It’s not a choice: Good quality needs relationships and measurement

photo-joshua-tepperI was thrilled when Dr. Joshua Tepper, CEO of Health Quality Ontario, responded on Twitter to a popular post: Medicine is Relationship, Not Quality Metrics.

Josh has a true heart for patient care and the centrality of the doctor-patient relationship. He is also passionate about quality.

He asked if I would post a response from him, if he wrote one.

I said, “Of course! I’d make it a stand-alone blog post!

So, here is Dr. Tepper’s response. I think it’s excellent and look forward to hearing what you think of it, too.

 

It’s not a choice: Good quality needs relationships and measurement

Pursuing the six dimensions of quality for improved patient outcomes

This blog is inspired by a posting from Dr. Shawn Whatley a couple months ago.

Shawn is a family doctor, health care leader and an active member of health care’s social media sphere. He does a nice job of bringing a range of different views to the forefront.

In his blog, “Medicine is Relationship, Not Quality Metrics,” Shawn shares the perspectives of two physicians who feel that the doctor-patient relationship is more relevant to good patient outcomes than quality metrics. He quotes Dr. Michel Accad, who says that measuring quality-related outcomes “actually makes quality worse.” He also shares the perspectives of Dr. Michelle Vilcini, who talks about what she sees as one of our collective failings: “trying to measure things that can’t be measured.”

I’ve had a few people ask me via Twitter for my thoughts, so here they are.

First and foremost, it is a false dichotomy to see this as an “either/or” choice. A good doctor-patient relationship is actually one aspect of quality; it is captured within the concept of being “patient-centred” – one of the six recognized dimensions of quality, as defined by the Institute of Medicine. The six dimensions, including safe, equitable, efficient, effective and timely care, have been widely adopted as a framework for quality here at Health Quality Ontario, where I work as President and CEO, and elsewhere. Patient-centredness is also the cornerstone of the College of Family Physicians medical home model.

The importance of patient-centredness is also reflected in a blog by Dr. Ashish Jha, a physician and health policy researcher. In one posting, Ashish reports the results he got after he asked his Twitter community for a one-word response to the question, “What makes a good doctor?” The top five responses were “empathetic”, “good listener”, “compassionate/caring/kind”, “humble” and “competent/effective.” His conclusion: “Most people assume that physicians meet a threshold of intelligence, knowledge and judgement and therefore, what differentiates good doctors from mediocre ones is the ‘soft’ stuff.”

There is no doubt that the “soft stuff” – being patient-centred, and nurturing doctor-patient relationships – is part of quality.

But there are a couple places where Shawn and I might have some differing thoughts on the matter.

With regard to the suggestion that we can’t measure the doctor-patient relationship, Shawn suggests that there is no way to accurately gauge the encouraging friendship between patient and provider. But I’d point to the many ways in which the primary care field is increasingly trying to measure that relationship through surveys that target the experience of the patient. There are examples of patient-centred metrics in the Primary Care Patient Experience Survey and the Commonwealth Fund Survey, two among many, which ask for ratings on aspects of the doctor-patient relationship. These surveys can clue individual providers and entire teams into some of the more subtle areas of their care that need improvement. It’s worth noting that there has also been at least one study suggesting a troubling link between patient satisfaction scores and the propensity to prescribe opioids and/or unnecessary testing. This speaks to a need to measure patient experience in addition to other dimensions of quality, such as safe and effective care, and it leads to my second point of divergence with Shawn’s posting.

Building a strong doctor-patient relationship and concentrating on patient-centredness is just one dimension of quality and good care. But care also needs to be safe, equitable, efficient, effective and timely. Naturally these dimensions overlap, and a strong patient-centered relationship will make the other dimensions easier to achieve, but I feel we must be conscious of all six dimensions – especially when discussing improving patient outcomes.

