Zen and the Quest For Quality

Screen Shot 2014-08-21 at 11.45.17 AMCelebrating its 40 anniversary this year, Robert M. Pirsig’s Zen and the Art of Motorcycle Maintenance bears several distinctions.  It is listed in the Guinness Book of World Records as the eventual bestseller that was rejected by more publishers than any other, 121.  It went on to sell more than 5 million copies, making it the most popular philosophy book of the past 50 years.  And it focuses on a truly extraordinary topic, which its narrator refers to as a “metaphysics of quality.”

Quality is a hot topic in healthcare today.  Hospitals and healthcare systems are abuzz with the rhetoric of QA and QI (quality assessment and quality improvement), and healthcare payers including the federal government are boldly touting new initiatives intended to replace quantity with quality as the basis for rewarding providers.  Yet as Pirsig’s narrator, Phaedrus (see Plato’s dialogue of the same name), comes to realize, quality is very difficult to define.

In fact, giving an account of quality is so difficult that it drove Zen’s author mad.  And this is a man whose IQ, 170, would make him one of the most intelligent people in any health system.  The problem, of course, is that there is a big difference between intelligence and wisdom, and in the quest for wisdom, mere intelligence often leads us dangerously astray.  Something similar is happening in healthcare today, where schemes to improve quality often precede sufficient efforts to understand it.

For example, we seek to gain greater control over healthcare outcomes through measurement, only to discover, to our chagrin, that people are massaging the data to meet their numbers.  We create new programs intended to increase patient throughput, only to discover unintended perverse effects on the quality of relationships between patients and physicians.  Initiatives intended to reduce error rates turn out again and again to stifle innovation.

Too often, we suppose that the best way to define and improve quality is to focus on systems, as though quality were simply an engineering problem, like writing a better instruction manual (the occupation of Zen’s Phaedrus).  We invest all our faith in task forces, enhanced information technology, and improved policy and procedures manuals.  We hire consultants, jigger incentive systems, and mandate training in the hippest quality methodologies.

If quality improvement were simply a matter of methodology, then Phaedrus, the smartest guy in the room, would have perfected it.  But Phaedrus’ quest leads him to a quite different conclusion, namely that “The place to improve the world is first in one’s own heart and head and hands, and then work outward from there.”  In other words, the love of quality is not something that can be injected into a health professional from the outside.  It must be nurtured from within.

This is a powerful message for health professionals, because it places them on a level playing field with those in the very highest echelons of healthcare leadership.  It may even give them a leg up.  Why?  Because quality is born first of the heart, second of the head, and third of the hands.  The first order of business is not to conduct a QI project, to earn an advanced certification, or to design systems that force people to pay more attention to quality.  Instead it is to care about what matters most.

And what matters most is not a quality scorecard or a financial statement.  What matters most is the life and health of each patient, and flowing from it the professional integrity and fulfillment of the health professionals who care for them.  The most real thing in healthcare is not found in the board room or the C-suite.  Instead it is found in the examination room, at the bedside, and in the hands and heads and hearts of real human beings.  It is found in relationships between patients and health professionals.

The best health professionals are here not to be schooled on quality by the experts, but to offer testimony to patients and colleagues, day in and day out, in deed as well as word, about what they know in their hearts quality to be.  In the final analysis, the love of quality cannot be taught by outsiders.  It is found by listening as closely as possible to the inner voice that recognizes when a patient’s needs are being met.

Consider this true story.  A colleague brought his elderly father, who was in the terminal stage of a long illness, to the hospital emergency department.  The man was dying.  In fact, he would be dead within 12 hours.  But the nurse seeing him insisted repeatedly that he receive an influenza immunization.  She was so intent on meeting her quality metric (percentage of elderly patients who are vaccinated) that she could not really see the medical and human reality unfolding before her.

