• Caring about quality and caring for the patient

    Is there a tension between caring about the quality of health care and caring for patients? It doesn’t seem like there should be, but let’s look more closely. We’ll start with current efforts to improve the quality of care.

    A lot of quality improvement programs approach ‘quality’ the way that Toyota does:

    16gg4-manufacturing-300x169[Toyota] strives for the absolute elimination of waste, overburden and unevenness in all areas to allow members to work smoothly and efficiently. The foundations of [our production system] are built on standardization to ensure a safe method of operation and a consistent approach to quality. Toyota members seek to continually improve their standard processes and procedures in order to ensure maximum quality, improve efficiency and eliminate waste. This is known as kaizen and is applied to every sphere of the company’s activities.

    I have found the ‘kaizen’ idea — to always look for small marginal improvements in practice — to be life changing. However, even if standardization makes sense on an assembly line, does it make sense in medicine?

    It does, according to Atul Gawande, because medical care comprises complicated streams of tasks and floods of data. This complexity leads to frequent errors and omissions of critical health services. Aaron has a definitive set of posts on quality problems in US health care. And these errors matter because there are lots of ways to die in the hospital.

    icu-patient[In] intensive care: at any point, we are as apt to harm as we are to heal. Line infections are so common that they are considered a routine complication. I.C.U.s put five million lines into patients each year, and national statistics show that, after ten days, four per cent of those lines become infected. Line infections occur in eighty thousand people a year in the United States, and are fatal between five and twenty-eight per cent of the time, depending on how sick one is at the start… [Similarly,] after ten days with a urinary catheter, four per cent of American I.C.U. patients develop a bladder infection. After ten days on a ventilator, six per cent develop bacterial pneumonia, resulting in death forty to fifty-five per cent of the time. All in all, about half of I.C.U. patients end up experiencing a serious complication, and, once a complication occurs, the chances of survival drop sharply.

    Standardization is meant to both reduce these risks and health care costs. Health care organizations (HCOs) define standards and algorithms for quality care. To make sure these standards are followed, HCOs inspect care retrospectively to insure that patients have been appropriately cared for. Clinicians are held accountable for quality through various incentives, and they must therefore accurately document the work they have performed.

    But is something lost in the translation of quality improvement from the Japanese shop floor to an American hospital ward? Here is Arnold Relman, writing about his hospitalization with a broken neck:

    what I hadn’t appreciated was the extent to which, when there is no emergency, new technologies and electronic record-keeping affect how doctors do their work. Attention to the masses of data generated by laboratory and imaging studies has shifted their focus away from the patient. Doctors now spend more time with their computers than at the bedside. [emphasis added]

    As I’ve written previously, time spent documenting care may be crowding out time spent interacting with patients. A recent study of emergency room physicians found that they spend more time interacting with screens than patients, clicking the mouse 4000 times in a 10-hour shift.

    Is there a point where attending to the standards conflicts with attending to the patient? Francis Peabody wrote the classic essay on the centrality of the doctor-patient relationship in medical care:

    The good physician knows his patients through and through, and his knowledge is bought dearly. Time, sympathy and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.

    Iona Heath believes that the caring relationship is being undermined, because

    The quality and outcomes framework diminishes the responsibility of doctors to think, to the potential detriment of patients, and encourages a focus on points scored, threshold met, and income generated.

    David Loxterkamp argues that

    …physicians who value the therapeutic relationship must be a little sympathetic to the plight of the mad scientist in Mary Shelley’s Frankenstein. He was taunted by the monster that he brought to life, “You created me, but I am your master.” Likewise, we have created a place in our exam rooms for a computer that needs our care and feeding. It now directs the flow and purpose of an encounter that once unfolded organically according to the particular needs of the patient.

    So is there a conflict between caring about quality and caring for the patient? I want to write more about this and I would like to hear from health care providers, patients, and family members. Send me email or get in touch on Twitter.

    @Bill_Gardner

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