PerspectivesAre you interested in submitting a Perspective Article? Be sure to read The Science Advisory Board's Editorial Guides for Perspective Articles. Click here. Quality Assurance…Bah…Humbug by David W. Crippen, M.D., F.C.C.M. A Member Since July 2003  There is a new buzz word created every time those charged with measuring the objective results of hospital care get bored with the old one. I might have the temerity to suggest that Continuous Quality Improvement (CQI) and the like is usually manipulated to fit preformed conclusions of what the business suit establishment feels is "good medical business" at that given instant.The issue of quality assurance in clinical medicine has been stalled at the level of committees and bureaucracy for as long as I have had anything to do with it. "Quality" is judged by these people in terms of "markers," with dependent variables fanning out from each of these themes. If a preordained level of compliance is measured for each marker, it is assumed that the variables covered by that marker are in compliance as well. This is how a bureaucrat looks at the world...by statistical probability and confidence levels. CQI is simply a practical method for creating politically correct form from the void of a chaotic medical microcosm. I suspect the reality is that compliance with each of these markers predicts nothing except that an isolated integer in an secluded sea of numbers has been reached. The end-product depends greatly on the capability of individuals to manipulate toward selfish goals. Does the 55 miles per hour National Speed Limit save lives? Depends on which side you listen to. Both have equally convincing statistics to support their side. If administrators desire to show that surgeons showing up late to surgery tie up rooms and hold up emergency cases they analyze the data one way. However, if they desire to show that it has no effect on the quality of care, then they analyse it another way. Those receiving the data filter it according to their biases as well. If the humans generating the numbers have an incentive to cook the books, patient care may actually suffer. If 95% compliance for patients not pulling IVs out of their arm is reached. It does not necessarily follow that patients are being made more comfortable. It more follows that they are being tied to the bed tighter, decreasing their comfort. If a cardiac surgeon's mortality score is above the allotted threshold, it may only mean that he has avoided any patient with the slightest chance of increased risk, not doing the aggregate of potential patients any favors in the process. It may also mean that he insures that his failures get admitted to rehabilitation floors that are in essence discharges from the medical part of the hospital. When they die later while ventilator dependent, it doesn't show up on his statistics. CQI can be viewed as a means to pacify those with complaints or promote political agendas of individual hospital departments, neither of which server much useful purpose. What are meaningful predictors of acceptable hospital care? In the end, I think deliverance of quality care in medicine depends almost exclusively on the internal incentive of individuals, but self-motivation is notoriously difficult to measure objectively. Those who go beyond the bare minimum tend to promote good care. What is the objective marker: physician activists storming into hospital administrators' office with murderous intent as an advocate of resource allocation favoring patient care? Where is the marker for physicians standing at the bedside making difficult decisions instead of by phone from their comfortable bed in the wee hours? What are the markers for individuals simply doing the right thing because it is simply the right thing to do? I recall several years back going to a meeting about "Quality Circles". The thrust of the idea was to assure quality by establishing an eclectic committee of righteous individuals from within the ranks of institution working stiffs who would come together, evaluate problems and "do the right thing". Further, they would be "empowered" to do the right thing by the hospital administration! I looked around incredulously! Everyone in the entire audience was taking it all in...no one was laughing! Everyone thought it was a great idea. I also noticed that the representatives from the hospital administration were smiling benignly and nodding at appropriate places. Hospital administrators allocating power to groups of employees with no controls? Is this possible? Sure. It's possible I can I win the Pennsylvania Lottery...as possible as an Arab Pope. Is this fish fresh? Sure…as fresh as the day it was caught and frozen six month ago. Of course, this idea quietly went the way of the Dodo. Hospital administrators want to see righteous change without diluting their power to control outcomes from same. Recall the "Hands across America" drive a few years ago: multitudes of ordinary citizens donating their time and energy to form a long human cheek by jowl chain across the country to dramatize social problems. This is what Quality Assurance bureaucrats understand. Glib and ostentatious displays of human emotion that prompt others to donate money, not grinding out effective rules for the use of expensive, high technology medical resources and forging a consensus policies that no one may like, but with which everyone can live. That is the nature of a political process. In many respects, Quality Assurance, as it is currently practiced at the hospital level, seeks to use a snowstorm of numbers to divert attention from decision-making that would necessarily be adversarial, confrontational, and politically labile. Good statistical methods, solid data, and accurate interpretation together can be beneficial to everyone if they are all willing to accept the "real" results. Individuals and groups who depend on an convoluted system of resource management that would fry Adam Smith's brain to a crisp usually refuse to accept such revelations if they are not friendly to their turf position. Right outside the door, life goes on as guided by the immutable laws of supply, demand, resource allocation and internal politics. The band plays on...the deck chairs swap position. ### David W. Crippen, MD, FCCM is Clinical Associate Professor of Critical Care Medicine at the University of Pittsburgh Medical Center. He also holds a secondary appointment as Clinical Associate Professor in the Department of Emergency Medicine. He trained in general surgery, Emergency Medicine and Critical Care Medicine. Dr. Crippen is a member of the Society for Critical Care Medicine, the European Society for Intensive Care Medicine, and the American College of Emergency Physicians. He is a Fellow of the American College of Critical Care Medicine, a Diplomate of the American Board of Emergency Medicine, and the European Diploma in Intensive Care Medicine. Over ten years ago Dr. David Crippen founded an international critical care medicine discussion group on the Internet (http://www.pitt.edu/~crippen/). Today, with over 1,000 members it has become a model for how the Internet can effectively facilitate communication and the exchange of information among professionals around the world. To read more about Dr. Crippen please visit his Science Advisory Board profile, Clinician Pioneers Professional Communications Via the Internet. ### << Previous Next >> [ View All Perspectives ] |
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