- Email: [email protected]
Fulfilling expectations
J
THORAC CARDIOVASC SURG
1993;105:194-200
Presidential Address
Fulfilling expectations Richard G. Fosburg, MD, La Jolla, Calif.
"Wat you are about to hear has a central theme: expectations. It also is about quality improvement-the quality of our relationships with patients, the quality of our treatment systems, and the quality of our teamwork with health professionals. Fulfilling expectations could have been expressed as meeting needs, but I sense that our expectations are always greater than our needs, just as our wants are greater than our needs. What you hear today has the potential to change your practice style. The Joint Commission on Accreditation of Healthcare Organizations has shifted its focus from structure and departmental organization to process and institutional performance. Accreditation standards are now defined as expectations that must be met. Furthermore, the leadership has a responsibility to set expectations. I aim to raise your expectations today by speaking to the concept of continuous quality improvement. Peer review is a chore at best and a witch hunt at worst. It has always been a negative activity aimed at finding a problem case, determining who was at fault, and taking some action that was designed to result in a behavioral change and prevent a recurrence. Traditional quality assurance has focused on individual clinical performance by case review and was based on identification of adverse outcomes. It placed the practitioner in a defensive position and, because it was performed in isolation from the actual event by unidentified people, it created anxiety. If someone failed a screen, the chart was sent to a peer reviewer who was asked to make an assessment. If From Scripps Memorial Hospital, La Jolla, Calif. Read at the Eighteenth Annual Meeting of The Western Thoracic Surgical Association, Kauai, Hawaii, June 24-27, 1992. Address for reprints: Richard G. Fosburg, MD, 9834 Genesee Ave., Suite 105, La Jolla, Calif. 92037-1214. Copyright
1993 by Mosby-Year Book, Inc.
0022-5223/93/$1.00/ +0.10
194
12/6/42097
deemed below the standard of care, the chart was referred to committee, which often, despite good deliberation, was unable to determine significance because the incident was an isolated event. The committee members had no knowledge as to the denominator. Further chart review thus became necessary to see if a pattern existed. This was time consuming and often a worthless undertaking. Fortunately the focus is changing to identify strengths, assess areas for improvement, and separate the process from any punitive connotations.' The Hospital Corporation of America (HCA) defines quality as follows: "At H CA achieving quality means the continuous improvement of services to meet the needs and expectations of the patients, the physicians, the payors, the employees, and the communities we serve." In medicine we have traditionally been focused on outcomes, and physicians have long been involved in the continuous improvement in patient care. What is different about this change by the Joint Commission is the emphasis on continuous quality improvement, which uses a monitoring and evaluation system driven by data collection and analysis. Presently we do not possess objective standards for measuring the value of a treatment, nor do we have a way for those who pay for that treatment to measure its value. What we do have is significant regional variations in the frequency of procedures, patients in whom poor follow-up has permitted their clinical problems to reach extremes before intervention occurs, patients in whom no behavior modification is attempted, and patients with chronic conditions who keep recycling through the care-giving process without any real expectation that a significant change can be made in their ultimate outcome. If we are to improve our outcomes, we must understand what produced those results. Dr. W. Edwards Deming refers to this as "profound knowledge." This requires a detailed understanding of every element in the care process beginning
The Journal of Thoracic and Cardiovascular Surgery Voiume 105, Number 2
before admission and continuing until recuperation is complete. Our former inspection systems failed because we did not address the quality issues until the patient was discharged. We looked at charts and found documentation lacking. We had no insight into the process when looking back.
The patient's expectations With rare exceptions patients do not recall who provided them medical services. Why? After all, they have entrusted us with their most precious possession, life, and their hopes for the future. What causes this lapse of memory? Could this forgetfulness be symptomatic of a problem in the medical setting? Admittedly the occasions are rare when a patient establishes a decade-long relationship with a physician. True, society is mobile and fragmented, and often the selection of a doctor is more a reflection of the insurance plan than the patient's choice. The complexity of care has led, in many instances, to a team approach that decreases the interaction between physician and patient. Even if you have known your doctor for a long time, the nature of the illness itself may result in referral to a specialist whom you have never met. Are these explanations for failing to recall a name? I don't believe so!
Experiencing illness Patients not only have diseases but they experience them as well. It is their expectation that physicians will be interested in hearing what they are experiencing! Doctors have been educated to look for, observe, and measure something called diseases, but the patient experiences an illness. The clinical encounter begins as a meeting of strangers. Too often what follows is very paternalistic. The patient places himself in the hands of a benevolent provider who knows both what to do and what is best. However, so often we do not know the values of the patient. We seldom ask. I believe the reason patient's don't recall who provided their care is an expression of that doctor's lack of communication skills and apparent lack of empathy, that capacity to understand what another person is experiencing from within the other person's frame of reference. Empathy encourages talk and trust and involves an ability to listen carefully, hear, and respect the voices of others. If your patient consistently requests no information and seems willing to follow any suggestion, it should prompt you to question whether or not you are really communicating. Does the patient understand or is some factor inhibiting the patient's participation in the process?
