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Posted by Ishani Ganguli November 30, 2011 11:01 PM
On a recent visit, my older brother challenged me to a dance-off. The forum was Wiiís Just Dance and the stakes (bragging rights) were high. Somewhere between Tik Tok and Walk Like An Egyptian* - my right hand gripping the controller, my arms and legs fighting against fatigue to hit each move with some semblance of precision - it occurred to me that these efforts were not unlike those of doctors and hospitals working toward quality standards.
In the last decade, with the aim of narrowing the quality chasm between the health care we provide and the health care we ought to provide, policymakers have turned to performance metrics to define and motivate our success.
Are we keeping our patientsí blood pressures below 140/90? Giving them antibiotics promptly when they are diagnosed with pneumonia? Double-checking their medication lists when they come to the hospital? Some of these process and outcome metrics are now reported publicly (Medicare uses Hospital Compare for example). Doctors and institutions are rewarded for doing well on them, with whatís called pay for performance or P4P: insurers, large employers, and physician organizations provide bonuses for achieving quality benchmarks. Ideally, these performance goals are evidence-based, clearly defined, and ambitious but not impossible to achieve.
Thereís some evidence that using performance measures does improve outcomes. But many worry about their imperfections and unintended consequences. For example, several of my primary care colleagues tell me that theyíve felt compelled to lower their elderly patientsí blood pressures more aggressively than they might have previously, even though for this population, the risk of falling down due to a low blood pressure often outweighs any long-term benefit of strict pressure control. Critics also note that doctors and hospitals focus their energy on prescribed metrics, often to the detriment of other aspects of high quality care that arenít reported or compensated.
Sounds a lot like Just Dance, right?
Minutes into our dance battle, I couldnít ignore the fact that the controller - the source of points - was in my right hand. This hand was an imperfect proxy for the rest of my body (of work). Despite this, it was all I could do to keep up with the next set of dance move instructions and Iíd try to conserve my energy by focusing on that arm. But it was in the moments when I forgot to think about winning and just danced like crazy that I did my best - my arms and feet moved in sync with the pink-haired lady on the screen and somehow, I moved in for the victory (Donít mention this part to my brother, heíll deny it).
Last week, back in the hospital, I had to face numbers that were more clinical in nature. At a quality improvement meeting, my co-residents and I each received a printout of the stats for our primary care patient: the percentage of notes completed on time, the number and names of patients who had not received their routine mammograms and colonoscopies, and others.
I scanned down my list: I had one patient who was overdue for a mammogram. I'd written 80% of my notes within a day of the visit.
This felt personal. My first instinct was to attack the numbers: The data were from only one month and the small sample size distorted my results, I protested silently. The woman who supposedly needed a mammogram had declined one, what was I supposed to do? I always finish my notes on the same day I see my patients, so that 80% must be wrong (As it turns out, that one was. The medical record interpreted a note that I had started a day early as being a day late).
Once I got over the judgmental stare of the Times New Roman on the page, I decided something. Performance measures arenít perfect and we should be aware of the pitfalls of setting and following them too rigidly. But there is plenty to learn from these data about improving the quality of all of our care. Sometimes, the best thing we can do is just dance.
*The original post incorrectly named this Bangles' song "Dance Like An Egyptian."
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