Physician perspective

Defining quality care means providing the right’ care

By Jean Edwards Holt, MD, FACS
San Antonio

One of the goals in health care should be to change our patients’ perception of "My doctor is good, he did everything for me" to "My doctor is good, he did the RIGHT thing for me." Inherent in this transition is defining what is right, in the present framework of cost containment. Hence come the words "value" and "quality."

I appreciate the Institute of Medicine’s 1990 definition that quality consists of the "degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge." To me, as a physician, the No. 1 concern with this definition is the concept of "desired" outcomes. According to many health care leaders, "desired outcomes" refers to outcomes desired by the patient. I sincerely question that an intelligent and informed patient, much less many we see without such a fund of knowledge, can judge appropriate health outcomes.

We should nevertheless strive for patient satisfaction, informed consent, and discussion of alternative treatment modalities. These are at the heart of "patient-centered care," an integral part of the doctor-patient relationship. However, patients, particularly older ones such as in my practice, often desire to be placed in the hospital unnecessarily; busy working adults desire "quick fixes," such as steroid injections instead of long-term physical therapy; parents desire antibiotics for a sick child even with no evidence of a bacterial infection. Are these desired outcomes quality medicine? What people want from health care may be an appropriate goal when considering customer-based business, but I still contend that a customer deciding on the shoes they want and the operation they want are not the same.

I propose instead that as the pendulum swings from pure cost containment as a stimulus for change to discussion of quality and value that this is the prime purview for the concerned, informed, and knowledgeable physician to step up to the plate and lead the charge in the discussion of what quality is and how it should be managed. This is not only desirable but essential.

For physicians, a difficult concept in this definition is the dichotomy of quality for the individual and the population concurrently. We have been trained with the individual patient as our focus. Payment by capitation is one way to urge us to better adapt to this dual concept. Six or seven years ago, when I first learned of this payment modality, it appeared inherently evil; withholding care seemed to be the only outcome. If we truly accept that improving the health of our society is our goal — not cost containment or utilization management — then payment to keep a population healthy is not inappropriate. The whole concept of capitation has been negatively affected by its association with the perceived evils of managed care. The capitation rate must, however, be distributed fairly and not just be what is left over after administrative and shareholder profits are sucked out of the health care dollar.

When we continue a discussion of quality for any length of time, we arrive at the need for complex and sophisticated information systems to gather data to transform that into information, which can help us gain knowledge about our practices and move toward righting what is wrong. Presently, when nonclinicians are entering clinical data, it often is flawed — the foundation of the process is incorrect, therefore the conclusions meaningless. However, we should continue to support advances in quality monitoring, even in light of inadequacies.

This convoluted web of achieving the right care at the right time by the right person in the right place with the data of what is right imposed onto a less-than-adequate infrastructure is quite frustrating to all of us. Just as I take pause that the present "administrative checkoff lists" imply real quality — patient satisfaction, nice receptionist, short waiting time, close to home, etc. — I also realize that our professional credentialing, board certification, hospital privileges likewise do not adequately address quality. Most physicians know colleagues meeting all our professional requirements that we would not consult for ourselves or our families. And yet, odds are they have a full waiting room. To redefine quality, therefore, we must be willing to focus on evidence-based medicine, foster outcomes measurement, and renew cooperative efforts with our colleagues, hospital administrators, managed care company executives, and our patients.