Fosburg 195
The patient interview The patient interview is potentially the most powerful, sensitive, and versatile instrument at the physician's command. It remains the hallmark of a good practitioner. Listening and understanding the perceptions, values, and feelings of others are the key components of caring. The manner in which things are said, including the tone of voice, eye contact, facial expression, body position, and gestures, reveal more message than words can convey. Actions or the lack of actions are more powerful than spoken messages. The patient may feel afraid, anxious, and confused. Do you sense these feelings? Do you give the patient your undivided attention rather than writing in the chart? Is he or she interrupted by your beeper, a device that declares your priorities higher than the patient's? Do you ask open-ended questions? Can you catch the nonverbal clues? Because we do so much filtering and filling in of the details, we always act on incomplete and biased information.' Listening is more than just being silent while someone talks. To be a good listener one must be inquisitive. How well do you meet the patient's expectations when everyone is allocated so many minutes of your busy schedule? With the advent of managed care we can anticipate less compensation for the time we spend with patients. We must therefore develop means to be more efficient with our time. Medicine has become an information industry. Our patients are far more sophisticated as a consequence of the popularity of health topics in the lay literature. At Scripps we have created a health resources library for laypersons that is staffed by volunteers. Patients can view videotapes, interact with computerized information, and read brochures. We hope to have all members of the health care team become educators when they interface with the patient.
Cardiac surgical programs As I reflect on reviews of cardiac surgical programs in my role as chairman of the Standards and Ethics Committee of The Society of Thoracic Surgeons, two things stand out. First, an effective quality assurance program was absent. Those inside the institution knew less about the program than the outside data collectors. You cannot manage what you cannot measure! If you are not analyzing the data your program generates, the cause of your failure will remain obscure. Second, there was a high profile of individuality. No one did everything the same way. Routines develop as a consequence of their being the best way to do something. They are analogous to the checklists pilots use before takeoff and landing. The goal
196
The Journal of Thoracic and Cardiovascular Surgery February 1993
Fosburg
is to perform the routine as perfectly as possible to reduce the chance of error. The worst time to work out a strategic plan is when things become unpredictable, unstable, and likely to get worse. Urgent action may be required and that demands a focus and a sense of priorities.
Severity of illness Whereas differences between surgeons may reflect differences in patient mix, and the application of severity adjustment measures makes those differences disappear, quality issues may also be obscured. Comparisons by the type of operation may be more appropriate than ones made after adjustment for severity because the adjustments eliminate the effects of differential case selection. Small patient volumes provide a particular challenge as well. In December 1991 New York State released data on 140 surgeons, which showed wide variation in riskadjusted mortality rates. Providers questioned the fairness of being compared with their competitors on this basis, citing the high cost of data collection whose quality was problematic. Additional criticism was directed at inadequate adjustment for co-morbidity. Incontrovertible, however, was the fact that surgeons with greater than 50 operations yearly had about one-half the death rate of those who performed fewer than 50 procedures. David Axelrod," former health commissioner of New York State, asked, "Should not patients have the choice to have their cardiac surgery done in an institution that does more than 60 cases per year? Can they rely on their community hospital to provide only those services it provides well, competently, proficiently, and cost-effectively?" He firmly believed that the rights of the patient to be protected from a practitioner with clinical shortcomings should be greater than the right of that practitioner to any clinical privileges or access to the hospital. The Medical Society of New York State wisely indicated that patients could endanger their health by seeking out higher ranked surgeons and thus creating lengthy backlogs. Additionally, they emphasized that the lowest ranked hospital in New York City became the highest ranked within I year by simply refusing high-risk cases. Clearly there is a need for patients to be better informed about the outcomes in their community and to playa larger role in their treatment decisions. Whether this kind of information really contributes is yet to be demonstrated, but I see no value in keeping our results obscure. It is in the public domain. I favor the voluntary disclosure of patient care outcomes, the quality indicators used in their derivation, and the utilization data on specific procedures. There is no secret in my mind as to what makes a good
program. The answer is simple-its people! But it is also true that people are not the cause of poor programs. It is not an issue of bad people but bad design. Dr. Deming attributes 90% of failures to process errors, not people. Substandard care results from poor process design, poor training, and inadequate information, not from stupidity, indifference, or greed. People, regardless of their position, try hard, act in good faith, and do not willfully fail to do what they know is correct. Poor program design, failure of leadership at some level, or issues external to the institution that are beyond one's influence are far more common.
Practice guidelines The Agency for Health Care Policy Research is sponsoring the development of clinical practice guidelines aimed at reducing treatment uncertainty and inappropriate choices and thereby improving patient outcomes. Management strategies are created that define the patient's course of treatment. Appropriately designed, they provide objectives and options facilitating informed choice. Practice guidelines, practice parameters, medical criteria, standards of care, whatever the names, are not new concepts. I am concerned that they remain extremely simplistic, belittle the importance of physician's judgment, and artificially compartmentalize the patient's care by ignoring the spectrum of an illness from its inception to recuperation. Four issues with guidelines still require resolution: ( I) disagreement as to processes and vocabularies, (2) the diversity of medical practice, (3) varying purposes and goals for guidelines, and (4) a lack of information as to scientific efficacy? The more complex a clinical problem, the greater the number of options." If guidelines are overly detailed, flexibility is lost and they become unnecessarily prescriptive. Where legitimate differences of opinion exist, guidelines will have to explain those differences. Development by a variety of professional societies leads not only to duplication but occasionally to a lack of concurrence, as occurred with coronary artery surgery. Who then decides which set of guidelines to use? Health Care Financing Administration based on cost? The courts? Unlikely, since the guidelines devoid of bright lines express areas where physicians disagree. Current guidelines are primarily written by physicians with little input from other health professionals. Shouldn't they have a contribution? Published guidelines in our discipline speak little to pre-hospital preparation, patient education, or rehabilitation, and they fail to address the patient's expectations. There are additional unanswered questions. Can complex medical problems actually be solved by blue ribbon
