Thursday, November 15, 2007

Reply from one of our doctors

People often ask me how our doctors feel about the things I post on this blog. The answer, of course, is as varied as our faculty, and -- trust me -- our faculty is not the least bit shy about letting me know how they feel. After I wrote a post on safety and quality a couple of weeks ago, one of our doctors wrote me the following note. I'd like to share it with you to get your reactions. Please understand that this is a world class clinician who is beloved by his patients and who has an exemplary record in safety and quality. So he is not saying we shouldn't be good at that, but he is saying something about how he thinks the hospital marketplace really works and what I should be emphasizing in public statements.

No one in their right mind could want anything but the safest possible hospital. But complex human organizations are inherently frail in the infallibility department. So while we have to work on this continually, we should not confuse that with "quality".

In the marketplace, people want the "best doctor". You will never hear anyone saying that they picked their doctor because the hospital he practiced at had a better safety record.

While we have to be excellent at safety, quality in the minds of the public is related to whether they think that the care they are getting from their doctor is the best. By this they mean, is the doctor practicing at the very highest level, making the right diagnosis, giving them access to the cutting edge and best therapies. Quality is not how many falls we have, because even though you and I know that the falls are dangerous and kill people, no one comes into the hospital thinking that they are going to fall.

If you make patient safety your acid test, you are not going to attract the kind of patients you need to stay in business. The difference, in the mind of the public, between quality and safety is huge. Quality means the medical care expectations. Safety is merely expected…until something goes wrong.

So, from my point of view, the emphasis at BIDMC has to be on quality, as in finding things that we are simply the best in the world at, and riding that wave.


Anonymous said...

I am an M.D. who learned about the literature on quality and safety the hard way (too long a story for here), but found it incredibly enlightening once it was forced down my throat. I believe this physician is confused about terms, for one thing. He/she views quality as what/how well the doctor does, and safety as what/how well the hospital does. It's nowhere near that simple, and he/she grossly underestimates the public's sophistication on this subject. No one will go to him as a high quality practitioner if they view BIDMC as a low quality institution (and quality includes high quality processes as well as high quality surgical equipment or nursing staff). Everyone knows hospitals can kill you just as dead as doctors!
I do believe that the constant changing of terminology by the government and accrediting organizations has contributed to this semantic confusion - we have had performance improvement, total quality management, continuous quality improvement, etc., etc., and patient safety has recently been added as yet another term.
I suggest you clarify the terminology used by the hospital and educate him/her and the other physicians about exactly what you mean when you talk about quality, and about safety. (I see safety as a subset of quality, but others may offer better conceptualizations.)

I will admit that I, too, used to view all the administrative ramblings about "performance improvement", etc. as so much job-preserving paperwork - until I learned exactly how far behind the health care system is in these areas compared to the rest of industry. Tell him/her about the analogies to the aviation industry, for instance, and I think he will begin to get the idea.
I think the take-home lesson for you, Paul, is that you and your quality improvement folks have a lot of education to do with your medical staff. They don't understand where you're going with this.

Jay Levitt said...

Your doctor is a smart doctor. I used to live in Wellesley, and would go to the Newton-Wellesley Hospital and its affiliated medical offices for all sorts of treatments. (As the joke goes, I'm one of those lucky people who, still in his 30s, bursts with the strength, vitality and bloom of someone at least three times his age.)

The last year I went there, they had huge congratulatory signs up. What was so newly wonderful about the hospital that was my second home? Had they just bought the new open MRI scanner? Was there new talent in from some prestigious university, or some new program launching?

No. The signs were about their "quality measures". Don't get me wrong. I love quality measures. On software. Not on me.

Apparently, they'd had the fewest central line infections, or maybe the lowest staff turnover, or the fewest lawsuits or the highest turn-in percentage of their post-rounds review forms, or something equally secondary to the business of actually, you know, caring for patients.

In fact, the only patient-relevant metric I can recall was a brag that they had the highest same-day outpatient release rate for some procedure.

