Patient Engagement

The Disguise of “Quality” Improvement in Healthcare

Quality Improvement – Seriously?

Don’t get me wrong – I’m a fan of quality improvement. Who wouldn’t be? It’s a concept that is difficult to argue with in healthcare. But I do want to argue that much of what we accept as “quality improvement” is really “quantity improvement” with little attention to quality by any measure that matters to a person who is receiving care – or for that matter, to many who are providing care.  The QI movement prides itself, for example, on the ubiquitous PDSA cycle, which uses the scientific method to do small tests of change. Of course, it is possible to measure whether patients feel their care was better in some way as a result of the initiative being tested, but we don’t often do that as often as we count things (minutes, completed charts…).

I’m all for calling a spade and spade! It is important to address issues of access, appropriateness, effectiveness and efficiency, but I think it’s time we gave evaluation of quality back to those we are here to serve. Patients and their families are in the best position to judge the quality of care. In a study of over 700 clinical encounters, patients gave their clinician a perfect empathy rating and reported their colds were less severe and lasted fewer days; those patients also showed a higher change in nasal neutrophils and in the cytokine IL-8[1]. Those results are of more interest to us than patients, who, I suggest would say that what mattered to them (and made them feel better) was that their doctor took them seriously and treated them with compassion. Sure, they probably care that their cold was shortened by two days, but really, I think what we want to know about from the patients’ perspective is whether the care provided made them feel better in a holistic way – or not. I can certainly tolerate illness, but I cannot abide being belittled by my care providers. As a patient, quality for me is about the relationship I have with my care giver – if I feel belittled in the process of care, I would still rate that as poor quality care even if I had a great outcome.

So, let’s not mistake quantity improvement and quality improvement – they are not interchangeable. In fact, sometimes they are contradictory – in our effort to be efficient, we can sometimes negatively impact the quality of care. We may be willing to accept the trade-offs, and maybe sometimes that is the best choice, but at the very least, we need to acknowledge that choice. I don’t believe that quality care – compassionate, kind care – takes more time or costs more. The most memorable of my own encounters, with what I judge as exemplary care, have been moments – brief encounters of authentic, genuine caring – moments of engagement, empathy – a look, a nod, the briefest touch that said “I understand – this must be hard for you – I have confidence in you.” That is what matters to me and I suspect to others. It is our willingness to witness and to encourage even more than our technical expertise that patients value. So, I think we need another name for quality improvement, one that is more honest. Efficiencies are important to patients – they like tests being done more efficiently and reduced wait times in ED; things like that do make a difference. But we are beginning to fool ourselves into thinking this is what is most important in terms of a quality care experience. If we do not turn this around, we will continue to lose focus on what really constitutes quality in care.

– Marion Briggs, BScPT, MA, DMan,

Northern Ontario School of Medicine

Fellow, AMS Phoenix Project

May 2014

[1] Rakel D, Barrett B., Zhang Z., Hoeft T., Chewning B., Marchand L., & Scheder, J. (2011). Perception of empathy in the therapeutic encounter: effects on the common cold. Patient Educ Couns. 2011 Dec. 85(3):390-7. doi: 10.1016/j.pec.2011.01.009. Epub 2011 Feb 5.


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