The Journal of Thoracic and Cardiovascular Surgery Volume 105, Number 2
panels? By setting requirements and insisting we follow guidelines are we not running the risk of moving toward mediocrity? Will innovation be stifled? Will guidelines so bind practitioners to treat certain illnesses in a particular way that further justification is required for deviating from a guideline? If deviation occurs will it be assumed to be incorrect? If so, our income will be dependent on adherence to federal standards and all fears concerning cookbook medicine would be realized. Chassin" has stated it will probably not be possible in any field of medicine to design guidelines that will take into account every possible factor that might constitute an exception to the standard. Rigid guidelines ignore creativity and the flexibility possessed by trained individuals who are able to tailor their treatment when the conventional might be inappropriate. How frequently guidelines will require revision and updating is unknown. If we wish to avoid being held to standards of quality derived by others, we must participate, but that should not deter our continuing criticism. Unfortunately, guidelines use past practices as the point of comparison. Scientific bodies would not accept historical controls as statistically meaningful, but the process of continuous quality improvement demands that we assess our past and aim to change our future. Guidelines can achieve success only when the methods used to develop them are fully explained, how consensus was achieved is identified, and citations of actual trials support their validity, reliability, and applicability. At the present time they have no capacity to address problems that lie outside of the physician's domain. Finally, what assurance do we have that the regulatory oversight needed to ensure conformance is cost-effective? At this juncture no one knows! Practice variation There will always be variations in medical practice.f Variation exists because no consensus exists as to what represents appropriate treatment for a given condition. Variation exists because patients are presented with treatment alternatives and have discretionary judgment plus choice. If there is strong agreement about the management of a certain condition, variation is less. If the risks and benefits are less well established, the variation is greater. Even today for many of the common medical conditions well-designed clinical studies to test alternative forms of therapy have not been done. Tradition and clinical experience determine choices more than clinical trials or protocol studies. To advance medical practice we need well-designedand carefully conducted clinical trials. Clinical research is the keystone for improvement in patient care. However, the patient's expectation is for the physician not only to provide his or her best advice but also
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to act in the patient's best interest. The patient expects to be counseled as to what is reasonable, likely, and probable. In situations of uncertainty are we meeting those expectations when we base judgment on personal anecdotal experience? It requires a high degree of intellectual honesty to distinguish between what is known and what is simply believed. More precious than technical skill, which anyone can acquire, more difficult than knowledge, which is available to all, the most prized attribute of a physician is judgment. We must diligently seek ways to enhance and nurture our judgment. What do we presently do when there is a conflict of interest between the physician as a scientist and a provider of care? We turn to the randomized controlled trial, a study design with the least observer bias and the least error in methodology. But frankly, almost all surgical procedures have never been subjected to a randomized control trial. I have trouble with such trials when the patient is randomly assigned to one arm or another. Should not the expectation be that the patient chose which arm he prefers based on provided knowledge of the options? These trials have traditionally had difficulty in enrollment, and we all are aware of trials that have been terminated prematurely because the adverse outcomes in one arm have raised alarm. Physicians who have a preference for one treatment, say percutaneous transluminal coronary angioplasty rather than bypass surgery, may simply not be forthright in defining the alternatives to the patient. They often will not enroll patients in trials whose objective might be to prove their chosen method of treatment less desirable. This can be a failure to act in the patient's best interest. The patient should be permitted to make voluntary and uncoerced decisions about his or her treatment after being provided information. Medicolegal implications Much that occurs in our medicolegal environment is patently punitive. The natural tendency given this environment is to hide or avoid responsibility for bad outcomes. If punished for them, people will chose to hide their mistakes. Continuous quality improvement can take place only in a candid, nonretributional, self-examining environment. Without malpractice reform the probability that continuous quality improvement will be widely successful is small. Role conflicts In contrast to industry, where the manager is often not the worker, in the hospital there are many providers of care who have managerial roles. We need to develop more teamwork, more collaboration, more we and less me in order to bring success to our quality improvement efforts.
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The Journal of Thoracic and Cardiovascular Surgery February 1993
Fosburg
16
14
12 ~CTLOS
10
- - MEAN CT LOS 17.381 - - - . - MEAN FY 91 18.71 --UCL
6
--LCL
4
2
O-!-H+tttttlft+l+tttttlft+l+tt+++-ft+I+tt+++-I+H+t+t+t-I+H+t+t+t-I+H+t+t+t-I+H+t+tI
DATE OF DISCHARGE
Fig. 1. CareTrac diagnosis-related group 106:length of hospitalstay, October 1991 to ApriI1992. Upper and lower confidence limits were calculated by means of 2 standard deviations. CT, CareTrac; LOS, length of stay; VCL, upper confidencelimit; LCL, lower confidence limit; FY, fiscal year. $80,000
$70,000
$60,000
i
- - CT TOT CHGS
$50,000
- - MEAN CT CHGS 1$50,4701 - - + - MEAN FY 91 1$56,6251
$40,000
--UCL $30,000
--LCL
$20,000.
$10,000
$0
DATE OF DISCHARGE
Fig. 2. CareTrac diagnosis-related group 106:October 1991 to April 1992. Upper and lowerconfidence limits we calculated by means of 2 standard deviations, Mean fiscal year 1991 charges were adjusted for price increases. For abbreviations see Fig. 1. One never achieves quality by accident. It is always the result of high intention, sincere effort, intelligent direction, and a common sense of purpose.
