Quality, Evidence and Avedis Donabedian

Quality is the holy grail of health care.  In the United States an entire industry of health care quality has been created.  Unquestionably, some of these health care quality initiatives have resulted in better patient care.  However, one has to question the overall return on investment of the health care quality initiatives over the last decade.  We invest an enormous amount of resources in improving healthcare quality but if the return on investment is poor the opportunity cost is enormous.  The resources could be better utilized elsewhere.  If the current health care quality initiatives have not resulted in great improvement why not?  Sometimes a dangerous discussion to have.  Often those who have the audacity to challenge a health care quality initiative are perceived as uncaring dinosaurs and dullards who just want to maintain the status quo when in reality most of the time just the opposite is true.  The current establishment of health care quality and patient safety does not encourage challenges.  If the assumption that the current health care quality industry is significantly under performing then what are the possible explanations?

First, there is an incredible drive in the health care quality industry to do something rather than something meaningful.  A 2007 publication entitled “The Tension between Needing to Improve Care and Knowing How to Do It” appeared in the New England Journal of Medicine.  The author’s main message was that in the field of health care quality and patient safety the focus is often on haste and action rather than evidence.  They outline and review the dangers of this approach.  Health care quality and patient safety is such an important field so why shouldn’t initiatives be held to the same evidence based standards as therapeutic interventions.  They mention that medical errors are the eight leading cause of death in this country but we don’t apply evidence based criteria to qualit yand patient safety as we do for treating the first seven leading causes of death.  Haste over data.

A second, and possibly more important, reason that the health care quality industry is underperforming is the complete absence of discussion of the human factor.  Avedis Donabedian was a physician and is considered the originator of modern health care quality research.  In 1966 he published a paper entitled “Evaluating the Quality of Medical Care.”  Donabedian is credited with deriving the “structure-process-outcomes” model of health care quality research.  He had a long and distinguished career and essentially established the foundations of health care quality.  Donabedian was also a true scholar and thinker.  Toward the end of his career he said:

“Systems awareness and systems design are important for health professionals, but they are not enough. They are enabling mechanisms only. It is the ethical dimensions of individuals that are essential to a system’s success. Ultimately, the secret of quality is love. You have to love your patient, you have to love your profession.  If you have love, you can then work backward to monitor and improve the system.”

Donabedian, after a career of research on systems and operations realized that an organization’s success is mostly about the people and the culture in which they work.  There is no structure or process that can prevent bad things from happening when the people factor is bad.  Alternatively, good people with a love for their work can overcome bad structure and process.

How can physicians love their patients and their profession in the current environment when everyone is an adversary?  How can physicians enjoy their work when there are legions of people, who themselves have never practiced Medicine, telling them how to do things better?  These same people add nothing to the quality of the care.  They just encourage everyone to generate more utilization at a lower cost.  That is the only training they have and that is what they are hired to do.

The successful health care system of the future will create the environment and culture where providers can love their patient and their profession.  The first step will be restoring the practice of Medicine to a profession and establishing a culture of caring.  All else will then fall into place.

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