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#QualityPT: Did We Take a Wrong Turn Somewhere?

Allan Macdonald, PT, MBA

I recently reviewed some interesting passages from a book where the main purpose was simple, menacing, and genius, all wrapped into a bound set of 592 pages. This Idea Must Die: Scientific Theories That Are Blocking Progress, edited by John Brockman, is a collection of essays where the authors have been challenged to examine “infallible” ideas, and make an argument to set aside, re-frame, and/or re-examine the seemingly infallible in order to make room for new ideas to advance. For example, Nina Jablonski argues to rid ourselves of the concept of race, and Hans Ulrich Obrist warns against the framing of unlimited economic growth—certainly an interesting essay for the homeowners among us in Toronto and Vancouver!

Ideas Must Die

Some of the essays are brilliantly executed and based on evidence, while others sound more like an author airing his/her grievances to the scientific world. The book can be read as a pop intellectual celebration with marginal net new contribution, or it can be seen as setting the stage for asking interesting questions about ideas that have long been framed as a “given”. It got me thinking. What ideas are impeding progress in the physical rehabilitation world?

This article is written from an “ideas must die” perspective, and I would ask readers to consider it as it is intended—a challenge to a seemingly infallible idea! I submit that the “quality movement”, which by and large has reduced and separated the client experience into manageable functions and specialties—quality, safety, client experience, performance measurement—has established conditions which are suboptimal for creating an excellent client/clinician therapeutic relationship, thus resulting in unsafe and suboptimal health outcomes. You may have heard a collective thud as the cadre of consultants, administrators and bureaucrats who have built healthy careers on building out “high-quality health care” fell off their chairs after reading the above statement!

Since the Institute of Medicine (IOM) published its seminal treatise on the sorry state of health care in the United States—Crossing the Quality Chasm—in 2001(1), it has been obvious that something had to change in the way that health care services were organized, delivered, and monitored. It was no different in the Canadian context. A 2004 report outlined how 185,000 Canadian patients suffered unintended harm while in hospital. (2)

No less than a revolution was launched in the health care world as professionals across the globe latched onto the seemingly infallible idea that the health care experience could be reduced, quantified, measured, and reported, launching a “quality movement” which most assumed would eventually lead to improved health outcomes for clients and families seeking out care. (3)

It is likely complete heresy to many to consider the fact that, despite pouring billions of dollars into a focused and reductionist approach to building out quality and safety in health care, we have seen little appreciable change. However, this is the case. Acknowledging isolated success at centres like Virginia Mason in Seattle (4), some writers have questioned the effectiveness of said “quality movement”. (5-8)

Is this something to be concerned about? Could it be argued that “change takes time”, and that many positive steps have been taken as we plod towards improved quality? Or is the lack of success of the “quality movement” a canary in the coal mine that reveals a deeper failure in transforming what is at the core of helping people live healthy and productive lives—the client/clinician relationship?

Has This Ship Sailed?

The client/clinician relationship is a complex entity and the methodologies, approaches, philosophical underpinnings, and orientation are different for nurturing trust and fostering health behavior change vs. improving highly measurable and transactional interactions that occur every day as a client seeks assistance from health care providers. Have we missed the boat? Have we poured time and resources into building a highly fragmented management system that can monitor quality of care while focusing less on the mechanisms and processes that create trust, empathy, and teamwork in the client/clinician relationship?

There are several important missing pieces of evidence that could further inform the “quality movement” discussion. Does a healthy, high-quality therapeutic relationship improve health outcomes for clients/families? What are the components of a healthy, high-quality therapeutic relationship, and how could they be improved? To what degree, if at all, does a quality improvement system with a heavily reduced set of functions and roles, set inside a fragmented set of microsystems, contribute to improved health outcomes? Has the focus on the transactional aspect of the health care spectrum resulted in improved health outcomes? Would a focus on the evolving client/clinician therapeutic relationship, and its primary success components, be the way to a safer, more reliable and affordable health care experience?

The client/clinician relationship is at the core of the overall objective of most health care professionals—helping people understand how to improve their health in an effective, convenient and affordable manner. Could it be that the mechanistic, reductionist, and dare I say it, scientifically oriented evidence-based approach could be getting in the way of a high-quality a safe health care-related experience?!

These are just some of the considerations that leaders, clinicians, and researchers firmly embedded in the seemingly infallible “quality movement” could ponder as they continue their noble work of contributing to effective, high-quality experiences every time a client asks for help.

References

  1. Institute of Medicine (IOM). 2001. Crossing the Quality Chasm. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C: National Academy Press.
  2. Baker, R., et el. 2004. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ, vol. 170 no. 11.
  3. Kenney, C. 2010. The Best Practice: How the New Quality Movement Is Transforming Medicine, New York, NY, PublicAffairs.
  4. Kenney, C. 2010. Transforming Health Care: Virginia Mason Medical Center’s Pursuit of the Perfect Patient Experience, New York, NY, Productivity Press.
  5. Baker, R. BEYOND THE QUICK FIX: Strategies for Improving Patient Safety. Institute for Policy, Management and Evaluation, University of Toronto.
  6. Hartzband, P & Groopman, J. 2016. Medical Taylorism. N Engl J Med; 374:106-108
  7. Rice, S. 2014. Despite progress on patient safety, still a long way across the chasm. http://www.modernhealthcare.com/article/20141206/MAGAZINE/312069987, downloaded on February 26, 2016.
  8. Watcher, R. 2016. How Measurement Fails Doctors and Teachers. Ney York Times. http://mobile.nytimes.com/2016/01/17/opinion/sunday/how-measurement-fails-doctors-andteachers.html?_r=1, downloaded on February 2, 2016.

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