The American hospital system is in a state of crisis. On the one hand there is competition to increase the profits that hospitals generate. On the other hand there is a concerted effort to improve the quality of care that is delivered by them. In some sense, these are competing values insofar as quality healthcare is an expensive proposition. Medical error accounts for a large portion of the failure in quality as well as the perceived lack of quality in care. In some respects, medical error is unavoidable. Physicians are humans and they will make mistakes. Furthermore, many hospitals are also teaching environments where less trained physicians are brought in to learn the profession and healthcare. However, simple organizational procedures can resolve a large number of these errors making the hospital a safer environment for patients. Quality improvement programs are another area where hospital management can make inroads at improving patient care, but so far the results of Quality Improvement protocols have been mixed.
In Alexander, et al., the question was raised about the effect that quality improvement implementation has in the clinical hospital environment (2007). The authors had a three prong hypothesis, the first being: that the more competitive the marketplace for the environment the higher association between quality improvement implementation and the levels of quality care. The second hypothesis was that the higher the penetration of managed care in the hospital, the stronger the association between quality improvement implementations and levels of quality care. The final hypothesis was that the greater the profitability of the hospital, the higher the correlation between the quality improvement implementation and the levels of care delivered. The sample of 1784 hospitals found that the first hypothesis was only partially supported. In fact, with increased levels of quality improvement initiatives acute myocardial infarction mortality, stroke mortality, and laproscopic cholecystectomy outcomes, the quality of the healthcare actually decreased. The results as to the second hypothesis found that the increase of managed care penetration into the system, the higher the quality improvement tool use, and once again though, hospital quality indicators showed a significant decrease. Finally, hypothesis three was also only partially supported by the findings and showed that in several key areas as hospital profitability increased, the quality improvement programs still resulted in a worse level of care.
These findings are alarming and quite sobering to say the least. Quality improvement programs require time and money to implement that is completely wasted if outcomes turn out worse than in the previous model. However, there is a substantial problem with the thesis of modeling outcomes as “quality care.” Healthcare is not a zero-sum game that can be easily distilled into numbers. Patients are all very different and have various co-morbidities that they bring to the table. Furthermore, there is no system that will drive mortality to 0. Patients come to the hospital because they are sick, and often fatally so. No amount of quality improvement or money thrown at the problem will ever change the fact that people are going to die. It is a wonderful thing to have a young patient with a single direct problem that can be easily managed or repaired, however that is rarely the case in a hospital. It is usually elderly people with a list of antecedent medical conditions that can run into multiple pages that utilize health care, and quality improvement be damned, many of them will die despite the highest levels of care deliverable. The view that the practice of healthcare can be distilled to mortality is sophomoric and shows a lack of understanding of medicine. Medicine is a ministry. People will die no matter what concoction, or operation is performed. The question is the quality of life that is able to be produced for people in their final days and the peace of mind that the physician is able to deliver for them – that they will not die alone, that they will be tended to, and looked after to the best of his abilities, even if they are lacking. It is a well known phenomenon that in the case of actionable medical error a patient is much less likely to sue a doctor that he likes regardless of how poorly the physician performed the procedure. That, in fact is the greatest indicator of “quality care,” that the patient feels he has a trustworthy ally in the face of life’s final onslaught and that this ally will stay by his side hoping to abate the effects deaths inevitable toll.
The ultimate conclusions of Alexander, et al. are sound. In order for a quality improvement initiative to be effective there must be adequate resources allocated to the problem. To have inadequate resources allocated will likely just create Kafkaesque bureaucracy that will only hinder patient care. It is obvious that forces external and internal to hospital administration will impact the effectiveness of quality improvement programs and that without adequate financial, strategic, and market imperatives, such initiatives will go nowhere.
Dr. Makary’s damning piece of literature is sobering too, for highlighting the effects of bad medical care on both the patient’s mortality and the cost that is added to the system because of it. However, he initiates his thesis with a phenomenally bad example. Indeed, every airline disaster gets a thorough investigation. However, this is likely because every time a plane lands and before every takeoff, trained crews go over every detail of the airplane beforehand. If people were to get a thorough review of their health even only once a month and repairs and tune ups performed as scheduled, mortality would be greatly improved. However, unlike airplanes, people tend to neglect their own healthcare until the consequences are quite catastrophic and the prognosis relatively dire. In effect, the hospital is more akin to every passenger on the airplane having a bomb on him with a random timer. Indeed, every hospital has a Dr. Hodad, but what we never learned was how many of Dr. Hodad’s patients were rejected by physicians such as Dr. Makary because they knew the outcomes would be bad or even only mediocre? Dr. Hodad may have had terrible outcomes, but perhaps his patients were in considerably worse shape than the rest of the departments patients, and it was only he that stood up and said “at least we must try.” Truly negligent handling of a patient is an unforgivable sin, and should be handled through appropriate channels. Some of Dr. Makary’s suggestions make excellent sense, such as the use of cameras. Others though make less sense, such as the use of dashboards. There is a great inequality in the level of knowledge between patients and physicians. A patient may do a Google search on his symptoms and think that he knows what he has and what standard of care should be applied based on the first three Google results, but that doesn’t replace years of medical school, followed by years of residency training. What that data will never reveal is which patients are rejected from admission into a hospital because of their bad condition and in an effort by the hospital to improve their numbers.
In sum, these articles represented interesting anecdotes into the functional aspects of hospitals and their management. Both articles though approached their theses from a position assuming a super educated patient and a maladaptive patient. Patient care and medicine is not so elementary and can not be reduced to the metrics that the authors have proposed – doing so will inevitably overlook the fact that in the end the physician is caring for a mortal. As such, these articles should make a professional think about the ways that they can improve the quality of care as measured by objective standards – but they should not be taken as end of the discussion on the meaning of health care quality.
References:
Alexander, J.A., Weiner, B.J., Shortell, S.M., Baker, L.C. (Aug. 1, 2007). Does Quality
Improvement Implementation Affect Hospital Quality of Care?. redOrbit. Retrieved from: http://www.redorbit.com/news/health/1019586/does_quality_improvement_implementation_affect_hospital_quality_of_care/
Makary, M. (Sept. 21, 2012). How to Stop Hospitals From Killing Us. The Wall Street
