Episodes of Care
A National Quality Forum steering committee met this week under the banner of “Efficiency and Episodes of Care.” At a previous meeting, they had agreed not to measure the cost of an episode of care, so I was interested to see how they would spend an entire day doing nothing. The “episode” under discussion was acute myocardial infarction (AMI), and they defined their study period as extending from one year prior to the event to one year after discharge. This, of course, involves many providers and many “episodes of care.” Some even wanted to involve the EMS system that brings the patient to the hospital. Next meeting, they’ll tackle world peace.
The draft document advocated avoiding “unnecessary costs.” Unnecessary was defined as care that is not appropriate or indicated. Thus, the process would be more efficient if the patient only received the care outlined in a protocol, with no thought to the cost of that endorsed care.
Not everyone was sold. George Isham suggested changing “avoid unnecessary costs” to “eliminate waste.” A subcommittee was promptly appointed to define waste. Robert Krughoff (of Consumer Checkbook) pressed the group to focus on cost and resource use. Others called for a change in culture, since “everyone around the table is invested in the present.”
There was the usual angst over process vs outcome, with most favoring outcome measures. In reality, however, outcomes are irrelevant. If you don’t have a reliable process, a good outcome is an accident--a matter of luck. But, as Emily Dickinson wrote:
“Luck is not chance.
Fortune’s expensive smile is earned.”
Good outcomes in healthcare should not depend on luck, but on reliable, consistent processes of care.
Elliot Fisher asked for an “uber measure to drive major change,” but the idea of cost as an “uber measure” did not occur to him. In a conversation after the meeting, Kevin Weis rejected the idea of measuring costs of care episodes on grounds that hospitals are already as efficient as they can be, because of the DRG payment system. In other words, “we’re so good, we don’t have to measure anything.” This is the standard pablum uttered by arrogant academics to avoid scrutiny. If you’re really good, you bask in the sunshine and welcome opportunities to demonstrate your excellence or discover opportunities to improve. On the other hand, if you’re a fraud, you shun exposure and hide behind any available smoke screen. I smell smoke.
The draft document advocated avoiding “unnecessary costs.” Unnecessary was defined as care that is not appropriate or indicated. Thus, the process would be more efficient if the patient only received the care outlined in a protocol, with no thought to the cost of that endorsed care.
Not everyone was sold. George Isham suggested changing “avoid unnecessary costs” to “eliminate waste.” A subcommittee was promptly appointed to define waste. Robert Krughoff (of Consumer Checkbook) pressed the group to focus on cost and resource use. Others called for a change in culture, since “everyone around the table is invested in the present.”
There was the usual angst over process vs outcome, with most favoring outcome measures. In reality, however, outcomes are irrelevant. If you don’t have a reliable process, a good outcome is an accident--a matter of luck. But, as Emily Dickinson wrote:
“Luck is not chance.
Fortune’s expensive smile is earned.”
Good outcomes in healthcare should not depend on luck, but on reliable, consistent processes of care.
Elliot Fisher asked for an “uber measure to drive major change,” but the idea of cost as an “uber measure” did not occur to him. In a conversation after the meeting, Kevin Weis rejected the idea of measuring costs of care episodes on grounds that hospitals are already as efficient as they can be, because of the DRG payment system. In other words, “we’re so good, we don’t have to measure anything.” This is the standard pablum uttered by arrogant academics to avoid scrutiny. If you’re really good, you bask in the sunshine and welcome opportunities to demonstrate your excellence or discover opportunities to improve. On the other hand, if you’re a fraud, you shun exposure and hide behind any available smoke screen. I smell smoke.
