How to create medical quality while hardly trying

The need for what we are calling medical “quality” is acute, yet the strategies employed to obtain it are destroying medicine.  Patient outcomes are inconsistent, care varies depending on many factors outside of disease state, and the cost of our medical system is not sustainable.  But to fix this, most health systems employ non-clinicians to audit charts while checking boxes such “A1C<8%?” and “DVT prophylaxis ordered within 24 hours?”  These non-providers then send threatening letters and cut salaries with “pay-for-performance”.  Unsurprisingly, such efforts are not working, and only end up creating distorted physician-patient relationships.  Yet, obtaining improved quality requires only a few key steps.

  1.      Choose strong clinician leaders.  We all have had enough of MBA and PhD types lecturing clinicians about medical quality.  Only practicing providers understand the difficult balancing act of the patient relationship, with its ethical duties, inherent subjectivity, and inevitable stresses.  A physician leader is required to set the tone of quality as the inevitable goal of the physician-patient relationship.  Find a leader who believes this deeply and is willing to have the difficult conversations to propagate it.
  2.      Define an ongoing consensus in your group regarding why you are providing medical care.  This is not the same as a mission statement or a physician compact, or any other document.  A consensus means an ongoing understanding, renewed monthly, daily and perhaps even hourly.  The medical profession often forgets to talk about why we commit our lives to it, and those who say, “I went to medical school in order to help other people,” are the ones you want on your team.  Some others may answer, “I wanted to have a comfortable profession.”  These are not the droids you are looking for.  A team that understands that they are in it for the patients first, will be a team that coalesces around the need for quality.
  3.      Agree that medical care is a process.  Perhaps this seems obvious to many people today, but if so, this is a recent advance.  When I was in medical school, we learned about diseases and people, but the actual provision of care was simply assumed with some magical hand-waving.  We now understand that every aspect of employing scientific tools to help one patient after the next implies an underlying process.  This realization has created an entire industry of process improvement and LEAN techniques that have improved care and patient experience immeasurably.  Remarkably, there are still clinicians around who have not figured this out.  Avoid them.
  4.      Create tools to measure and visualize the process. Useful data regarding how the processes work are essential.  I find that most understand this crucial step by now.  Create tools, then publish and diffuse them.  Everyone, and I mean everyone, from environmental services to the CEO, should see the same process data, regularly.  When we hide process data we give the impression that the data reflect embarrassing individual performance and not group process.  Use this tendency to conceal data as a reminder to relentlessly return to the underlying process.  We unfortunately rely on individual clinician brilliance to make up for increasingly complex cases where the process sophistication has not kept pace with the care provision.  Do not mistake process errors for clinician inadequacies.
  5.      Agree that medical care is not JUST a process.  This step is listed last, but may be the most important.  No one went through years of grueling training to be just a well-oiled step in a process.  And the heart of quality, the heart of the quality that has meaning to most people, resides in the relationships, conversations, empathy, and medical wisdom that exist outside of “process.”  Clinicians burn out when we forget to emphasize this, dwell on this, and celebrate this.  Doctors live for the parts of care that are NOT processes, and patients value them too.  The first 4 steps of creating quality are designed to become transparent so that we can spend nearly all our time in this last one.  A high-functioning medical group hardwires the first four steps as its baseline, and then retains excellent clinicians by cultivating everything that is NOT process: clinical acumen, empathy, continuing education, compassion, service, and professional development.

Notice that none of the steps contain monetary incentives nor payer alignment nor any of these attempts to monetize quality.  Focus on the five steps and you simply won’t need so-called pay-for-performance.

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