Finally there is the suggestion in Shawn’s work that having a good doctor-patient relationship means you don’t need “a bunch of numbers” to measure it. In response to that, I’d go back to Ashish’s Twitter exercise. One of his Twitter followers responded to Ashish’s question with the following comment: “If your doctor doesn’t use the best data available to them to take care of you, do they really care about you?” Quality metrics and relationship building are connected more than we might think. Of course we can and should comfort, support and listen to our patients. But we also need to let them know when they are due for a Pap smear or a colorectal cancer screening test, or when a cholesterol-lowering medication might increase their chances of living to see their grandchildren graduate from high school. These are the metrics that make a difference.

I’d argue that we shouldn’t try to choose between good relationships or measurement – one is a dimension of the other. Similarly we should be cautious in suggesting that important things like the doctor-patient relationship can’t in fact be at least partially measured. We’d be doing a disservice to our patients to dismiss all quality-related outcomes when data about our practice can help us provide better care.

Thank you to Dr. Irfan Dhalla and Anna Greenberg for providing their input and advice on this blog.

 

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8 Replies to “It’s not a choice: Good quality needs relationships and measurement”

  1. I agree that balance is important. Data to help get things right is absolutely necessary but when resources are finite we have to be judicious on how we put them. At this point it seems to me that we have plenty of metrics to work with so we should be allocating the vast majority of dollars, whether new or old funding, to front line health care.

    I think the pendulum has at this point swung too far toward measuring and it is time to realign the energy. Frankly, those in administration often seem enslaved by the numbers as they do not have front line experience. Pragmatic use of metrics is important. These two articles show some downsides of sticking slavishly to measuring: http://mobile.nytimes.com/2016/01/17/opinion/sunday/how-measurement-fails-doctors-and-teachers.html?referer=https://t.co/rC9PX9rP3d&_r=0

    http://theincidentaleconomist.com/wordpress/the-burden-of-checklists-and-the-importance-of-core-metrics/

    Don’t get me wrong: I am not against gathering knowledge but I still want to do it and use it wisely.

    1. Great note, Gerry! I really appreciate you sharing your thoughts and those two links, too.

      Mulling this over for a few weeks, I realize that those of us who question the clarity-measurement-accountability fad get painted as anti-measurement obscurants. We do not question measurement because we think it is wrong or inaccurate per se. We question it because we think it will never come close to capturing the millions of data points required to make a great decision.

      We do not fight measurement; we fight limited measurement that leaves out the bulk of truth.

      But that leads us to ask, “How much measurement do we need?” Those of us who question the primacy of measurements in decision-making – crisp data points on spreadsheets and graphs – argue that there is too much we leave unmeasured, and our mental faculties are not up to the task, to make great decisions based primarily on measurement and audit. We believe that we need the billions of data points from the 320,000 patient services provided each day. We believe that we need to rely on the non-expert/front-line/end-user sources of information, which offers more wisdom and relevance than an aggregate or average.

      Does a small group of elites know what’s best for a population, based on data sets and averages? Or do the millions of interactions (trading decisions) hold better information about what’s best? I believe this debate hinges on political philosophy: big state knows best vs. free individuals making decisions aligned with their best interests. Marx vs. Adam Smith.

      Again, thank you so much for taking time to share your thoughts, Gerry!

      Best regards,

      Shawn

  2. I am enthused by this conversation, as started by Shawn and continued by Joshua.

    We are in a world where data is the ultimate currency, whether that be the goods purchased on your Visa card, the searches you frequently do on Google, or the trends found by monitoring your FitBit. When we don’t understand what will happen to the things we measure, I believe that’s where things break down, not in the measurement itself. Ultimately, what we look at needs to be seen in context of everything else going on, which is were we get hung up in measurement of things like patient experience, outcomes, and the IOM’s six domains of quality. There is a lot of complexity.

    Measures must be meaningful, but meaning has different contexts and applications for different people. Good measures should likely be comparable, but humans are round pegs and frequently we try to shove the insights from measurement of their thoughts into square holes. And our relationships are multifaceted, which makes even asking the right question incredibly complicated.