Quality initiatives will come and go.  So, too, will quality standards, as the science, technology, economics, and culture of healthcare continue to evolve.  What will not change, however, is the core commitment of health professionals to care well for their patients.  As Zen and the Art of Motorcycle Maintenance reminds us, the real cycle we are working on is not the hospital, the healthcare system, or the government.  In Pirsig’s words, “The real cycle you’re working on is a cycle called yourself.”

Richard Gunderman, MD is a professor of clinical medicine at the University of Iowa

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  1. The next time I hear that a clinical f***-up had to be a systems problem, I think I’ll be physically ill. My favorite recent example was a frail, CO2-retaining post-op patient with terrible emphysema who was over-narcotized by a series of “team members” who hadn’t bothered to actually learn anything about this specific patient and his specific needs, and just followed the “protocol” for postop analgesia. But I’ll guarantee that all his Joint Commission quality metrics were met, because that’s what our hospital lives for.

    Great post, Dr. Gunderson. I also loved your Atlantic article about Press Ganey scores and pain treatment. Keep up the good work!

  2. I understand your desire to put the patient first.
    I actually believe it is a 3-way tie between patient, provider, and insurer.
    Each needs to win in the short term, and especially over the long-term.
    Medicare has no reserves in which to pay claims.
    It accesses its reserves by issuing more debt, simply bringing closer the day of reckoning.
    Insurers, on the other hand, at least have reserves that they liquidate, dollar for dollar, through pre-funding of intact investments.
    Why would you want an insurer to operate without a reserve fund?
    Don Levit

  3. ‘We used to have people who were responsible for providing “quality health care.” They were called DOCTORS.”

    The Iron Man Theory of Medicine. The Shame and Blame Culture.

  4. When administrators try to partner with physicians invariably it is to practice medicine without a license. Doctors treat patients. Administrators have a completely different job.

    As an example since HMO’s are capitated one local HMO’s motto was “Delay in treatment means profit”. I don’t think physicians should think way, but that is what seems to happen when administrators try to practice medicine vicariously through their employees M.D. license.

  5. I agree that quality does come from the heart, and especially in the health care field we should be doing our utmost to ensuring that those getting help are getting help from the right people.

  6. You may be right, Bird, that single payor is a better way, but given the political climate it’s hard to see that happening any time in the reasonably near future. What you say about hospitals and docs is sometimes but certainly not always true. I cannot tell you how many physicians I have encountered during the past decade or so who are deeply and profoundly committed to their patients. This is why we need more of these physicians who are passionate about caring for their patients, to step forward into leadership roles. If more do so things can change and change rapidly. Physicians remain among the most respected and trusted individuals in our society — far more than most employers or health plans. Have physicians leveraged that immense clout to drive us toward a more patient-focused health care system?

  7. the better way is the single payor system. And the single payor is the patient. Right now the hospitals work for the employers, the doctors work for the insurers and nobody works for the patient.

  8. Ideally the management method has been decided upon by physician leaders in partnership with administrators. If physicians — with nurses and other clinicians — lead the way on determining how to manage a practice then the practice is more likely to be focused on the needs of the patient as opposed to the needs of a hospital, health plan, or private equity firm. But physicians need to lead the way. If doctors stand up and lead I think we can make significant progress in reducing the amount of distraction and noise that makes so many practices so difficult. Certainly their are serious barriers — regulators, governments, health plans, etc. But when doctors come together, define a consensus pathway forward, and then engage in sustained leadership, good things can happen. If there is a better way I do not know of it.

  9. “that lacks the kind of management method which enables the very best work to be done.”

    That makes one pause and think about who is determining the type of management being talked about. If the management style is that of an HMO then it may not be chaotic, but it may not be good for the patient.

  10. Insightful, well-written post. It is a compelling reminder of what health care is (should be) all about.

    “What matters most is the life and health of each patient, and flowing from it the professional integrity and fulfillment of the health professionals who care for them.”