Critical pathways Critical pathways, sometimes called clinical progressions, are multidisciplinary care plans with a time line. They represent transition from a segmented, departmen-
tal, or service-oriented approach to a patient-focused approach. They link continuous quality improvement with clinical management decision-making by establishing standing orders, developing clinical indicators and educational materials, and trending of results. Comparisons between those on the pathway versus those who are not aid outcome analysis. By focusing attention on those procedures that result in the best care and studying the
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199
250
200
~ICUHRS
150
- - BASE MEAN (431 - - CT MEAN (261 100
- - NCT MEAN (331
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DATE OF blSCHARGE
Fig. 3. Diagnosis-related group 106: Baseline auditof intensive care unit (ICU) hoursfor non-CareTrac (NCT) and CareTrac (C or CT) cases in 1991. Non-CareTrac cases for 1991 exclude lengths of stay greater than I standard deviation.
reasons for success rather than failure, everyone becomes aware of changes in the system that will effect a significant improvement in patient outcomes. Consensus opinion identifies minimal essential components of care yet permits guiding protocols to be individualized. Contrast this methodology to that of practice guidelines that currently focus on physician activities instead of the entire care team. The key elements of critical pathways are (1) the education of the patient and the family about the continuum of care from preadmission to postdischarge planning, (2) assessment of interventions and their impact on expected clinical outcomes, and (3) charting by exception. The pathways address diagnostics, medications, diet, activity, the tracking of variance, trending, and continuous evaluation. The patient-oriented pathway, written in laymen's terms, describes the patient's movement through the hospital and is posted in his or her room. It is impressive to see the interest and interaction among patients as they compare their progress against the posted expectations. At Scripps we call our pathways CareTracs. They provide benefits to a number of recipients. For the patient, the expectations are defined, and he or she becomes more realistic through understanding. The power of this selfexpectation is awesome. It makes everyone feel like a winner. Unrealistic expectations may lead to disappointment, but keeping the patient focused on the pathway promotes his or her sense of accomplishment. Let's look at early extubation after coronary artery surgery as an example. Patients who are extubated present a less frightening appearance to relatives, can begin oral med-
ications sooner, need less sedation, can verbally communicate their needs, and can interact with their families and care givers. For the nurse the benefits are dramatic. Not only is there enhanced collaboration with all the team members, but there is increased staff satisfaction. The nurses have an improved documentation system that uses exception charting. Only those events not delineated on the pathway need to be charted. This results in increased productivity and more time to spend with the patient. The nurses are additionally empowered in decision making. For the hospital the benefits are decreased length of stay, decreased resource utilization, and increased patient and staff satisfaction. The pathway provides an efficient way to evaluate new products and procedural changes, as well as providing a valuable feedback loop to critically improve the process. For example, we have historically moved the patient through the hospital. The patient goes everywhere for service. Weare now considering bringing the services to the patient by cross-functional training. Nurses can draw blood instead of the phlebotomist, respiratory therapists can perform electrocardiograms, and volunteers can expand their roles into direct patient care. For the managed care contractor the pathway defines length of stay and use of resources and facilitates discharge planning. Through a system of collaboration, uniform outcomes become a common mission. Fig. 1 shows the impact of the pathway on length of stay in diagnosis-related group 106, coronary artery bypass with catheterization, the same admission at Scripps. Fig. 2 shows the effect on charges. Fig. 3 iden-
200
The Journal of Thoracic and Cardiovascular Surgery February 1993
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120
100
~
80 ---+-'- ICU_EXT
~
~
8
- - BASE MEAN 1221 60 - - CT MEAN 1161
~
Q
- - NCT MEAN 1181 40
20
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DATE OF blSCHARGE
Fig. 4. Diagnosis-related group 106: Baseline audit of intervalfrom intensive care unit (ICU) to extubation (hours) for non-CareTrac (NCT) and CareTrac (C or Cn cases in 1991. Non-CareTrac sample cases for 1991 exclude lengths of stay greater than one standard deviation.
tifies the intensive care unit length of stay, and Fig. 4 shows the hours to extubation. Note that patients not on the CareTrac also benefited from the nurses' experience. The most striking event is the elimination of variation and the collaborative influence on non-CareTrac patients as well. In summary, I have mentioned many issues and many expectations. For continuous quality improvement to succeed, barriers must come down. Everyone must be willing to listen, to learn how to improve their processes, and to speak out so others can improve theirs. This will require a cultural change. Physicians have preferred not to acknowledge mistakes, continue to be apprehensive about peer review, remain reluctant to accept responsibility for their colleagues' behaviors, are concerned with threats of legal actions, and are convinced that it is not their business. As surgeons we only need to reflect on failed angioplasties as an example of our reluctance. Quality is not a program, but a philosophy. You don't make quality happen; you allow it. You don't tell people what to do; you tell them what you want accomplished. Because the only way to avoid mistakes is to never do anything, we must not regard problems as bad. The Japanese regard problems as opportunities to showcase their talents and make a valuable contribution. For this to occur, the environment must be receptive. Hospitals have been quite successful at guarding hospital-specific information regarding their quality and efficiency. I believe this is a barrier to effective change.
Until the purchasers of care know exactly what they are buying, we cannot expect the marketplace to influence costs. I believe in the public release of health outcomes information. It is a powerful motivator for change. Additionally, I think hospitals should be benchmarking their results with comparable facilities to achieve continuous quality improvement. It is only by doing the right thing, the right way, every time, and on time, that we can truly meet and possibly exceed our patients' expectations. REFERENCES I. Goldman RL. The reliabilityof peer review assessments of quality of care. JAMA 1992;267:958-60. 2. Tannen D. You just don't understand: women and men in conversation. New York. William Morrow, 1990:37. 3. Kritchevsky SB, SimmonsBP. Continuousquality improvement:conceptsand applications for physician's care. JAMA 1991 ;266:1817-23. 4. Axelrod D. Perspectives: a state health commissioner. Health Affairs. 1988;7(2 suppl):54-7. 5. HirshfeldEB.Shouldpracticeparameters be the standard of care in malpractice litigation? JAMA 1991;266:2886-91. 6. Brennan T. Practice guidelines and malpractice litigation: Collision or cohesion? J Health Polit Policy Law. 1991;16: 67-85. 7. Chassin MR. Standards of care in medicine. Inquiry. 1988;25:437-53. 8. The Cardiology Working Group. Cardiology and the quality of medical practice. JAMA 1991 ;265:482-5.
