Questions on Quality: Sail or Sink?

Quality in healthcare: we talk about it, debate about definitions, wonder if we can and if we do measure it. For some of us, it’s an intricate concept that feels like it could make your head explode. For others, it’s common sense: to give the best care, to the right patient, at the right time. 

If it is true that all good things (i.e. Danish-sounding ice-cream) come in small packages…can we at least hope that quality in healthcare comes in cargo loads? Or are we bound to provide healthcare on islands of excellence in a sea of mediocrity?

I will not use this space to expand on the "quality" etymology or on matters of semantics. Instead, I would like to focus on 3 areas related to quality that I came across in discussions and readings this week:

1. Statistics to the rescue (or need to be rescued):

Healthcare Quality Council of Alberta (HQCA) talks about the six dimensions of quality: safety, effectiveness, efficiency, accessibility, appropriateness and acceptability. These benchmarks are used for example by the Alberta Bone and Joint Institute (ABJI) to build a picture of performance in areas such as post-surgery complications, surgery time, length of stay in hospital, waiting time for surgery, and patient mobilization. They compare the results with the benchmarks (see projects). While this model converts quality variables into numerical values for statistical purpose, it is obviously not perfect. For example, we know we have surgical site infections, but we are not yet able to track down the source - is it poor compliance to antibiotic prophylaxis? Or surgeon’s technique? Other factors? Tracking compliance by looking through paper charts makes data collection difficult and ineffective. We want to improve, but we are not yet able to reach to the source of the problems we identify.

2. More surgeries...are a good thing!?

Three academic hospitals in the US (one is Johns Hopkins) are considering cutting low volume surgeries in an attempt to keep patients safer.  This hit the news lately and intrigued the medical community. A recent calculation shows that 11,000 patient deaths could have been prevented over 2 years if they would have had surgeries in high volume centers rather than low volume hospitals. This brings up the discussion on healthcare access, data transparency and points to a shift in the hospital payment model based on quality rather than volume in surgeries (in the US). It will be interesting to follow this storyline and find out if quality will trump quantity, and at what cost.

3. Quality improvement in nursing: a Must or a Should

If you are practicing nursing for a while, you might not be aware that "participating in quality improvement activities" is part of your job description. QI is part of the Practice Standards for Regulated Members and is included in the definition of terms.  Unfortunately, as with many areas in healthcare, we lack measurement. How do we know that nurses participate in QI? Can we measure it? Does completing the annual learning modules count as a QI activity? (n.b. Steve Jobs was known for asking employees  what project have you been working on? rather than how long have you been with the company? but I digress). So should we make this QI participation mandatory? An attempt to answer this question was made in a paper, where the author states that "the current approach to QI has the potential to undermine the professional values of nursing". Frontline seems to be "running out of gas", there is talk about "improvement fatigue" and "change fatigue"... this author is not only diagnosing this peculiar condition, but offers treatment options.

  

Interesting questions, with convoluted answers. It proves that we are talking about quality, we strive for the ideal, and that we have a ways to go. Hopefully sharing this information will be useful and will make us think more about solutions. I subscribe to Ridley’s theory that "in social evolution the decisive factor is selection by imitation of successful institutions and habits".  

To conclude, I think this quote summarizes my message well: "Great things are done by a series of small things brought together”. As long as we keep on making small things better and keep the conversation going, we are sailing towards that archipelago of excellence.