As I was finishing residency, we talked increasingly about “quality metrics.” In primary care, these included diabetic control, hypertension control, depression control etc.
These are all worthwhile goals. We should be trying to control and manage these chronic diseases as improving their treatment will prevent a large number of expensive and debilitating complications down the road.
Now that I am out in the real world, the importance of quality metrics varies wildly from system to system. Additionally, as a locums, I don’t hear much about it. Moreover, I am in the ED more often now and those metrics don’t apply.
Not surprisingly, cash-strapped rural hospitals are often a little behind the zeitgeist. So, their definition of quality is different than what I was used to in residency.
Clinicians Don’t Decide
What I have learned more about is the culture of metrics. Clinicians rarely determine metrics or their system for collection. Administrators is optimize metric collection for themselves, not the people who are actually trying to achieve them.
Administrators manage the system, so it is natural they would try to manage that system to make their jobs easier. What that has translated to is doctors being data entry clerks.
I could maybe even stomach this if it meant administrators actually improved the system. Yet, that seems rare.
I can be a team player.
Instead, what I usually see is administrators trying to game the system to make the metrics look good. Rarely will they roll up their sleeves and get their hands dirty trying to make the system work for the people who depend on it.
Moreover, there is still a pervading fear of liability in administrative circles. So, administrators translate the idea of quality, of improved care, to mean low-liability care.
Low-liability care is not quality care.
Sometimes they overlap, but the goal is completely different. We can expose patient’s to loads of unnecessary tests, procedures, and risks and still have low liability-care. Rise of c-section rates, anyone?
Yet, we all know that is not quality care. The corporatist administrative class doesn’t care. The concepts of black-eyes and feathers in their caps are what motivates the culture of the administrative class , not patient outcomes.
Moreover, systems can charge for many of these interventions. It is a win-win for an administrator – charge more money and decrease liability at the same time. Why do it any other way?
The Institute of Medicine’s famous To Err is Human report pointedly articulated how systemic flaws are often the cause of poor patient care almost 20 years ago. Nonetheless, we cannot hold the stewards of these systems personally responsible for failing to manage systems appropriately.
Layers of obfuscation and bureaucratic interactions prevent us from holding people accountable. Only nursing home administrators even have licenses that can be revoked.
I want to emphasize this point – even though the evidence is clear that systemic processes are at least as responsible for poor patient as clinicians’ actions – only clinicians have a licensing process.
Would administrators care more about actually providing good patient care if they could lose their career through licensure revocation? It might at least lead them to feel more responsibility for the systems they manage.
How did we get to this point?
I think physicians have been trying to keep their heads down, see patients, and get out as soon as possible. The rVU gerbil wheel has tricked many of us into abrogating our duty to try and make things better.
Additionally, as physicians, we treat one patient at a time. Our training to think of problems as individual in nature can sometimes constrain our problem solving.
What if physicians received training in organizational theory and leadership as a standard? Would it be better? I don’t know. But, I know we can’t fix what is wrong with American medicine one patient at a time.
Systemic problems rarely have individual solutions.
“The only thing necessary for the triumph of evil is for good men to do nothing.”― Edmund Burke (disputed attribution)