THORAC CARDIOVASC SURG
1993;105:194-200
Presidential Address
Fulfilling expectations Richard G. Fosburg, MD, La Jolla, Calif.
"Wat you are about to hear has a central theme: expectations. It also is about quality improvement-the quality of our relationships with patients, the quality of our treatment systems, and the quality of our teamwork with health professionals. Fulfilling expectations could have been expressed as meeting needs, but I sense that our expectations are always greater than our needs, just as our wants are greater than our needs. What you hear today has the potential to change your practice style. The Joint Commission on Accreditation of Healthcare Organizations has shifted its focus from structure and departmental organization to process and institutional performance. Accreditation standards are now defined as expectations that must be met. Furthermore, the leadership has a responsibility to set expectations. I aim to raise your expectations today by speaking to the concept of continuous quality improvement. Peer review is a chore at best and a witch hunt at worst. It has always been a negative activity aimed at finding a problem case, determining who was at fault, and taking some action that was designed to result in a behavioral change and prevent a recurrence. Traditional quality assurance has focused on individual clinical performance by case review and was based on identification of adverse outcomes. It placed the practitioner in a defensive position and, because it was performed in isolation from the actual event by unidentified people, it created anxiety. If someone failed a screen, the chart was sent to a peer reviewer who was asked to make an assessment. If From Scripps Memorial Hospital, La Jolla, Calif. Read at the Eighteenth Annual Meeting of The Western Thoracic Surgical Association, Kauai, Hawaii, June 24-27, 1992. Address for reprints: Richard G. Fosburg, MD, 9834 Genesee Ave., Suite 105, La Jolla, Calif. 92037-1214. Copyright
1993 by Mosby-Year Book, Inc.
0022-5223/93/$1.00/ +0.10
194
12/6/42097
deemed below the standard of care, the chart was referred to committee, which often, despite good deliberation, was unable to determine significance because the incident was an isolated event. The committee members had no knowledge as to the denominator. Further chart review thus became necessary to see if a pattern existed. This was time consuming and often a worthless undertaking. Fortunately the focus is changing to identify strengths, assess areas for improvement, and separate the process from any punitive connotations.' The Hospital Corporation of America (HCA) defines quality as follows: "At H CA achieving quality means the continuous improvement of services to meet the needs and expectations of the patients, the physicians, the payors, the employees, and the communities we serve." In medicine we have traditionally been focused on outcomes, and physicians have long been involved in the continuous improvement in patient care. What is different about this change by the Joint Commission is the emphasis on continuous quality improvement, which uses a monitoring and evaluation system driven by data collection and analysis. Presently we do not possess objective standards for measuring the value of a treatment, nor do we have a way for those who pay for that treatment to measure its value. What we do have is significant regional variations in the frequency of procedures, patients in whom poor follow-up has permitted their clinical problems to reach extremes before intervention occurs, patients in whom no behavior modification is attempted, and patients with chronic conditions who keep recycling through the care-giving process without any real expectation that a significant change can be made in their ultimate outcome. If we are to improve our outcomes, we must understand what produced those results. Dr. W. Edwards Deming refers to this as "profound knowledge." This requires a detailed understanding of every element in the care process beginning
The Journal of Thoracic and Cardiovascular Surgery Voiume 105, Number 2
before admission and continuing until recuperation is complete. Our former inspection systems failed because we did not address the quality issues until the patient was discharged. We looked at charts and found documentation lacking. We had no insight into the process when looking back.
The patient's expectations With rare exceptions patients do not recall who provided them medical services. Why? After all, they have entrusted us with their most precious possession, life, and their hopes for the future. What causes this lapse of memory? Could this forgetfulness be symptomatic of a problem in the medical setting? Admittedly the occasions are rare when a patient establishes a decade-long relationship with a physician. True, society is mobile and fragmented, and often the selection of a doctor is more a reflection of the insurance plan than the patient's choice. The complexity of care has led, in many instances, to a team approach that decreases the interaction between physician and patient. Even if you have known your doctor for a long time, the nature of the illness itself may result in referral to a specialist whom you have never met. Are these explanations for failing to recall a name? I don't believe so!
Experiencing illness Patients not only have diseases but they experience them as well. It is their expectation that physicians will be interested in hearing what they are experiencing! Doctors have been educated to look for, observe, and measure something called diseases, but the patient experiences an illness. The clinical encounter begins as a meeting of strangers. Too often what follows is very paternalistic. The patient places himself in the hands of a benevolent provider who knows both what to do and what is best. However, so often we do not know the values of the patient. We seldom ask. I believe the reason patient's don't recall who provided their care is an expression of that doctor's lack of communication skills and apparent lack of empathy, that capacity to understand what another person is experiencing from within the other person's frame of reference. Empathy encourages talk and trust and involves an ability to listen carefully, hear, and respect the voices of others. If your patient consistently requests no information and seems willing to follow any suggestion, it should prompt you to question whether or not you are really communicating. Does the patient understand or is some factor inhibiting the patient's participation in the process?
