What is high quality healthccare? And how do I not know how to answer this question after seven years of medical education? The easy answer to my second question is that I was never taught; however, I think the issue is a little more troubling than that. If asked, I think many physicians, myself included, would come up with a list of factors that play into quality of care: it should be accessible, guided by best evidence, safe, compassionate, and timely. However, I would suggest that this list is missing an important element, and moreover, that this missing element is the key to improving the quality of care we provide to patients.
High quality healthcare: What’s missing
The theory of quality improvement is not a new field – it was first developed in the 1920’s, pioneered by Drs. Shewhart and Demming, both physicists. They defined methods for improving industry efficiency, as well as the statistical framework for measuring the effect of interventions. Their ideas have since been employed widely in industry to ensure high quality products and services, while minimizing cost. However it is only recently that their ideas have made their way into healthcare, despite there being an evident need.
It is well-known that healthcare in Canada, and in most of the developed world, is approaching a financial crisis. Currently in Ontario, 43% of the provincial budget is spent on healthcare, and this is projected to rise to 80% by 2030. Other provinces, and other countries, face similar situations with rapidly rising healthcare costs. Although there is much discussion about the cause of rising costs, as well as about how to pay for them, the bottom line is clear – the current course is not sustainable.
On the other hand, healthcare outcomes could certainly be better. In particular, there is often a wide gap between recommended best practices, and observed clinical practice. Taking ischemic heart disease as an example, the evidence is clear that all patients, barring contraindications, should be on a beta-blocker, an ACE-inhibitor, aspirin, and a lipid lowering agent with specific targets. Moreover the vast majority of physicians are aware of these recommendations. However repeated studies demonstrate that less than 1 in 4 of these patients receive ideal therapy.
Quality improvement methods that address both of these issues are an ideal fit. In industry, it has long been understood that quality improvement includes standardizing and streamlining processes, while decreasing the opportunity for human error. However, early attempts at implementing quality improvement in healthcare have not always gotten it quite right.
It is human nature to remember our failures, and we are often told we learn from our mistakes. It is not surprising, then, that attempts at quality improvement often involve addressing adverse outcomes, and preventing their recurrence. Unfortunately, while there is certainly benefit in preventing serious adverse events, even when we are successful, the overall effect is relatively small. Since adverse events are by definition outliers, addressing them will have very little impact on the average patient.
Thus we come to the oft-overlooked aspect of high quality healthcare – it should be consistent. Once we include this ingredient, it becomes clear that to provide high quality healthcare, we must focus less on outcomes, and more on processes.
Why is there such high variability in hospital length of stay, for example, after elective orthopedic procedures? Certainly some of it comes from patient variability, but studies suggest that the observed variability exceeds by far that which would be expected based on patient characteristics alone. Furthermore, all patients require the same things – pain control, physiotherapy, patient education, and assessment of safety – prior to successful discharge.
By analysing a patient’s journey from presentation to discharge, and identifying the steps required for ideal care and safe discharge, we can optimize and standardize this path, thus improving consistency, encouraging compliance with best practices, and reducing inefficiencies. Also, by addressing the process as a whole, changes have an impact on every patient, not just the outliers, so their effects are likely to be greater than those achieved by focusing on specific outcomes.
In short, it is time to move away from preventing bad outcomes, and focus instead on ensuring the best outcome, and the optimal path, for each patient. We must become process experts, and focus on providing consistently high quality healthcare. Without this approach, we have little hope of tackling the looming issues facing medicine today.
- Drummond, D. Commission on the Reform of Ontario’s Public Services. 2012.
- Pearson. The lipid treatment assessment project: a multicenter survey to evaluate the percentages of dyslipidemic patient’s receiving lipid-lowering therapy and achieving low-density lipoprotein cholesterol goals. Arch Intern Med. 2008; 160(4):459-67
- FitzGerald, J. Regional Variation in Acute Care Length of Stay after Orthopaedic Surgey Total Joint Replacement Surgery and Hip Fracture Surgery. J Hosp Adm. 2013; 2(4).
- Haddadsm. Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs: RHL commentary (2010). The WHO Reproductive Health Library; Geneva: World Health Organization.