Ten action items for improving the quality of care delivered by the US health care system.
In my previous post, “When Medical Quality Suffers, People Are Harmed,” I discussed the consequences of medical and surgical errors. It is disheartening to read the US statistics surrounding this topic. We pale in comparison to many other countries (even some third-world nations). Speaking as a former physician executive, often in charge of quality improvement and appropriate utilization management, I'd like to present 10 immediate steps that will reduce poor quality of care.
Ten Steps That Reduce Poor Quality Care
1. Group practice of medicine, preferably operating around a hospital that includes peer review, performance incentives, shared information and a computer-based tracking system.
2. More effective public health and preventive services available to the entire population, based on its dynamic needs.
3. Group-based payment for health services, structured through the use of insurance or taxation for sharing the costs of health care, broadly across people and time.
4. Shared responsibility and accountability by patients, doctors and/or systems of care, as the case may be for: adverse life-style choices where there has been little of no intervention, non-compliance where patients are quite capable of adhering to appropriate medical/surgical recommendations, failure to cost-share and prevent clearly unnecessary care, excesses, and failure to use or follow peer-reviewed standards of care.
5. Enhance coordination between medical and community services. We also need to make improvements in medical education that will strengthen the social content of curriculum and expand the supply of general practitioners, (in contrast to specialists).
6. Align the incentives to ensure that everyone's on the same page with a single goal of providing efficient, effective, and accessible care. I as a practitioner should be able to earn a premium, the healthier I make you. Should that fail, at least recognize my efforts and its quality. Note: this is not the same as “pay per performance” (See: "Pay for Performance and Other Impotent Incentives" and "Quality Incentive Payment Systems: Promise and Problems"). We must align the incentives so that patient, practitioner and facility have the same objective—the right care at the right time and place. There cannot be any incentives for delaying care—bureaucratic hurdles, as it were. There can be no incentives for over-utilizing—for instance, giving unnecessary antibiotics or shotgun, “blind alley” testing. There can be no incentives for under-utilizing, such as, over-referral (ie, dumping patients), delaying or cutting short physical therapy, skipping patient education, mental health care, etc). Incentives should include, but not be limited to providing payment when pre-established goals and objectives are met. In other words, wherever possible, we should be aligning payment and quality in the interest of motivating improvement.
7. Transparency and public reporting See "Error Reporting and Disclosure" especially as it discusses systems improvement such as electronic error reporting.
8. Encouraging real, salutary quality improvement It would be misleading to say that mere transparency had motivated surgeons, for instance, to make improvements that they would not have done otherwise. I believe that most if not all concerned professionals are or should be interested in continuous quality improvement. Indeed, I have found that most practitioners will pick up on real or even putative deficiencies, learn from the introspection, and develop new techniques, improving what has to be improved, incrementally if necessary. In "Deaths Drop after Release of Bypass Surgery Results,” it is not proven that this was cause and effect, but it's certainly suggestive that patients will choose wisely if given the needed information. On the other hand, if you think that certain surgeons, given the spotlight will avoid the riskier cases, we should be seeing a decrease in the number of bypass surgeries. I cannot find any evidence of that. If anything, the average age and number of co-morbidities in bypass cases seems to be increasing.
9. This brings us to the final point of the need to be closing the feedback loop in real-time (ie, at the point of contact with the patient and with believable data). For that one needs acuity adjusted data, which will allow comparing apples to apples, not apples to oranges.
10. Finally, one needs a longitudinal perspective -- all care over time, regardless of setting, the definition of a reliable type of observation -- an 'episode of care.' (See: "Report Cards That Support")