Healthcare Efficiency

It’s interesting when seemingly intelligent people write something that is totally wrong.  Especially when they’re not running for president.  It usually happens when very smart people write about something a bit outside of their area of expertise.  The case in point is a Sounding Board article from the 9 Aug NEJM.  (Since it’s not in the public domain, I can’t reference the work.) Three academics from CA and Canada condemn recent patient safety and quality initiatives mostly on grounds that the initiatives weren’t studied thoroughly enough.  It’s a little like the Republican approach to Global Warming--Let’s study it more before we do anything.
My first quarrel is an ethical one.  These folks make their money off studies, and they’re saying, “This might be OK, but you need to pay me to study it first.”  Talk about a conflict of interest.

They make seven arguments against current efforts (not all are totally wrong):

Argument One: There is no urgency  about safety/quality. “Bold efforts . . . confer only a small benefit.”  The example they cite is the reduction in residents’ work hours.  Sorry fellas.  Long hours lead to errors.  This has been demonstrated in aviation, trucking, healthcare, and in the laboratory.   The respective industries objected, just as academic medicine reluctantly modified their exploitative labor practices.   

Argument Two: Quality improvement efforts can cause harm, and maybe the status quo is better.  Reminds me of an quote (edited) from Machiavelli:  “Nothing is more difficult that the establishment of a new order of government.  (This) grows partly from the incredulity of men in general, who have no faith in new things until they have been proven by experience.”  They also decry the “errors introduced by computerized entry of physician orders” (CPOE).  Yes, there are unintended consequences of any change, but CPOE is here to stay.  Get with it guys.

Argument Three: Emulating successful organizations doesn’t always work.  Well, no.  Sometimes we emulate the wrong part of the system.  And factors such as culture and leadership influence success.  But that shouldn’t keep us from benchmarking and trying strategies that work for others.  

Argument Four: “Implementing solutions in practice can present numerous challenges.   I guess academics are just not used to difficulties.  Life must be boring when nothing you do presents a challenge.  They point out that strategies to improve hand washing don’t work everywhere, and we shouldn’t try to improve until we know more about “organizational theory and ergonomics.”  And in the meantime?

Argument Five: Strategies that seem promising may prove ineffective on further study.  No comment.

Argument Six:  Randomized, controlled trials are relevant to quality improvement.  Here is where they lose it by being so fixated on the virtue of controlled trials that they miss the distinction between operations management and clinical research.  This is not a new drug for cancer.  It’s ensuring that the new drug is administered safely and in a timely manner to the right patient.  It doesn’t take a double blind study to shorten the door-to-doc time in the ER.  When patients die because someone inadvertently shut off the oxygen during anesthesia, it doesn’t take a double blind trial to devise a solution.  

Argument Seven: Spend more money on evaluation before you do anything.  There is a small grain of truth here, tho it doesn’t take money.  For example, one of the key tenets of ISO 9001 is to measure important process and their outcomes.  Is it going well, and did it turn out the way we planned?  We should do this continuously for everything we do.  Of course the reasons to measure are detect opportunities for improvement and to document the effects of improvement efforts.  Doesn’t take a PhD or a double blind trial.  Just a run chart.

In their last paragraph, they assert that “quality improvement is on common ground with the rest of biomedicine.”  I don’t think so.  Clinical trials may demonstrate that it’s beneficial to give ASA for chest pain in the ER, but the systems analysts will tell us how to accomplish that every time at the lowest cost.  

One valid criticism of quality improvement efforts is that they have frequently failed to accomplish concrete results.  This paper demonstrates the reason.  Laboratory research or clinical trials may tell us what drug or operation to use for a given condition,  but quality improvement is about bringing that result to the right patient faster, better, and cheaper.