Dr. T (pity the fool) – oops that was Mr. T – writes

have been following your thoughts on Quality measurement for some time,and largely agree with you. I am the medical director of a 15 physician hospitalist group in the midwest, and here’s my question:

Is there perhaps some value in at least a few QI metrics as a surrogate for a larger more robust method of evaluating quality, until such a thing exists? i.e. is there any value in the “if you can’t even get THIS right” line of thinking.

By way of illustration, my personal bent is that for the vast majority of doctors attitude=quality. That is, those docs who are engaged in their work, care enough to stay current, stop to review a clinical entity they are less familiar with when they encounter it, talk to families, and look for answers to clinical questions instead of passing the buck to someone else or falling back on comfortable old habits; oddly; those are the docs (at least in my group) who DO tend to use IDSA guideline based antibiotics for CAP, who actually make mention of an ejection fraction in the H/P of a HF patient, who consistently provided DVT prophylaxis.

Those who blow through rounds, are “too busy” to talk to families, haven’t read a journal since residency, etc, they TEND to do poorly on QI metrics as well.

I have talked and written a great deal about the shortcomings of quality metrics as they now exist (see my blog or happy’s hospitalist with a view) but without an attitudeometer, how else do I approach this?

T raises an important question. Given that quality is multidimensional, can we even measure it. If we can, then do performance metrics predict that overall measure.

T suggests, albeit implicitly, that physicians who have overall excellent quality will have excellent samples of quality as measured through performance metrics. I wrote 2 years ago about my opinion of excellence. How do I judge physician excellence?

My experience does not jive with T’s. I know physicians who get great report cards, but cannot care for other problems or make correct diagnoses.

Of course, we are exchanging anecdotes here. Onora O’Neill has said:

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 believe she is wise in her philosophical musings. She opines that measuring quality requires observation from an experienced professional. We evaluate medical students, interns and residents through observation. Our evaluations have consistency.

Quality is very difficult to measure, but that should not encourage us to tout inadequate measures as proxies. Performance measurement has face validity to accountants, insurance executives and politicians. Practicing physicians understand this problem, but if we reward measured performance (either through incentive payments or lack of penalties) then many physicians will focus on “buffing” the chart rather than caring for the patient.

I do not mind performance measurement as an indicator, but reject the concept of equating them with quality. I worry that talking too much about quality, when we mean performance measures, influences physicians to focus only on those measures. As we measure performance, we should always remember the context. I hope I’ve made my point.

Related posts:

1. Quality measurement – a delusion
2. Comparative effectiveness research – more thoughts
3. How to insure quality
4. Measurement – the good and bad
5. Safety rather than quality

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