Most people in medicine shy away from the term “quality measure.” It promises more work and worse outcomes.
Most people intuitively suspect that quality measures are a superstition.
The American business community is structured around a model of large national corporations run with centralized planning and goal-setting to achieve desired corporate outcomes. That is one of many structures of business. It is one that is so popular in the United States, we believe that this model represents the rational way to do everything that people need.
Inherent in the superstitions held by modern American corporations is the unfounded that belief that management by the Taylor method is a way to implement the most efficient production method in any particular case.
It utilizes a style of management known at Taylorism, which is too complex to explain in detail here. A few aspects of Taylorism are familiar to the new American revolution in medical care. Production is maximized by using several interchangeable unskilled employees, where previously one skilled employee was necessary for that point of the process. Employees are not driven by any sort of professionalism. Their goal is to receive pay for the minimum amount of work.
The individual workers are not capable of originating independent processes for their work. They are not capable of understanding what separates good work from shoddy work. They are not motivated to infuse their work with quality.
It is possible that in mass manufacturing of products, such as huge volumes of clothing made overseas, Taylorism is a workable model. When applied to medical care, it is a dangerous superstition that destroys the quality of care.
The worker – the doctor and nurse in the clinic – are supposed to loaf around. Without work, they would sleep on the job; it’s all the same to them, Taylorism would say. They would do fast and shoddy work without oversight.
It is amazing how often this message is broadcast in propaganda in the American reporting environment. Look at all these opiate addicts! It must be the fault of careless doctors. The British Medical Journal states that medical care is the third leading CAUSE of death in America! Something must be done! Clean up those lazy clinics! the public demands.
Few people understand that lousy clinics are the inevitable product of the new American healthcare revolutions. Find a bad clinic – you are looking at a clinic that has been sequentially “improved” over the last 30 years to substandard mediocrity at best.
If the people who add the value to produce what you manufacture are shiftless, uncaring slobs, they must be watched over, of course. If your business is coal mining by shovel and pickaxe, then a measurement of productivity would be the number of tons of coal mined by each miner per day.
But if your business is something far more complex, like healthcare, the Taylorist model really shouldn’t be used. But it is. Now, the quality supervisors have a much harder job than just measuring tons of coal per miner per day. There are all sorts of actions that go into being an excellent doctor or nurse. The paradox is, the best observer of competence in a doctor is another doctor, in a nurse another nurse. But hiring two doctors to oversee the work of one is an unprofitable paradox. This paradox is seen in many centralized corporate and government entities. Huge panels of doctors and nurses are not doctoring or nursing, and may never again. They are the overseers.
To oversee professional operations more efficiently, then, it is necessary to use stand-ins for professional oversight. There are measures, and they are simple, so that an untrained person can evaluate the quality of the product.
This is where Taylorism in medicine breaks down completely. Nobody questions the possibility that thirteen check-boxes can reliably describe the quality of a patient’s encounter with the doctor or nurse. So of course, the same corporate measures set up for retail clerks are brought into medicine. Did the doctor smile when (s)he entered the room? Did you get what you want? (e.g. opiates?)
If you want to understand where the prescription opiate disaster came from, it is Taylorism. Customer satisfaction, in medicine, is often applying a limber hand to the prescription pad. Patients love you for it, whether their desires are self-injurious or not.
Opiates – morphine, for example – have been part of human society longer than any written language. Opium was known in paleolithic days. Its proper and improper use stretches back before the dawn of history. There is nothing new in society about opiates; rather, there is insight into the society based upon how its members use, and abuse, opiates.
But, back to the problem of quality. All these measures of quality are dreamed up, listed, formulated and quantified without any scrutiny at their birth. Is this a nonsense measure? Are we simplifying something into a number that cannot be simplified?
Early on in CABG surgery, it became obvious that poor inner-city hospitals had worse outcomes than fancy suburban hospitals. Of course, the measurers said – the inner city hospitals have quality holes where all the quality leaks out.
What was happening, the suburban hospitals were cherry-picking not only for ability to pay but likelihood of a good outcome. The hospitals of last resort did not have that luxury. They took the “no-touch” cases from the suburbs.
The unexpected outcome of this thoughtless imposition of quality measures in inner city hospitals is seen all over medicine. If a patient can’t get you a good score, why see them? The more “pay-for-performance” is used without credible quality measures, the more distorted the field of care will become.
Except in DPC, the trend is irreparable. Too many people want to be on the decider side of the coin. The chairs in the boardroom are nicer than those plastic disease magnets in the ER. We will drift in the direction that is seen elsewhere in America. There are plenty of healthcare employees, that’s for sure. If it weren’t for having to take care of patients, it sure is a cushy job for many workers who never touch a patient in their life.