Top 10 issues in hospital medicine for 2008, issue 3: confusing performance with quality

Dr. Robert Centor, an academic hospitalist, is Division Director of General Internal Medicine at the University Of Alabama School Of Medicine in Birmingham and Associate Dean for the Huntsville Regional Medical Campus. He is also a member of the ACP Board of Regents and past president of the Society of General Internal Medicine. He is perhaps better known to many of us as the blogger at DB’s Medical Rants. There he recently wrote a post titled Quality improvement is a misnomer in which he said:

"Quality improvement" implies that patients will have better outcomes. Yet, few studies exist that show that improving performance measures really improves outcomes.

This model makes the unsubstantiated assumption that improving performance measures equates with improved outcomes, and thus we can label our efforts as quality improvement.

The quality movement has largely failed due to widespread confusion between quality and performance. Why are performance and quality (real quality, things that matter in patient outcomes) fundamentally different? It’s all in the motivation. Real quality is driven by a desire to make a difference for patients, regardless of money or public perception. Performance, on the other hand, focuses entirely on public perception. As Dr. Robert Wachter said in his blog just the other day, performance is driven by shame and embarrassment. He also wrote:

…hospitals are doing organizational cartwheels trying to improve their performance on the publicly reported indicators.

Those words speak volumes. Think for a moment about hospitals doing cartwheels trying to improve their performance. It’s all about putting on a show. A natural consequence of hospitals’ excessive concern for perception is a nearly exclusive focus on publicly reported indicators. Therein lies the failure of today’s “quality” movement.

There’s nothing inherently wrong with publicly reported measures. The problem arises when hospitals focus on them to the exclusion of other measures which, though below the public radar screen, matter more. The result is that hospitals tend to ignore measures with the greatest potential to impact meaningful outcomes such as early goal directed therapy against sepsis and applied hypothermia after cardiac arrest, which have a NNT of about 6 for survival and good neurologic outcome, respectively. Many of the high public profile measures nowadays are either non-evidence based (rapid response teams), have a very poor bang for the buck (pneumococcal vaccine, NNT 50,000), have serious unintended consequences (the 4 hour antibiotic rule) or have failed to improve outcomes in the way they were promulgated (heart failure core measures).

If we want better health related outcomes we must focus on real quality, not performance. But with today’s explosion in web based reporting and hospitals scrambling to improve their image, don’t expect it to happen any time soon.