The first time I met one of my staff physicians on Internal Medicine, he told our team he had just one rule:
“Our team must contact the patient’s family physician during the admission, inform him or her of the situation and plan for appropriate patient follow up after discharge.”
If you talk to any hospital physician or family doctor, they would almost certainly agree that this type of integration between hospital and community is essential for reducing avoidable ER visits, readmissions and improving other key health outcomes. Put more simply, it’s just good care.
And so you would think contacting a patient’s family doctor during a hospital admission would be the standard of care – but it’s not. There’s no rule or expectation; rather, it’s just something nice to do.
I’m not here to criticize health care providers who do or don’t act a certain way. I’m sure there are many best practices which some providers do that others don’t, and vice versa.
That said, I don’t think we can deny the harsh truth: It’s no longer about knowing what needs to be done to provide higher quality of care at a lower cost. We know enough answers to begin implementing.
The more important question is: why aren’t we doing so?
You can’t improve what you don’t measure
There are three necessary requirements for improvement in health care:
- There must be metrics by which you can measure improvement.
- The results of these metrics must be delivered back to providers.
- Providers must be motivated to change.
In our health care system, I think we often delude ourselves into thinking we do all 3, when realistically we only do #1.
Readmission rates, ER visits, length of stay, etc: we have developed an abundance of actionable metrics that we can use to improve our health care system. Of course, many experts find some of these metrics controversial (for valid reasons), but I’d much rather test these metrics, learn and improve them than do nothing but argue while patient care suffers.
Most hospitals are mandated to publicly report these metrics. Is this “feedback” good enough to drive change? I don’t think so. Why would any individual or team of providers be motivated to improve if they don’t even know how they are doing?
Feedback has to be delivered right to the frontline providers in order to drive change. Showing that a hospital as a whole is succeeding or failing at a certain metric won’t do anything.
Having a department head say “hey guys, our metrics are bad, let’s all try to do better, OK?” won’t drive improvement. It’s just easier for frontline providers to believe it’s someone else delivering suboptimal care. Not holding providers accountable makes that even easier.
However, numbers don’t lie.
An average 30 day readmission rate of 20% across a hospital doesn’t tell us anything about how Dr. A’s team has a readmission rate of 10% but Dr. B’s is 30%. Given equivalent populations, clearly Dr. B has room to improve, because we know a readmission rate of 10% is possible.
On top of that, if Dr. B’s team themselves see they have room to improve, they not only have greater motivation to improve, they can now measure improvement and identify strategies that objectively lead to better outcomes.
Of course, it is more complicated than that, and we have to ensure providers are operating within a framework that deters “gaming” of the system. For instance, if we only measured readmission rates, then you could choose to never discharge a patient and your readmission rate would be 0%.
In any case, my point is that the metrics we currently collect have limited utility because 1.) we don’t collect metrics at the frontline provider level and 2.) we don’t feed this data back.
I honestly believe most health care providers want to deliver better care – but we won’t know what better is unless we can measure it.
Is feeding back data enough?
I wish I could believe that simply delivering health outcomes data back to providers would be enough motivation to drive improvement. While this is the case for some providers, it would be naive to think it true for all of us. We are all human after all.
We need to make it easier for providers to do the right thing. Take engaging the family doctor during a patient’s admission, for example. How could we motivate providers to do that?
One option is to make it mandatory. The problem with this option is that it will likely create disgruntled providers, and you can only make so many actions “mandatory” before everyone turns on you.
The second option, which I prefer more, is to not tell providers what to do. Instead, we feed back the metrics, and hold providers accountable in some way. We find incentives to drive improved patient and system outcomes, but we don’t tell providers how to do it. Providers will naturally experiment with strategies until they find those that optimize outcomes.
The fact that we underutilize actionable metrics in health care is striking and scary. That the health care system is complex is no longer an excuse – we can’t afford to keep making that excuse.
Can feeding health outcomes data right back to the frontline actually work? I don’t know, but someone needs to try it.
Joshua Liu is the CEO of Seamless Mobile Health and a physician specializing in hospital readmissions. He is a 2012 graduate of the University of Toronoto Medical School.
Add a billing code for “…contact the patient’s family physician during the admission, inform him or her of the situation and plan for appropriate patient follow up after discharge.” That’s the only way it’ll get done.
Thanks for the feedback.
There is a lot of data being collected in the healthcare system, including patient-reported outcomes, clinical data, outcomes, costs, etc. However, it’s not just important that we collect data or even the right data – that data must be delivered back to stakeholders in a way that is meaningful and can lead to action.
Although organizational level data can lead to improvements, I do think the more granularity we can provide (i.e. delivering the appropriate data & feedback to the appropriate provider), the more incentivized stakeholders are to improve and the greater impact we will see on the data overall. It’s easy to dismiss organizational data as someone else’s problem, it’s certainly harder to ignore if the data is a reasonably accurate representation of your own performance.
How do we do this? I’ve actually been fortunate to witness some great local examples. The University Health Network hospital in Toronto has piloted a Team Scorecard in their General Internal Medicine and General Surgery department over the past few years (details: http://www.thecicc.com/teamscorecard.html). They provided front-line health care teams with weekly “report cards” on patient satisfaction, quality of care, efficiency, and inter-professional team health. I don’t know the results of the project yet, but anecdotally, I hear it has been very well received by the clinical teams. I would personally like to see more of this, and it would be good for larger studies to assess the utility of this type of feedback on patient care.
In terms of measurement being a criteria for progress – I agree, certainly not everything can or should be measured. I do think that broadly speaking, in order to ensure we are moving in the direction we want, we need to be able to identify some sort of metrics to measure performance and targets we want to achieve – with the caveat that both metrics and targets need to regularly be reviewed for relevance.
Strong post. I like the core argument, which is that we need to rethink how the feedback part works and get data in the hands of providers directly instead of feeding it into the system. Tell us more about your vision.
On the other hand, I disagree strongly with your argument that measurement is a criteria for progress (unless I misunderstand you), it is only a tool. Indeed, I worry that we are becoming obsessed with the idea that we can quantify eStrong post. I like the core argument, which is that we need to rethink how the feedback part works and get data in the hands of providers directly instead of feeding it into the system. Tell us more about your vision.
On the other hand, I disagree strongly with your argument that measurement is a criteria for progress (unless I misunderstand you), it is only a tool. Indeed, I worry that we are becoming obsessed with the idea that we can quantify everything. There are times when we’re better off not measuring and relying on common sense ..
verything. There are times when we’re better off not measuring and relying on common sense ..