Lara Goitein

Standardized Best Practices and Individual Craft-Based Medicine: A Conversation About Quality

Standardization of medical care through protocols, order sets, and other tools is increasingly a part of efforts to improve quality. The authors, a physician beginning a new position as director of a community hospital quality program and the chief quality officer of a health care system and director of a course in health care delivery improvement, discuss the benefits and risks of standardization in health care. Recommendations for responsible standardization are presented.

Virtual Quality: The Failure of Public Reporting and Pay-for-Performance Programs

Is there too much focus on measuring and reporting quality rather thanontheconditionsneededfor improving it?TheCenters for Medicare & Medicaid Services (CMS) and other organizations require physicians and hospitals to publicly report performance on quality measures, and the CMS and privatepayersare tyingreimbursementpartly todata fromsuch measures in pay-for-performance programs. However, as the director of an intensive care unit performance improvement program, I know that it is difficult—and sometimes counterproductive—to try to improve a complex systemsimply by rewarding or penalizing the results. Holdinghealthcareprofessionalsand institutionsaccountable for qualitymetrics can backfire. For example, because reported qualitymeasures are limited in number and reflect national rather thanlocalpriorities, theymaydivertattentionfrom other, perhaps more important, problems in individual hospitals—a formof teaching to the test.Efforts to improveperformancecanalso leadtogaming, throughchanges indocumentation and coding, or even changes in clinical practice. As examples, health care professionals and institutions may avoid high-riskornonadherentpatients,1basetriagedecisionsontheir effectonperformancemeasures (suchaschoosingnot toadmit patientswhoare likely tobereadmittedfromtheemergencydepartment to reduce readmission rates), or omit screening that might identify conditions, such as hospital-acquired venous thromboembolism, that could reflect poorly onperformance.2 What is less frequently discussed, but just as important, is thatpublic reportingandpay-for-performance systems shift the focus of quality improvement todocumentation. In sodoing, these efforts take quality improvement out of the hands of clinicians anduncouplemeasurement from its clinical context. The hope is that the required measurements will jumpstart a cycle of continuousquality improvement inwhichdata areused tohonepractice.However, there is no guarantee that datawill be soused. Indeed, the tasks ofmeasurement and reporting fully occupymany hospital quality improvement departments, leaving fewresources for actually improvingmedicalpractice.Toensurestandardization,eachmeasuregenerally requires aheftymanual to specifymethods and sometimes its own information technology and specialized staff. This bureaucraticwork usually falls to nonclinical (or nonpracticing) staff; theymayhave little understandingof, or authority over, processes on the wards. In practice, such staff may deal almost entirely with improvements based on building documentation into the flow of work or modifying coding, creating the illusion of improved performance. Hospitalhallwaysarefullofdisplaysofchartsshowingprogress on various qualitymeasures; hospital leadersmeet to discuss qualitymetrics, and administrators sendnewsletters that congratulate staff on accomplishing quality goals.However, in many hospitals, patient care is largely unaffected. Busy physiciansandnursesrushbyhallwaydisplaysanddonotreadnewsletters thatreportqualitymetrics.Whentheypayattention, they tend to regard the data with skepticism: after all, they do not perceive much change save perhaps for some additional requirements for documentation. Few clinicians sit on quality committees, andstill fewerhavea role in theactual implementation of quality improvement projects. The findings of a study3 presented in this issue of JAMA InternalMedicine reinforceconcernsabout theunintendedconsequencesofpublic reportingandpay forperformanceandalso suggest a gapbetweenquality improvement activities andpatient care. Lindenauer et al3 surveyed hospital leaders (chief executiveofficersandexecutives responsible forquality) about publicly reported quality measures required by the CMS. Althoughmost respondents said that theyused themeasures extensively, more than half were concerned that the measures encouraged teaching to the test, and almost half reported trying to maximize performance primarily through changes in documentationandcoding.Also important is thathalf ormore believed that the CMSmeasures did notmeaningfully distinguishamonghospitalsoraccurately reflectqualityofcare,even for conditions specifically targeted by themeasures. In short, the study findings suggest that many hospital leaders doubt theclinical relevanceof thesemeasures.This skepticismisconsistentwithnational data: studies of public reporting andpayfor-performance programs in the United States have failed to demonstrate a clear connection to improved quality.4,5 Howcan these results beexplained?The respondentsmay haveunderstood that althoughpublicly reportedmeasuresare highly influential,muchof their effect doesnot reach thebedside. Thismaybeclearest to thosemost closely involved in the mechanics ofmeasurement and reporting. Executives specifically responsible for quality (eg, chief quality officers) were more than twice as likely as chief executive officers to believe that hospitals attempted to maximize performance on mortality and readmissionsmeasuresprimarily by changingdocumentation and coding andmuch less likely to believe that the measureswere clinicallymeaningful fordifferentiatingamong hospitals. Therewas generally less skepticismabout the clinical relevance of measures of process and patient experience, such as use of venous thromboembolism prophylaxis and patient satisfaction, than about outcome measures, such as mortalRelated article page 1904 Research Original Investigation Health Care Quality Attitudes

