Quality, Defined


Pornography. There can be few better hooks for readers than that. Just typing the word is a bit uncomfortable. As is, I imagine, reading it. But it’s effective, and likely why you’ve made it to word 37 of my column—34 words further than you usually get, I imagine.

“What about pornography?” you ask with bated breath. “What could pornography possibly have to do with hospital medicine?” your mind wonders. “Is this the column that (finally) gets Glasheen fired?” the ambulance chaser in you titillates.

By now, you’ve no doubt heard the famous Potter Stewart definition of pornography: “I know it when I see it.” That’s how the former U.S. Supreme Court justice described his threshold for recognizing pornography. It was made famous in a 1960s decision about whether a particular movie scene was protected by the 1st Amendment right to free speech or, indeed, a pornographic obscenity to be censured. Stewart, who clearly recognized the need to “define” pornography, also recognized the inherent challenges in doing so. The I-know-it-when-I-see-it benchmark is, of course, flawed, but I defy you to come up with a better definition.

I would hazard that 0.0% of physicians would argue with the premise that we are obliged by the Hippocratic Oath, our moral compass, and our sense of professionalism to provide the best possible care to our patients. If we accept that we aren’t doing that—and we aren’t—then what is the disconnect?

Quality Is, of Course…

I was thinking about pornography (another discomforting phrase to type) recently—and Potter Stewart’s challenge in defining it, specifically—when I was asked about quality in healthcare. The query, which occurred during a several-hour, mind-numbing meeting (is there another type of several-hour meeting?), was “What is quality?” The question, laced with hostility and dripping with antagonism, was posed by a senior physician and directed pointedly at me. Indignantly, I cleared my throat, mentally stepping onto my pedestal to ceremoniously topple this academic egghead with my erudite response.

“Well, quality is, of course,” I confidently retorted, the “of course” added to demonstrate my moral superiority, “the ability to … uhhh, you see … ummmm, you know.” At which point I again cleared my throat not once, not twice, but a socially awkward three times before employing the timed-honored, full-body shock-twitch that signifies that you’ve just received an urgent vibrate page (faked, of course) and excused myself from the meeting, never to return.

The reality is that I struggle to define quality. Like Chief Justice Stewart, I think I know quality when I see it, but more precise definitions can be elusive.

And distracting.

It’s Not My Job

Just this morning, I read a news release from a respected physician group trumpeting the fact that their advocacy resulted in the federal government reducing the number of quality data-point requirements in their final rule for accountable-care organizations (ACOs) from 66 to 33. Trumpeting? Is this a good thing? Should we be supporting fewer quality measures? The article quoted a physician leader saying that the original reporting requirements were too burdensome. Too burdensome to whom? My guess is the recipients of our care, often referred to as our patients, wouldn’t categorize quality assurance as “too burdensome.”

I was at another meeting recently in which a respected colleague related her take on the physician role in improving quality. “I don’t think that’s a physician’s job. That’s what we have a quality department for,” she noted. “It’s just too expensive, time-consuming, and boring for physicians to do that kind of work.”

Too burdensome? Not a physician’s job to ensure the delivery of quality care? While I understand the sentiment (the need to have support staff collecting data, recognition of the huge infrastructure requirements, etc.), I can’t help but think that these types of responses are a large part of the struggle we are having with improving quality.

Then again, I would hazard that 0.0 percent of physicians would argue with the premise that we are obliged by the Hippocratic Oath, our moral compass, and our sense of professionalism to provide the best possible care to our patients. If we accept that we aren’t doing that—and we aren’t—then what is the disconnect? Why aren’t we seeking more quality data points? Why isn’t this “our job”?

Definitional Disconnect

Well, the truth is, it is our job. And we know it. The problem is that quality isn’t universally defined and the process of trying to define it often distracts us from the true task at hand—improving patient care.

Few of us would argue that a wrong-site surgery or anaphylaxis from administration of a medication known to have caused an allergy represents a suboptimal level of care. But more often than not, we see quality being measured and defined in less concrete, more obscure ways—ways that my eyes may not view as low-quality. These definitions are inherently flawed and breed contempt among providers who are told they aren’t passing muster in metrics they don’t see as “quality.”

So the real disconnect is definitional. Is quality defined by the Institute of Medicine characteristics of safe, effective, patient-centered, timely, efficient, and equitable care? Or is it the rates of underuse, overuse, and misuse of medical treatments and procedures? Or is it defined by individual quality metrics such as those captured by the Centers for Medicare & Medicaid Services (CMS)—you know, things like hospital fall rates, perioperative antibiotic usage, beta-blockers after MI, or whether a patient reported their bathroom as being clean?

Is 30% of the quality of care that we deliver referable to the patient experience (as measured by HCAHPS), as the new value-based purchasing program would have us believe? Is it hospital accreditation through the Joint Commission? Or physician certification through our parent boards? Is quality measured by a physician’s cognitive or technical skills, or where they went to school? Is it experience, medical knowledge, guideline usage?

We use such a mystifying array of metrics to define quality that it confuses the issue such that physicians who personally believe they are doing a good job can become disenfranchised. To a physician who provides clinically appropriate care around a surgical procedure or treatment of pneumonia, it can be demeaning and demoralizing to suggest that his or her patient did not receive “high quality” care because the bathroom wasn’t clean or the patient didn’t get a flu shot. Yet, this is the message we often send—a message that alienates many physicians, making them cynical about quality and disengaged in quality improvement. The result is that they seek fewer quality data points and defer the job of improving quality to someone else.

Make no mistake: Quality measures have an important role in our healthcare landscape. But to the degree that defining quality confuses, alienates, or disenfranchises providers, we should stop trying to define it. Quality is not a thing, a metric, or an outcome. It is not an elusive, unquantifiable creature that is achievable only by the elite. Quality is simply providing the best possible care. And quality improvement is simply closing the gap between the best possible care and actual care.

In this regard, we can learn a lot from Potter Stewart. We know quality when we see it. And we know what an absence of quality looks like.

Let’s close that gap by putting less energy into defining quality, and putting more energy into the tenacious pursuit of quality.

Dr. Glasheen is physician editor of The Hospitalist.

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