and outcomes by establishing and enforcing standards and risk-adjusted measures. Organ transplantation is used as an example (Wall Street Journal, February 1, 2006).

Undoubtedly, the issue of quality will link up with the pay for performance movement and it will create quite a stir in health care (check out Kate Steadman and Matthew Holt). The long and the short of it is that change is coming but exactly how and when is not yet clear. Meanwhile, I wonder how much we can learn from the experience in the steel, railroad, airline, automobile and newspaper industries where the need to restructure has some momentum. My conclusion is that misery loves company but there will be little sympathy, and change is inevitable but not always controlled.

I was struck by a recent post from Grunt Doc and the comments that lamented the collapse of the house of cards that is health care. Providers and patients are discouraged and they have been discouraged for some time. Although the wish may be for a quick end by decapitation, I fear the change will be more like being run over slowly by a steam roller.

The lessons of history tell us that when change comes it will not be in the form or on the time table that was expected. Patience is not only a virtue, it is necessary. I am confident that Grunt Doc and those who commented on his post have already gotten a good night's sleep and continued the good fight.

The essence of health care is the desire and effort to improve the health of people who seek your expert assistance. As the years pass you will find that your efforts made more of a difference than you could ever realize at the time.

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