That does not give me warm fuzzies as a patient. "We'll get you right out of here!" is most definitely not the same as "We'll get you well enough to leave." One's a cost metric; the other is a care experience.

Sounds like I might want to try BI for a patient care experience.

DDx:dx said...

Boy, he said it! Quality! Find the best doctor...It's usually the one you have to wait the longest for.( I saw a late night infomercial touting the credentials of the endorsing doc,"If you wanted an appointment with her you'd have to wait SIX months!)
I want to respectfully disagree with this guy. I think there are SOME(not alot) measurements of quality that might not "sell" but are Time from dx pneumonia to Abx...I have seen LOTS of patients who LOVE their doctor who is giving them bad care...And what does the "market" have as an answer for that? Please the patient, satisfy the customer? I believe medicine should have ideals, not respond to popular culture's whim....The market is not to be snubbed, but it's pressures are to be responded to, not to provide direction.

Anonymous said...

Speaking as a patient, "hospital quality" does matter to me.

An attending physician isn't in the hospital with me 24/7, but the nurses, residents, the pharmacists, and other staff -- the TEAM -- are there. They're the ones really taking care of me, and the ones who can keep me safe. "Hospital quality" is a reflection, not only of the individuals employed, but how well they work together in a complicated, demanding world.

Now, granted, my only hospitalization has been for childbirth, which has a different selection process than an acute illness. Be that as it may, I chose the BIDMC for my eventual delivery (based upon my knowledge of their efforts in OB safety), and only then chose my OB based upon that.

Anonymous said...

The physician who wrote the note might be interested in today's post on The Health Care Blog entitled "When is a medical error a crime?". It addresses issues of both quality and safety and provides some more educational links also. It behooves every physician to be aware of these issues.

Anonymous said...

The good doctor's thinking is of a previous age. He reveals that when he says "You will never hear anyone saying that they picked their doctor because the hospital he practiced at had a better safety record."

People are gradually coming to realize that "picking the best doctor" is no guarantee of a good outcome. Instead, the best assurance is picking the hospital that has the best record.

Hang in there!!!!

Anonymous said...

Patients are more sophisticated on the subject of safety because media outlets are covering safety issues. Granted, that coverage may not be the best in the world, but it reaches a mass audience and patients are paying attention. In the past, patients expected safe care in all facilities, but the data never supported that belief.

Anonymous said...

I think the doctor is probably right about how people pick doctors and hospitals now--or at least, those who make an active choice.

Lots of people just choose a doctor near their house, from some insurer's preferred providers list, and if to their surprise they end up in a hospital it's the one to which their doctor admits, or the one to which the ambulance takes them. There's no billboard that's going to make a big difference there; it's building referral networks, getting satellite hospitals, all the stuff BIDMC is doing along with everyone else in town. In that sense, the line infections pitch is not to the patients themselves--it's to the community doctors who are going to choose which hospital to affiliate with, and refer patients to.

But for speaking to those patients who do make a more active choice, I think the goal is not to market reliability in and of itself (a billboard that says "fewer line infections than any other hospital in town" might not strike inspiration into a marketing department's heart), but to market BIDMC as a place that cares enough about patients to make reliability a goal. I think your doctor is right that people choose doctors as people ("my doctor is the best doctor in the field of..."; or "my doctor is incredibly kind and always listens to me"). But selling those people as people who care not just about the latest cutting-edge treatment but also about every detail of the ordinary is a reasonable marketing approach, if the care behind the quality efforts is what's emphasized.

Line infections in and of themselves are not a sales pitch; what's worth selling is a bunch of people who not only deliver the extraordinary, but also sweat the details of the ordinary, and do so because they care. The line infections are deeply important from a medical point of view. But they aren't important from a marketing point of view in themselves, because they're abstract to most people. For the popular imagination, things like line infections or other quality measures are probably more important symbolically.

Every affirmative marketing pitch has as its corollary an unspoken negative statement about the competition. The pitch for quality must suggest by implication that doctors who only emphasize being "the best" in the most conspicuous of ways (e.g., being the first to deliver a new treatment, or the best-known practitioner of a particular approach) are egotists who care about _looking_ good as opposed to _being_ good. They deliver the newest medicine through the line, but the line was placed sloppily.