    Making matters worse is the nagging thought that we have as physicians that somehow, somewhere, sometime measurement of outcomes or experience will be used to punish us. I am not sure where this comes from. From the culture in which we were trained? From our perfectionistic and type A personalities? From our autonomy? This speaks to the need for authentic conversations around accountability. We are defend our accountability to our individual patients, as this is held sacred. But we are just beginning to wrap our minds around accountability to populations and to the health care system as a whole. This is an expanded view of responsibility and will take time for doctors and nurses to assimilate. Accountability does not equal blame. It simply matches intent to outcomes. We all want to do the right thing, but every now and then we should look inward to see if that desire to do best actually produces the desired effect. Measurement is how we do this. It is not to be feared.

    Perhaps we are not asking the right questions yet. Perhaps we don’t have the right measures. The only way we can tell this is if we apply them, look at the outcomes and then use that information to course-correct. The more nimbly we can use our data to drive out such insights, the more often we ask about things like experience and relationship, the better off we will be. It is possible to apply some degree of rigor to the measurement of soft things like relationship, and perhaps it will be more qualitative than quantitative, but that’s perfectly okay. The fact that we are asking at all has changed the course of how we maintain and enhance the relationship we have with our patients. I personally want that feedback.

    Thanks again Shawn and Joshua for providing this forum for thought! Kudos to you both.

    1. Wow! What a thoughtful, thorough, and articulate comment. Really excellent, Darren.

      You honed right in on the key issues: are we asking the right questions, will data be used against us, how do we interpret data to improve care, what does accountability mean….and more. Brilliant. I hope everyone gets a chance to read through you note.

      I think you paint the best possible use of measurement. If doctors get to partner with data creation, collection and interpretation, I am certain most docs would want to use it to improve the care they provide.

      Thank you SO much for taking time to read and share your insight. You speak from many hours thinking and working in this space.

      Best regards,

      Shawn

  3. Darren, I am with you about wanting good quality information to make decisions in dealing with patients.

    I would like to comment on this small part of your comment:
    “Making matters worse is the nagging thought that we have as physicians that somehow, somewhere, sometime measurement of outcomes or experience will be used to punish us.”

    I can tell you where this comes from. Before there were electronic medical records, OHIP was collecting data, looking for outliers on the bell curve and auditing them. That is a reasonable thing to do to check for fraud. Unfortunately, the auditors could only look at the charts and not be there at the patient encounter. Thus if normal findings were not recorded for efficiency’s sake, OHIP would assert that the exam was not done and clawback fees from doctors. This led to some doctors rubber stamping their paper charts with a list of all systems so that they could put tick marks and fulfill the requirements of possible audits.

    With EMR the check marking is built into the system. It still wastes clinical time during the patient encounter as I see numerous complaints online about this online. Nevertheless, it does save the data collectors lots of time and allows for measuring of lots more things whether practically useful or not.

    Now that there is more data to analyze, physicians can be scrutinized and “punished” for being outliers even if their care is exemplary. The most egregious example of this was the Medical Review Committee administered by the College of Physicians and Surgeons of Ontario on behalf of OHIP.

    http://www.theglobeandmail.com/news/national/gentle-dr-hsu-and-the-audit-that-haunted-him/article746626/

    History has warned doctors that data collection can and will be used against us.

    Again, Darren, knowledge is power but it can be difficult to know if the knowledge is indicative of the practical situation.

    1. Yes, I hear you Gerry. I was just starting my career in Ontario during the MRC days. Those were dark times and we have lots of institutional memory.

      For measurement and accountability to be fully embraced by doctors I work from the philosophy that the first presentation of the data should be to the physician him/herself. In all the primary care environments I have worked in that have had such exposure (my own office, groups I have assisted as an OntarioMD Peer Leader etc) little had to be done to get the individuals on board other than show them their own results. Our inherent competitiveness, type-A personalities and authentic desire to be really great docs drives all the change after that! It becomes a positive experience.

      Benchmarking of groups and teams is another issue, but individuals can more easily blend into the averages there. In terms of outliers, I think the real benefit will be figuring how to help them improve once identified. This can be a truly transformational bit of work if handled with dignity and respect. Physician leadership in this domain is key.

      Thanks for the response!

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