Fosburg 195
The patient interview The patient interview is potentially the most powerful, sensitive, and versatile instrument at the physician's command. It remains the hallmark of a good practitioner. Listening and understanding the perceptions, values, and feelings of others are the key components of caring. The manner in which things are said, including the tone of voice, eye contact, facial expression, body position, and gestures, reveal more message than words can convey. Actions or the lack of actions are more powerful than spoken messages. The patient may feel afraid, anxious, and confused. Do you sense these feelings? Do you give the patient your undivided attention rather than writing in the chart? Is he or she interrupted by your beeper, a device that declares your priorities higher than the patient's? Do you ask open-ended questions? Can you catch the nonverbal clues? Because we do so much filtering and filling in of the details, we always act on incomplete and biased information.' Listening is more than just being silent while someone talks. To be a good listener one must be inquisitive. How well do you meet the patient's expectations when everyone is allocated so many minutes of your busy schedule? With the advent of managed care we can anticipate less compensation for the time we spend with patients. We must therefore develop means to be more efficient with our time. Medicine has become an information industry. Our patients are far more sophisticated as a consequence of the popularity of health topics in the lay literature. At Scripps we have created a health resources library for laypersons that is staffed by volunteers. Patients can view videotapes, interact with computerized information, and read brochures. We hope to have all members of the health care team become educators when they interface with the patient.
Cardiac surgical programs As I reflect on reviews of cardiac surgical programs in my role as chairman of the Standards and Ethics Committee of The Society of Thoracic Surgeons, two things stand out. First, an effective quality assurance program was absent. Those inside the institution knew less about the program than the outside data collectors. You cannot manage what you cannot measure! If you are not analyzing the data your program generates, the cause of your failure will remain obscure. Second, there was a high profile of individuality. No one did everything the same way. Routines develop as a consequence of their being the best way to do something. They are analogous to the checklists pilots use before takeoff and landing. The goal
196
The Journal of Thoracic and Cardiovascular Surgery February 1993
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is to perform the routine as perfectly as possible to reduce the chance of error. The worst time to work out a strategic plan is when things become unpredictable, unstable, and likely to get worse. Urgent action may be required and that demands a focus and a sense of priorities.
Severity of illness Whereas differences between surgeons may reflect differences in patient mix, and the application of severity adjustment measures makes those differences disappear, quality issues may also be obscured. Comparisons by the type of operation may be more appropriate than ones made after adjustment for severity because the adjustments eliminate the effects of differential case selection. Small patient volumes provide a particular challenge as well. In December 1991 New York State released data on 140 surgeons, which showed wide variation in riskadjusted mortality rates. Providers questioned the fairness of being compared with their competitors on this basis, citing the high cost of data collection whose quality was problematic. Additional criticism was directed at inadequate adjustment for co-morbidity. Incontrovertible, however, was the fact that surgeons with greater than 50 operations yearly had about one-half the death rate of those who performed fewer than 50 procedures. David Axelrod," former health commissioner of New York State, asked, "Should not patients have the choice to have their cardiac surgery done in an institution that does more than 60 cases per year? Can they rely on their community hospital to provide only those services it provides well, competently, proficiently, and cost-effectively?" He firmly believed that the rights of the patient to be protected from a practitioner with clinical shortcomings should be greater than the right of that practitioner to any clinical privileges or access to the hospital. The Medical Society of New York State wisely indicated that patients could endanger their health by seeking out higher ranked surgeons and thus creating lengthy backlogs. Additionally, they emphasized that the lowest ranked hospital in New York City became the highest ranked within I year by simply refusing high-risk cases. Clearly there is a need for patients to be better informed about the outcomes in their community and to playa larger role in their treatment decisions. Whether this kind of information really contributes is yet to be demonstrated, but I see no value in keeping our results obscure. It is in the public domain. I favor the voluntary disclosure of patient care outcomes, the quality indicators used in their derivation, and the utilization data on specific procedures. There is no secret in my mind as to what makes a good
program. The answer is simple-its people! But it is also true that people are not the cause of poor programs. It is not an issue of bad people but bad design. Dr. Deming attributes 90% of failures to process errors, not people. Substandard care results from poor process design, poor training, and inadequate information, not from stupidity, indifference, or greed. People, regardless of their position, try hard, act in good faith, and do not willfully fail to do what they know is correct. Poor program design, failure of leadership at some level, or issues external to the institution that are beyond one's influence are far more common.