The quality pitch is that being good means sweating the small stuff; it means caring about each detail of the ordinary as well as the extraordinary. That's what the quality movement represents at its best. At its worst it's just widget-counting. That means that if you're going to sell quality as opposed to "excellence" in the "Boston's Best Doctors" sense of the word, the billboard has to promote the passionately-felt intentions of the widget-counters, not the number of widgets that the widget counter counted.

Jay Levitt said...

The billboard has to promote the passionately-felt intentions of the widget-counters, not the number of widgets that the widget counter counted.

Thanks. That's what I was clumsily trying to say.

Yes, it's interesting to read about the widgets here on the blog, from a geek perspective. And I really admire BI for publishing their stats.

But when I'm nauseated and dizzy and waiting three hours to wait some more in an exam room, the very last thing I want to see is a big poster that makes me feel even less human, even more like "just a number" - especially one that makes me feel like a cost center!

Take a look at their recent press release:

"In a recently released health care industry study, Newton-Wellesley Hospital was named as one of the nation's 100 Top Hospitals that has achieved a level of excellence in clinical outcomes, efficiency of operations, financial performance, and growth of patient volume."

If I'm an investor, that's great news. And if I'm on staff there, I'm proud. But as a patient? Only one of those affects me positively - clinical outcomes - and you couldn't put it any more, well, clinically. As for the others, well - "efficiency of operations" usually smells like "scientific management" scams of the 1950s, or overblown ISO-9000 metrics of today. I don't particularly care about growth in patient volume, other than to hope it's not going to be too crowded after I read this big poster and get to the aforementioned waiting room. But the worst: "Financial performance."

I don't care how much you consider your center to be a "community hospital", not one of those nasty for-profit hospitals that franchise their way into your city like so many MCI-Leavenworth corporate prisons. It's an artificial distinction from this side of the colonoscope, OK? Maybe the other lens makes it look nicer.

And it's hard to make that case to doctors, because they're proud of how hard they work, and how much they improve. Ditto for the administrators; they're putting in great programs, they're modernizing systems, they're training on the newest technology. That's all really good, except in no case are you measuring how people *feel* about having come to BI. What are you going to do, give them a J.D. Powers survey? And, even if you do - unless they're buying a Saturn, people don't want to be told that others have told them they made the right choice. They want to walk in and feel welcomed.

If your water heater broke, and you know nothing about water heaters, you want to find a plumber who knows what he's doing, has experience, maybe has membership in group that means "quality". So that's analogous. But you don't want a plumber who, on the first visit, starts taking apart your heater and says "You know, you're in good hands with me. I have one of the highest fix rates on these indirect gas-fired models in the country - nearly 79%." And you say "So there's a 21% chance it won't work?"

And he says "That's not the point. Thanks to an advanced GPS dispatch system, I can have my guy on the road within 20 minutes if your call. (That sounds good.) And if I see he goes over the 2 hour recommended maximum, I can call him and remind him of the call queue on his palmtop. (Wait, so you make him leave?) This keeps every day fairly predictable in cost and revenue, and our books are some of the cleanest in the industry." All stuff to be proud of that you just did not want to hear right then.

Nobody's figured out how to really capture patient experience into metrics. But I can assure you that, whatever baseline you use, any visit involving posters talking about "operation efficency" and "financial performance and growth" do not contribute to the vibe you want.

Maybe I'm being too abstract. Here. Fuzzy animals: In the waiting room chairs. Cost recovery percentges by insurance type: In the locked drawer. Helpful empaths who sit with you until they call your name? Waiting room. Average time from patient death until bringing that room back online for new patient: locked drawer.

OK, rant over.

Anonymous said...

