The word “quality” gets thrown around a lot in discussions of healthcare. In Washington, D.C., politicians like to opine that Americans will have “higher quality” health care at a lower cost. Do you think they know what they mean by “higher quality”? Have you ever thought about what quality in health care really means?
Actually, quality means a lot of different things to a lot of different people and organizations within our healthcare system in the United States.
Quality, like obscenity: “I know it when I see it”
The English Oxford Living Dictionary defines quality as “the standard of something as measured against other things of a similar kind; the degree of excellence of something” or alternatively, “a distinctive attribute or characteristic possessed by someone or something.” These definitions don’t really help us all that much.
Attempting to define quality reminds me of the famous quote of Supreme Court Justice Potter Stewart. In 1964, Justice Stewart said that he could not define “obscenity” but “I know it when I see it”. Sometimes I feel that way about defining quality in healthcare. As a doctor, a chief medical officer and an occasional patient – in regards to quality, “I know it when I see it”.
What do we actually want to measure?
One way to figure out how to define quality is to look for areas of healthcare that we wish to measure and to which we wish to attribute a degree of quality. Some examples include:
- The skill of the doctor and other providers to make correct and timely diagnoses
- The skill of the doctor in ordering the correct tests
- Tests that are performed correctly
- Test results are shared with the patient in a timely and understandable way
- The doctor or other provider’s literal skill in performing a surgical or other procedure
- Staff answer the phones when patients call
- Access to care is reasonably timely for both routine needs as well as urgent or emergent needs
- Providers communicate with each other about complex patients to assure the best outcomes
- Doctors follow up with patients at the correct intervals
- Hospital and ambulatory facilities are clean
- Healthcare personnel adequately wash their hands
- Groups of physicians score high on their quality measures as dictated in their contracts
- Providers avoid over-testing and over-treating
- Information technology produces highly accurate, aggregated actionable data from EHR, claims, lab and other sources
This short list demonstrates that measuring quality in all of these domains is not easy. Much attention has been paid to the quality measures doctors must hit in value based care contracts. These measures, such as rates of completing mammograms, Pap smears or colonoscopies, are useful, but as you can see from the list above, they cannot come close to measuring the totality of care and by extension the total quality of care.
Quality as perceived by patients
The list above refers to concerns that a patient, physician, healthcare system, or payer might have about aspects of quality performance. But how is quality as perceived by the patient reflected back to the providers?
Currently a movement is afoot to use more patient-reported perceptions of care as useful feedback to providers. Some insurers call these PROM – Patient Reported Outcome Measures. For example, patients may use IT to report back to their providers on how they are recovering from an elective surgery or how they might be progressing with treatment for depression. I believe there is tremendous opportunity in using feedback from patients that flows directly in to the electronic health record.
This should and will be an area of growth and innovation in the years ahead. Any industry, including healthcare, should receive and perceive all feedback as gold on the path of continuous quality improvement.
So how should we use “quality” in healthcare?
“Quality” is used in myriad ways in the healthcare setting.
- Individual patients have their own personal definitions of quality at the micro level. For example, measures of quality might be the patient’s satisfaction with the wait time in the exam room or how the doctor communicated.
- Providers have their own definitions of quality – whether that refers to a specific quality measure – all of a provider’s patients under 2 years old received the appropriate vaccines – or to the overall care provided to a patient and the patient’s outcomes.
- Payors also measure quality of care at both the micro level of services provided to a specific patient, and in the aggregate macro level in terms of measures that track the quality of care provided to a population.
I hope this blog has stimulated your interest in the meaning of the word quality when it is used in conjunction with healthcare. Questions are power, so never stop asking!