Relentless determination

I recently saw a note from a person I respect very much that set forth an important and interesting point of view:

Measuring quality in health care is an imperfect process. We can collect and measure such factors as compliance rates, trends, outcomes, complications and adherence to protocols, all of which are important in helping us improve care and safety of patients. And our tools and our understanding of what constitutes meaningful quality and safety measures are constantly improving. But at the same time, there are very important aspects of quality that cannot currently be quantified. For example, we have no yardsticks for technical expertise, critical thinking, fund of knowledge, keen judgment, passion, compassion, talent, profound curiosity or relentless determination to do best by each patient.

This is beautifully written and it is hard to disagree with. It reminds us that all is not measurable and that we must cherish and respect the humanity of doctors, nurses, and others who have devoted their lives to eliminating human suffering caused by disease. It captures, too, the discontent felt by many in the medical profession, particularly those who were trained years ago and who practiced for many years in a very different environment.

I believe that the discontent arises from the fact that those served by the health care establishment, those paying for it, and those supervising it are now demanding more accountability from the professions engaged in it. Those groups, too, have figured out that, for decades, those in the medical professions have ignored many important aspects of the science of care delivery. The subject gets short shrift in medical schools, in residency training programs, in academic journals, and in the administration of hospitals.

We have learned from studying other industries that have engaged in and achieved process improvement that such improvement requires an approach to the organization of work that is very different from that seen in most hospitals. But it also requires measurement and transparency. While even the best calculations and data don't tell all, they do tell a lot, and they are the only way we have for an organization to hold itself accountable.

But those in the medical profession sometimes fall into the trap of believing that because measurement is an inherently reductionist and mechanistic act, it can never be sufficiently accurate to reflect the overall realities of patient care. The paradox is that without it, we can inadvertently fall into the trap of self-congratulatory statements about our good intentions. Only with it can we demonstrate that we actually have a "relentless determination to do best by each patient."

I have spent innumerable pages on this blog discussing these points and giving examples from BIDMC in the hope of sharing our experiences for the benefit of all. As you have seen, I gratefully borrow from concepts that Berwick, Batalden, Spear, Conway, James and many others have been espousing for many years. We at BIDMC have devoted ourselves to implementation of these concepts, and yet we consider ourselves infants along the path of learning to walk. But we believe that this is an essential part of the mission of an academic medical center during an era in which the public is demanding greater accountability from the medical profession.