Practice guidelines The Agency for Health Care Policy Research is sponsoring the development of clinical practice guidelines aimed at reducing treatment uncertainty and inappropriate choices and thereby improving patient outcomes. Management strategies are created that define the patient's course of treatment. Appropriately designed, they provide objectives and options facilitating informed choice. Practice guidelines, practice parameters, medical criteria, standards of care, whatever the names, are not new concepts. I am concerned that they remain extremely simplistic, belittle the importance of physician's judgment, and artificially compartmentalize the patient's care by ignoring the spectrum of an illness from its inception to recuperation. Four issues with guidelines still require resolution: ( I) disagreement as to processes and vocabularies, (2) the diversity of medical practice, (3) varying purposes and goals for guidelines, and (4) a lack of information as to scientific efficacy? The more complex a clinical problem, the greater the number of options." If guidelines are overly detailed, flexibility is lost and they become unnecessarily prescriptive. Where legitimate differences of opinion exist, guidelines will have to explain those differences. Development by a variety of professional societies leads not only to duplication but occasionally to a lack of concurrence, as occurred with coronary artery surgery. Who then decides which set of guidelines to use? Health Care Financing Administration based on cost? The courts? Unlikely, since the guidelines devoid of bright lines express areas where physicians disagree. Current guidelines are primarily written by physicians with little input from other health professionals. Shouldn't they have a contribution? Published guidelines in our discipline speak little to pre-hospital preparation, patient education, or rehabilitation, and they fail to address the patient's expectations. There are additional unanswered questions. Can complex medical problems actually be solved by blue ribbon
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panels? By setting requirements and insisting we follow guidelines are we not running the risk of moving toward mediocrity? Will innovation be stifled? Will guidelines so bind practitioners to treat certain illnesses in a particular way that further justification is required for deviating from a guideline? If deviation occurs will it be assumed to be incorrect? If so, our income will be dependent on adherence to federal standards and all fears concerning cookbook medicine would be realized. Chassin" has stated it will probably not be possible in any field of medicine to design guidelines that will take into account every possible factor that might constitute an exception to the standard. Rigid guidelines ignore creativity and the flexibility possessed by trained individuals who are able to tailor their treatment when the conventional might be inappropriate. How frequently guidelines will require revision and updating is unknown. If we wish to avoid being held to standards of quality derived by others, we must participate, but that should not deter our continuing criticism. Unfortunately, guidelines use past practices as the point of comparison. Scientific bodies would not accept historical controls as statistically meaningful, but the process of continuous quality improvement demands that we assess our past and aim to change our future. Guidelines can achieve success only when the methods used to develop them are fully explained, how consensus was achieved is identified, and citations of actual trials support their validity, reliability, and applicability. At the present time they have no capacity to address problems that lie outside of the physician's domain. Finally, what assurance do we have that the regulatory oversight needed to ensure conformance is cost-effective? At this juncture no one knows! Practice variation There will always be variations in medical practice.f Variation exists because no consensus exists as to what represents appropriate treatment for a given condition. Variation exists because patients are presented with treatment alternatives and have discretionary judgment plus choice. If there is strong agreement about the management of a certain condition, variation is less. If the risks and benefits are less well established, the variation is greater. Even today for many of the common medical conditions well-designed clinical studies to test alternative forms of therapy have not been done. Tradition and clinical experience determine choices more than clinical trials or protocol studies. To advance medical practice we need well-designedand carefully conducted clinical trials. Clinical research is the keystone for improvement in patient care. However, the patient's expectation is for the physician not only to provide his or her best advice but also
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to act in the patient's best interest. The patient expects to be counseled as to what is reasonable, likely, and probable. In situations of uncertainty are we meeting those expectations when we base judgment on personal anecdotal experience? It requires a high degree of intellectual honesty to distinguish between what is known and what is simply believed. More precious than technical skill, which anyone can acquire, more difficult than knowledge, which is available to all, the most prized attribute of a physician is judgment. We must diligently seek ways to enhance and nurture our judgment. What do we presently do when there is a conflict of interest between the physician as a scientist and a provider of care? We turn to the randomized controlled trial, a study design with the least observer bias and the least error in methodology. But frankly, almost all surgical procedures have never been subjected to a randomized control trial. I have trouble with such trials when the patient is randomly assigned to one arm or another. Should not the expectation be that the patient chose which arm he prefers based on provided knowledge of the options? These trials have traditionally had difficulty in enrollment, and we all are aware of trials that have been terminated prematurely because the adverse outcomes in one arm have raised alarm. Physicians who have a preference for one treatment, say percutaneous transluminal coronary angioplasty rather than bypass surgery, may simply not be forthright in defining the alternatives to the patient. They often will not enroll patients in trials whose objective might be to prove their chosen method of treatment less desirable. This can be a failure to act in the patient's best interest. The patient should be permitted to make voluntary and uncoerced decisions about his or her treatment after being provided information. Medicolegal implications Much that occurs in our medicolegal environment is patently punitive. The natural tendency given this environment is to hide or avoid responsibility for bad outcomes. If punished for them, people will chose to hide their mistakes. Continuous quality improvement can take place only in a candid, nonretributional, self-examining environment. Without malpractice reform the probability that continuous quality improvement will be widely successful is small. Role conflicts In contrast to industry, where the manager is often not the worker, in the hospital there are many providers of care who have managerial roles. We need to develop more teamwork, more collaboration, more we and less me in order to bring success to our quality improvement efforts.
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- - MEAN CT LOS 17.381 - - - . - MEAN FY 91 18.71 --UCL
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DATE OF DISCHARGE
Fig. 1. CareTrac diagnosis-related group 106:length of hospitalstay, October 1991 to ApriI1992. Upper and lower confidence limits were calculated by means of 2 standard deviations. CT, CareTrac; LOS, length of stay; VCL, upper confidencelimit; LCL, lower confidence limit; FY, fiscal year. $80,000
$70,000
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- - CT TOT CHGS
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--LCL
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$10,000
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DATE OF DISCHARGE
Fig. 2. CareTrac diagnosis-related group 106:October 1991 to April 1992. Upper and lowerconfidence limits we calculated by means of 2 standard deviations, Mean fiscal year 1991 charges were adjusted for price increases. For abbreviations see Fig. 1. One never achieves quality by accident. It is always the result of high intention, sincere effort, intelligent direction, and a common sense of purpose.