    I would only add this: Given the enormous complexity within health care it is essential to have a methodology — lean, for example — that enables physicians and all other caregivers to eliminate distractions and fully focus attention on patients. I suspect there are many clinicians out there who have the “heart, head, and hands” but work in a chaotic environment that lacks the kind of management method which enables the very best work to be done.

  11. Great piece by RG, as always.

    I wonder though whether there are some who are positively content in following protocols, to the point of preferring such a system.

    Judgment is hard work.

  12. noble prize winner Bernard Lown md said it best when he said that “medicine is primarily a social discipline” and Voltaire said “Doctors are men who prescribe medicines of which they know little, to cure diseases of which they know less, in human beings of whom they know nothing”

  13. Another stellar post, Rich. Nice work.

    “The problem, of course, is that there is a big difference between intelligence and wisdom, and in the quest for wisdom, mere intelligence often leads us dangerously astray.” — Beautifully stated. My corollary is that health is no more a product of medicine than wisdom is one of education.

    Looking forward to your next essay.

  14. Kudos to Dr. Gunderman for his thoughtful, and analytical evaluation of our current “quality morass.”

    We used to have people who were responsible for providing “quality health care.” They were called DOCTORS. If someone didn’t do the right thing, they may or may not have received a butt-chewing. The most powerful incentive for the hospital to provide quality care to the patient was likely the surgeon, whom everyone respected and likely feared a little bit.

    One of the most powerful experiences of my medical education was being fortunate enough to spend some time under the tutelage of a small-town general surgeon. He was the most scholarly, genteel, polite, and skilled physician (or person) I think I have ever met. He was so revered and respected in the community that one day he almost made the Director of Nursing break into tears from one simple courteous statement. It was during an operation wherein the staff had forgotten to supply an important surgical tool, and we stood there in sterile scrub, hands folded across chests, for what was about 10 mins (but seemed an hour).

    The surgeon said kindly: “Nurse X, you understand that WAITING – is the thing that I do LEAST well.”

    I thought the entire nursing staff was going to faint. The item was produced forthwith.

  15. Excellent article. Your example of a nurse giving a flu shot to the dying patient is right on target. That explains much of the quality guru’s methodology of thought. Everything is checklist and the more checks in the box the higher the so-called quality. Thus that one added checkmark to many of the quality experts is the answer to compassionate care at the end of life and real quality care for the rest.

  16. wonderful article….but if we start listening to the patient, and delivering true patient centered care what will the NCQA nazis do? They have to actually go back to there job as nurses and contribute something positive to the system, although they would probably be the nurse demanding the hospice patient increase his crestor to 40 mg because his ldl is 102.

  17. “the rhetoric of QA and QI (quality assessment and quality improvement)”

    Pedantic quibble here. We have the narrow QC, wherein I started my white collar career in the 80’s (“quality control,” including “SPC” — Statistical Process Control, e.g., http://www.bgladd.com/papers/ITORL2.PDF), QA (“quality assurance” — the broad gamut of policies and procedures put in place to assure compliance with the explicit organizational objectives of quality), and QI (“quality improvement” methods/tactics — think PDSA, Lean, Six Sigma, Agile. Simple applied science, done properly). The work of Dr. Toussaint and ThedaCare is particularly instructive in the latter regard apropos of teh healthcare space.

    I am not a big fan of Six Sigma or “Agile,” btw. Deming got it right. Most of what has followed is essentially old wine in pricey new bottles.

    “The first order of business is not to conduct a QI project, to earn an advanced certification, or to design systems that force people to pay more attention to quality. Instead it is to care about what matters most.”

    Indeed. Simon Sinek would say “Start with “WHY?”

  18. “Instead it is found in the examination room, at the bedside, and in the hands and heads and hearts of real human beings. It is found in relationships between patients and health professionals.”

    A very profound, but self-evident statement, Richard. Why is it that we trust everyday Americans to determine quality in clothing, food, cell phones, etc, but think that we have to regulate and govern quality in health care? The ultimate end is that we need those human relationships between physicians and patients to work, not just checking off a box that something has been “done”.