As a patient, I also get a weird vibe after seeing financial performance announcements. But while I think fuzzy animals and (clinical outcome) signs put our heart at ease as patients, I think ultimately, we should strive to be better patients. It's dangerous that so many of us believe that our doctor is the best doctor. This kind of comfort-thinking gives patients a sense of complacency that results in less demand for all-around safety and efficiency. A agree with felix above, that there are more than doctors at a hospital, and that doctors cannot work alone. It's the continual fine-tuning of the system that results in good clinical outcomes, but of course, patients cannot see that as directly as they see their doctors' bedside manners or the big imaging technologies.

While we can detect 'quality' by seeing those big new machines and hearing about such and such new procedure, we cannot directly see the 'little' things that very much do matter. So I think it's ok if we patients feel uncomfortable for a while, because we need to get used to the new terminology and understand that patient care is not just about what we think of our doctors (although this certainly plays a part in trust, etc). There are very real measures of safety and efficiency (we are paying, however indirectly) that we as patients should demand and know about, and not just assume are there...

Anonymous said...

That's an interesting letter, and sounds like it's making testable predictions. I'd guess that patients use rely to some degree on a recognition heuristic when choosing a hospital close to them. For most that means the important factors in their hospital choice will be things like USNews ranking, NIH funding (indirectly) and anecdotal experience. Since the first two of those probably weight "quality measures" like advanced/experimental treatment over "safety measures" like line-infection rates (for now), I'd guess your doctor's description is somewhat correct. But as a normative guideline, it's way off base. For most patients, the perceived benefit of going to a hospital with the most advanced PET scannner may be greater than going to the hospital with the lowest incidence of cath-related UTIs, but that says nothing about what is likely to be the relevant factor in their care. I for one (and not to kiss up) have always seen your blog as an effort in debiasing.

Anonymous said...

As a former nurse, the reputation of my doctor is not my top priority when choosing a hospital - or even a doctor. The best docs in the world can be undone by understaffing, administrative logjams, unresponsive office organization and lousy communication. Safety may be an imperfect measure, but it does provide an excellent snapshot of how well the various systems in a hospital coordinate to provide the final product - patient outcome.

And in a perfect world, patients would actually have a choice of hospitals, but are increasingly hamstrung by their insurance coverage. We seem to endlessly mired in a system that increasingly punishes both patients and doctors for participating.

Anonymous said...

Yes, I think felix has come closest to the heart of the matter, when he said it is teamwork and it is complex.

I think it is a useless exercise in semantics to say that safety is a subset of quality or vice-versa.
Safety is important enough to have a Roman numeral of its own!

I work at one of the 50 safest hospitals in the country (as evaluated by Leapfrog). I know what that means, being part of the team. I know the details--the continual educational pieces we go through to prevent errors, the follow-up when a medical error does occur--so that we all learn from that error. I am being asked continually to be vigilant, to double-check, to collaborate and ask questions, so that two heads rather than one, are watch-dogging. We report and analyze near-misses . . . We collect data on our patients, adding it to a large international database, allowing us to place ourselves on the graphs related to patient outcomes.

I recently chose to have knee surgery at the hospital where I work. I had plenty of choices--hospitals closer to me, in better neighborhoods, with nicer interior decor, some spa-like. I chose MY inner-city hospital for myself--and was gratified at how service-oriented people were. How caring and careful. My patient ID was checked numberless times; my allergies to meds were asked over and over; the "right site" for surgery was repeatedly re-established. Medical history was rechecked where it might be salient (such as what other meds was I taking--had I had any meds in the last 24 hours?).

When you check in to a hospital, you are vulnerable. You are no longer taking care of yourself. You are letting others take care of you, and you want to be sure that they will be as careful of your well-being and safety as you yourself are. The folks who have direct patient care work, especially.

By the way, if your original post was true--that patients choose the doc, not the hospital--then how would hospitalists have any role in patient care? IF we are very careful, giving good reports to docs and nurses who take over patient care from shift to shift, then hospitalists can do a fine job. And they fill a need. Nurses pass on a patient's care to the next shift 3x/day, and if they are careful, it can be seamless in protecting the patient and ensuring continuity of care.