I received a comment today on my quality rant.

Even when the guidelines have retrospectively been shown to be flawed, where’s the evidence of patient harm? Did the harm outweigh the benefits? You should know better than to make an argument without these numbers.

Sounds like a straw-man argument to me. If you’ll actually take the time to talk with the folks at, say, the NQF or NCQA you might be pleasantly surprised.

First, please do not threaten – that is so unnecessary.  Dr. Groopman has quoted instances of harm.

Guidelines should be guidelines (see our JAMA editorial) not rules.  I have spoken to many quality leaders and was not pleasantly surprised.  The point that I have tried to make is that the conceptual framework is flawed. 

When I see a patient, I have a long list of tasks.  I must make the correct diagnosis (or diagnoses).  This requires a careful history, often a physical examination, and then appropriate diagnostic testing.  We teach the patient about the diagnoses; we assess their belief system and construct a therapeutic plan which fits their needs.  Sometimes they have a problem that has an associated guideline or performance indicator.  Often I try to satisfy the guideline, but sometimes the guideline really does not fit the patient.

Often we have to prioritize multiple problems, in which case the guidelines (and performance indicators) really do not help.

I have written about this often in the past.  Please reread this "classic" post – How do I judge physician excellence?

Finally, I will once again quote the British philosopher Onora O’Neill who wrote:

The new accountability is widely experienced not just as changing but I think as distorting the proper aims of professional practice and indeed as damaging professional pride and integrity. Much professional practice used to centre on interaction with those whom professionals serve: patients and pupils, students and families in need. Now there is less time to do this because everyone has to record the details of what they do and compile the evidence to protect themselves against the possibility not only of plausible, but of far-fetched complaints.

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In theory again the new culture of accountability and audit makes professionals and institutions more accountable for good performance. This is manifest in the rhetoric of improvement and rising standards, of efficiency gains and best practice, of respect for patients and pupils and employees. But beneath this admirable rhetoric the real focus is on performance indicators chosen for ease of measurement and control rather than because they measure accurately what the quality of performance is.
 

I cannot tell you how to measure quality, because quality is a complex amorphous concept.  I suppose there are no shortcuts to measuring quality, and simple check lists and audits do not measure quality.  What do they measure?  Perhaps my readers can tell me, because I do not think they really measure anything.

Related posts:

1. What is quality – a reader asks
2. Trust and the IOM report on medical errors
3. Quality measurement – a delusion
4. My position on performance measures
5. Guidelines as goals

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