Quality in Healthcare, Patient Wait Times, & MD Arrogance

Physicians believe that:

Anyone who delivers care in less time than me must be cutting corners and providing low quality care. Same goes for clinics, hospitals, emergency departments…

Do physicians believe, then, that taking longer would improve quality? Does more time equal more quality?

Deep down, many physicians believe that:

The highest quality care happens at precisely the speed at which I provide it, or could provide it, if I chose to work at my top speed.

This could just be physicians resisting change for their own reasons. But I think there’s more…

Outcomes & Quality in Healthcare

Patients believe compassion equals quality, and rightly so: quality care must be compassionate.

But patients also want great outcomes.

Time determines outcome for most EM care (ICES Quality Report, 22 of 48 indicators are time based).

Many papers show ways to decrease waste for patients: see articles on LEAN and time in emergency care.

EM associations teach ways to increase speed without decreasing quality (Physician Efficiency, Canadian Journal of Emergency Medicine; Doing Things Faster Without Sacrificing Quality, ACEP), and many report ways to speed up care (Speed it up from Stanford 2013; ERs Move to Speed Care, WSJ 2011).

Time equals quality in emergency care. There is no evidence that patient waiting or taking-a-long-time-to-provide-care equals quality.

Humility can help to improve performance. Are we willing to look for ways to improve based on others’ success?

Healthcare Accountability vs. Healthcare Incentives

War erupts when:

Bureaucrats demand accountability without expecting to pay for it.

Physicians expect incentives without any accountability for outcomes.

We need both.

Accountability without payment = slavery.

Incentives without accountability = robbery.

No accountability or incentive = retirement (or tenure, or union seniority, or sinecure)

We need rigorous accountability AND meaningful incentives. We need system leaders to be comfortable with both. We need experts able to align incentives and reward outcomes that benefit patients.

But, accountability presupposes freedom.

Accountability must be demanded inversely to the amount of rules given:

If payers micro-manage every system process and detail, they remove freedom from providers and have no right to demand accountability.

Give providers freedom, then demand accountability. It makes no sense to demand accountability without giving providers freedom to deliver results.

What do you think? Do we need more accountability? More incentives? More freedom?

Medicare vs. Patient Care

Conference participants wore ‘I Love Medicare’ pins in Calgary.

Nietzsche might ask

Do you love medicare because patients benefit, or do you love medicare because you benefit?

Do you love ‘free care’ more than patient care?

People can care more about the idea of universal health care than they do about the care patients receive.

They deny data showing

long waits

poor patient outcomes

lack of access

lack of coordination

high cost

inefficiency

lack of control

provider frustration

Their solutions focus on

more control

more funding

more rationing

more cuts to salaries > 100k

more patient education to divert access

They would rather fight for a failed system than fight for improved patient care.

dog-ma-tism

n. An arrogant, stubborn assertion of opinion or belief

dog-ma-tism n.

1. positiveness in assertion of opinion especially when unwarranted or arrogant

2. a viewpoint or system of ideas based on insufficiently examined premises

Medicare dogmatism will guarantee mediocrity at best.

We need a system that:

puts patients’ needs first

makes patient experience central to funding

gives patients great access

offers patient choice

guarantees quality care (Quality should be a given)

demonstrates business excellence

attracts the best leaders

rewards great outcomes; not mediocrity

aligns incentives for every provider

rewards grass-roots provider innovation

gives control to health-care experts

This can happen in a publicly funded system, but it will never happen if people resist change.

We need to stop thinking that health-care is so special, complicated and unchangeable.

Do we love medicare more than patient care? Can we have an adult conversation about change? What do you think?