Posted by: notdeaddinosaur | April 29, 2014

Words That Don’t Mean What You Think They Mean: “Quality”

Round and round and round we go yet again. The system is broken! Do something! Healthcare reform!

“Pay for performance” morphs into “measure (and pay) for quality.” The big problem is that no one has bothered to actually define the term, maybe because everyone assumes they know what it means — and that everyone else agrees with them. Wrong.

Quality is very much in the eye of the beholder, and can be surprisingly subjective. From my previous post:

Quality is like pornography; you know it when you experience it. But it cannot be measured; only assessed, and then only subjectively.

What does “quality” really mean in the context of medical care?

Some argue that when you have an operation, the surgeon shouldn’t leave anything inside you that shouldn’t be there. Others would say that everyone taking care of patients should wash their hands before and after every patient contact. Certainly all medical professionals should maintain proper licensure and credentials. I think of those things as basic expectations; more the difference between “acceptable” and “unacceptable”. “Quality” is different from “not unacceptable.”

Enter the idea of looking at “outcomes” (another meaningless word, also previously addressed by me here and here.) To reiterate: only certain kinds of illness and injuries have measurable outcomes. Fractures (should) heal. Surgically treated illnesses (should) resolve after operation. And so on. It’s generally accepted that there is a direct causal relationship between medical treatment provided and resolution of the condition, though this is not always so. Postoperative complications are not always preventable. Some fractures won’t heal. Cancers sometimes recur. So even the measurement of “outcomes” as a proxy for “quality” is fraught with hazard.

What about the relationship between “quality” and “Patient satisfaction”? Two words: Press Ganey. Short version is that there are times (lots of times) when what people think they want from doctors is not only not what they need, but can be dangerous, useless, and expensive. The patient is not the customer (and even so, the customer is not always right). When you actually look, it seems like the more satisfied people are, the worse their care.

So what does “quality” mean in the setting of primary care? Me again:

Quality in medical care has more to do with meeting the needs of individual patients and less to do with checking off boxes on a preventive care form. Some patients want detailed explanations of every facet of their medical care. Others prefer a more “Just the facts!” approach. 

What does it mean to be a high quality primary care physician? According to me:

[T]he ability to bring more than one style of communication to bear in meeting the needs of a varied patient base.

How do I and other skilled primary care physicians accomplish this? That’s simple (not the same as easy): time. Taking the time to listen, get to know what kind of communication the patient wants and needs from us, and then providing it. That’s quality. Find a way to pay for it (or at least find a way to not penalize it) and stand back while things fall into place.

How to measure it? No one has a clue.

Why not?

Because it can’t be done.



  1. I agree, there are somethings that can’t be measured. But not everyone who fills out a Press Ganey survey is out to bash a doctor. I fill them out and I am often complimentary.

  2. “[T]he ability to bring more than one style of communication to bear in meeting the needs of a varied patient base.”

    I like that. I’m an EM physician — much the same dynamics. I’ll have to think about whether I measure up to that standard.

  3. […] One of my long time favorite bloggers – the Dinosaur – had a wonderful post on KevinMD yesterday.  I have gone to her original post for the link – Words That Don’t Mean What You Think They Mean: “Quality” […]

  4. […] payments as “incentives” for “Quality” care. The only problem is that, as I’ve written before, all of their “Quality” measures are in fact nothing but proxies for cost, most of which I have […]

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