Critical pathways Critical pathways, sometimes called clinical progressions, are multidisciplinary care plans with a time line. They represent transition from a segmented, departmen-
tal, or service-oriented approach to a patient-focused approach. They link continuous quality improvement with clinical management decision-making by establishing standing orders, developing clinical indicators and educational materials, and trending of results. Comparisons between those on the pathway versus those who are not aid outcome analysis. By focusing attention on those procedures that result in the best care and studying the
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Fig. 3. Diagnosis-related group 106: Baseline auditof intensive care unit (ICU) hoursfor non-CareTrac (NCT) and CareTrac (C or CT) cases in 1991. Non-CareTrac cases for 1991 exclude lengths of stay greater than I standard deviation.
reasons for success rather than failure, everyone becomes aware of changes in the system that will effect a significant improvement in patient outcomes. Consensus opinion identifies minimal essential components of care yet permits guiding protocols to be individualized. Contrast this methodology to that of practice guidelines that currently focus on physician activities instead of the entire care team. The key elements of critical pathways are (1) the education of the patient and the family about the continuum of care from preadmission to postdischarge planning, (2) assessment of interventions and their impact on expected clinical outcomes, and (3) charting by exception. The pathways address diagnostics, medications, diet, activity, the tracking of variance, trending, and continuous evaluation. The patient-oriented pathway, written in laymen's terms, describes the patient's movement through the hospital and is posted in his or her room. It is impressive to see the interest and interaction among patients as they compare their progress against the posted expectations. At Scripps we call our pathways CareTracs. They provide benefits to a number of recipients. For the patient, the expectations are defined, and he or she becomes more realistic through understanding. The power of this selfexpectation is awesome. It makes everyone feel like a winner. Unrealistic expectations may lead to disappointment, but keeping the patient focused on the pathway promotes his or her sense of accomplishment. Let's look at early extubation after coronary artery surgery as an example. Patients who are extubated present a less frightening appearance to relatives, can begin oral med-
ications sooner, need less sedation, can verbally communicate their needs, and can interact with their families and care givers. For the nurse the benefits are dramatic. Not only is there enhanced collaboration with all the team members, but there is increased staff satisfaction. The nurses have an improved documentation system that uses exception charting. Only those events not delineated on the pathway need to be charted. This results in increased productivity and more time to spend with the patient. The nurses are additionally empowered in decision making. For the hospital the benefits are decreased length of stay, decreased resource utilization, and increased patient and staff satisfaction. The pathway provides an efficient way to evaluate new products and procedural changes, as well as providing a valuable feedback loop to critically improve the process. For example, we have historically moved the patient through the hospital. The patient goes everywhere for service. Weare now considering bringing the services to the patient by cross-functional training. Nurses can draw blood instead of the phlebotomist, respiratory therapists can perform electrocardiograms, and volunteers can expand their roles into direct patient care. For the managed care contractor the pathway defines length of stay and use of resources and facilitates discharge planning. Through a system of collaboration, uniform outcomes become a common mission. Fig. 1 shows the impact of the pathway on length of stay in diagnosis-related group 106, coronary artery bypass with catheterization, the same admission at Scripps. Fig. 2 shows the effect on charges. Fig. 3 iden-
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The Journal of Thoracic and Cardiovascular Surgery February 1993
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Fig. 4. Diagnosis-related group 106: Baseline audit of intervalfrom intensive care unit (ICU) to extubation (hours) for non-CareTrac (NCT) and CareTrac (C or Cn cases in 1991. Non-CareTrac sample cases for 1991 exclude lengths of stay greater than one standard deviation.
tifies the intensive care unit length of stay, and Fig. 4 shows the hours to extubation. Note that patients not on the CareTrac also benefited from the nurses' experience. The most striking event is the elimination of variation and the collaborative influence on non-CareTrac patients as well. In summary, I have mentioned many issues and many expectations. For continuous quality improvement to succeed, barriers must come down. Everyone must be willing to listen, to learn how to improve their processes, and to speak out so others can improve theirs. This will require a cultural change. Physicians have preferred not to acknowledge mistakes, continue to be apprehensive about peer review, remain reluctant to accept responsibility for their colleagues' behaviors, are concerned with threats of legal actions, and are convinced that it is not their business. As surgeons we only need to reflect on failed angioplasties as an example of our reluctance. Quality is not a program, but a philosophy. You don't make quality happen; you allow it. You don't tell people what to do; you tell them what you want accomplished. Because the only way to avoid mistakes is to never do anything, we must not regard problems as bad. The Japanese regard problems as opportunities to showcase their talents and make a valuable contribution. For this to occur, the environment must be receptive. Hospitals have been quite successful at guarding hospital-specific information regarding their quality and efficiency. I believe this is a barrier to effective change.
Until the purchasers of care know exactly what they are buying, we cannot expect the marketplace to influence costs. I believe in the public release of health outcomes information. It is a powerful motivator for change. Additionally, I think hospitals should be benchmarking their results with comparable facilities to achieve continuous quality improvement. It is only by doing the right thing, the right way, every time, and on time, that we can truly meet and possibly exceed our patients' expectations. REFERENCES I. Goldman RL. The reliabilityof peer review assessments of quality of care. JAMA 1992;267:958-60. 2. Tannen D. You just don't understand: women and men in conversation. New York. William Morrow, 1990:37. 3. Kritchevsky SB, SimmonsBP. Continuousquality improvement:conceptsand applications for physician's care. JAMA 1991 ;266:1817-23. 4. Axelrod D. Perspectives: a state health commissioner. Health Affairs. 1988;7(2 suppl):54-7. 5. HirshfeldEB.Shouldpracticeparameters be the standard of care in malpractice litigation? JAMA 1991;266:2886-91. 6. Brennan T. Practice guidelines and malpractice litigation: Collision or cohesion? J Health Polit Policy Law. 1991;16: 67-85. 7. Chassin MR. Standards of care in medicine. Inquiry. 1988;25:437-53. 8. The Cardiology Working Group. Cardiology and the quality of medical practice. JAMA 1991 ;265:482-5.