Mother’s Day for Women in Medicine—Better Than Roses

A few days before we were invited to write this Mother’s Day article, both of us—mother (M.A.) and daughter (L.G.)—walked arm in arm in one of the many marches in January 2017 to underscore women’s rights in the face of the new Trump administration. The sense of intergenerational connection was palpable. Thousands of daughters—millennials and members of generation X— fell in step with their baby-boomer mothers, many of whom had started marching for women’s causes back in the 1960s. In medicine, that warm intergenerational connection has been present for many years—but for men, not women. We know of many father-son pairs who have made their mark in medicine, but mother-daughter pairs are relatively new (and sometimes hidden, since mother and daughter often have different surnames). Being such a pair, we have reminisced at length about our lives in medicine. Because they straddled the entry of large numbers of women into the profession, our experiences differed from each other far more than would be likely for a father and son. We entered medical school exactly 30 years apart (both in Boston). In 1963, M.A. was one of only 8 women in a medical school class of 75 (an unusually high percentage then). When L.G. entered medical school in 1993, there were approximately equal numbers of men and women. We thus directly experienced the enormous changes that occurred as women progressed from being a small and often unwelcome presence in medical school to, as of today, being about half,1 and from being a tiny percentage of practicing physicians to a third.2 When M.A. entered medical school, physicians, almost all of whom were men, were threatened by the entrance of women into the profession, in part because the “feminization” of a profession usually meant a decline in status and income (and still does). Many of the men in M.A.’s class were openly hostile to the women, accusing them of irresponsibly taking up a place that should rightfully be filled by a man. Professors addressed the class as “gentlemen,” as though willing the women to disappear. For residency, women were shunted toward certain specialties, such as pediatrics and psychiatry, and away from others, like surgery (not coincidentally, the higher-paid fields). It was eminently clear that many professional opportunities were, in practice, closed to women. No accommodations were made for pregnancy or motherhood, despite the fact that medical training coincides exactly with women’s prime reproductive years (and day care was rare). When M.A. became pregnant in her second year of residency, she was not invited back for a third year. The offset for M.A. was the opportunity to care for patients in a way not possible for L.G. The relationship between resident and patient was closer in the 1960s because care was provided almost exclusively by 1 resident, rather than teams, and patients stayed in the hospital much longer (about 8 days on average).3 This afforded the time to witness the entire course of illness, from presentation to full recovery. Although residents, then as now, spent long hours in the hospital, the pace was more leisurely. There were many fewer diagnostic tests in those days, so ascertaining the diagnosis by history and physical examination—the interesting detective work—was more a focus, and residents came to know their patients well, even if they could do less for them. Sometimes patients would initially be worried by having a woman physician, assuming she would be less competent, but that concern almost always quickly dissipated. When L.G. was in medical school and residency (19932001), she felt no discrimination whatsoever from the men in her class or from male faculty. With perhaps the exception of the very top of organizational hierarchies, she had the impression that every opportunity was open to her. Men and women physicians shared a strong camaraderie. This was the “era of high throughput”4 and before the institution of work-hour limitations. Hospitals were making concerted efforts to increase market share, and for those that were successful, the number of admissions was increasing, while the length of stay was dropping. Patients had to be very sick to be admitted to the hospital. So the intensity and acuity of workload was high, the pace frantic, and the hours often more than 100 per week.5 Since patients were discharged so rapidly and their care was shared among many services and physicians, it was hard to develop the kind of close physician-patient relationships that M.A. remembers. In contrast to M.A., who found refuge from the skepticism of her peers in her relationships with patients, the primary joy in work for L.G. lay in the relationships among fellow trainees. Their unwritten code was always to go the extra mile to help one another, and their shared experience seemed to trivialize any differences, including gender. We each observed that women nurses sometimes responded to women physicians, at least on first contact, with less respect and more resistance than to their male counterparts. It was interesting to us to see this phenomenon confirmed by the survey of Adesoye et al6 in this issue of JAMA Internal Medicine, in which 38.8% of physician mothers reported discrimination from nursing or support staff.6 (This was more than any other type of discrimination investigated, with the second most common type—not being included in administrative VIEWPOINT