Quality goals and flipped priorities

What would you think if you received this message from management: “You can ignore chlamydia…it is not one of the quality goals for this year.” Or if you were told at a meeting to discuss a mandated quality initiative: “All you have to do to get credit for BMI screening is just click the box that says you will talk about it at the next visit.” (These are both true stories.)

No reasonable clinician would interpret this to mean they should not consider chlamydia worth diagnosing and treating. No manager would want their clinical team to actually ignore chlamydia.  No hospital quality team believes that checking a box committing to talk to a patient later will decrease the morbidity from obesity.

Nonetheless, words matter. They not only create our cognitive frameworks and biases, they also reveal them. That’s why these seemingly innocent and almost humorous comments are so disturbing. The accidentally revealed truth of these message is that the items selected to be measured, tracked and financially incentivized as quality goals are special BECAUSE they are incentivized goals, not because of their intrinsic merit. Selection confers merit more often than merit drives selection.

It should be the other way around.  We should measure, track and incentivize things because they are demonstrably important, and because we know that doing so will improve patient care. The first problem, of course, is that quality in medicine is very hard to define and impossible (so far at least) to effectively incentivize. A second important issue is the risk of unintended consequences.  

Unfortunately, many of quality programs are like the drunk looking for his wallet under the street light, not because that is where he lost it, but because the light is good there. (This is sometimes called the drunkard’s search or the streetlight effect.) We design quality initiatives based on what seems easy or convenient, and then wonder why things go bump in the night.

Some days, the only way to cope is to pretend one doesn’t care about administratively conceived and driven QI initiatives, retreat into the exam room, and immerse oneself in the joys of 1:1 patient care.



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