In 2004, Malcolm Gladwell1 wrote about quality in the New Yorker. He discussed how people identified their preferences for different types of spaghetti sauce, and that there was no one perfect sauce preferred by everyone. However, there were three types with different characteristics, each with its own advocates: plain, spicy, and extra chunky. In other words, perfection was a plural.
My first foray into research also involved taste. My colleagues and I conducted a taste test as part of a comparison of various antacids, hoping to provide information to patients that might help them decide which antacids they should buy.2 Had we been aware of the research that Gladwell described, we might have realized that knowing what scored highest on the taste test might not help in the compliance and acceptability of antacids if there were bimodal or trimodal spikes in desirable characteristics of antacids, such as existed in spaghetti sauce.
So what is the point of discussing spaghetti sauce and antacids? The science of health care quality requires the same types of rigorous investigation of people’s preferences that is performed by those who create products for consumers. Many of us in health care have assumed we knew what patients wanted—to get better from whatever was wrong—and our job was to marshal the information and resources to meet that goal. We did not realize that for many patients, particularly those with chronic diseases, cure might not be possible, and management of various symptoms and complications would be the goal. We did not understand the multifaceted nature of quality defined by the Institute of Medicine in Crossing the Quality Chasm3 as safe, timely, efficient, effective, equitable, and patient-centered. Just as with spaghetti sauce, quality is a plural.
How can academic health centers provide leadership in this rapidly developing area? There are five ways in which academic health centers are uniquely positioned to contribute to the national dialogue on quality in health care. These are
- developing quality measures,
- engaging in quality improvement science and methodology at academic clinical facilities,
- educating students, residents, and faculty in principles of quality improvement,
- engaging with patients and the public in defining and implementing patient-centered quality in health care, and
- becoming models of high-quality health care delivery.
The obstacles to taking advantage of these opportunities are that the expertise of researchers and educators that typically resides in discrete silos will need to be deployed to the clinical environment, and information that is carefully protected in the clinical environment will need to be shared with researchers and educators.
These obstacles must be overcome because there are crucial questions about quality that need answers. For example, there are questions about quality measures that academic health centers could investigate and subsequently provide information to and have dialogue about with such institutions as the Centers for Medicare and Medicaid Services. Quality measures have become a critical part of payment incentives for hospitals and physicians. Because the measures will be tied to reimbursement, physicians will examine them critically to see whether the measures are relevant to their practices and whether the data will have a positive impact on improving patient outcomes compared with the time and energy required to report them.
There are presently over 200 measures from which physicians can choose to report. Currently, only 29% of physicians have participated in the Physician Quality Reporting System.4 Why is the participation so low despite incentives for reporting? How could the system be improved? If the current measures are not the right ones to measure quality, what might be better? These are just some of the questions that academic health centers could explore.
Academic health centers also need to engage in developing better quality improvement methodology. Current methodologies have been drawn from other industries, such as the airlines or automobile industries, which can engage in highly standardized approaches to improve products. Although there may be information that can be transferred into the health care environment, this should be done carefully and with appropriate scrutiny of unintended consequences. Academic health centers have the research culture and capacity to do the careful work in the science of quality improvement and safety, including the creation of databases and the display and sharing of data to drive improvement. To succeed, academic institutions will need to build bridges between the academic silos of research and clinical care.
Researchers and clinicians are not the only groups that must participate in fostering quality improvement. Students, residents, and faculty can become change agents at their current institutions and at their future institutions if they can learn the basic principles of quality improvement and can have hands-on experience addressing quality problems. This will require major investments in training faculty and allocating precious training time to quality activities. However, once begun, this activity can become embedded into the culture and become self-reinforcing. The multiplier effect of thousands of graduating residents bringing their new knowledge into community hospitals could be enormous. The information and expertise to accomplish this will require bridging the education and clinical silos.
In this issue of Academic Medicine, Boudreaux and Vetter5 describe the creation of a section on quality and patient safety in a department of anesthesiology and how the section has augmented the education of students, development of faculty, and improvement of care. Theirs is one example of how a focus on quality and safety can build bridges between our clinical and educational missions.
In addition, patients and their families must be partners with academic health centers in the improvement of quality in health care. We cannot assume we know what patients would like from health care providers without asking them and presenting information to them. Even if we can recite the attributes of quality, we may not know which of these would be most important at any one moment in time. Jay Barach,6 a physician seeking a heart surgeon for his own surgery, nicely presents the dilemma that occurs when one is confronted with choices between effectiveness and patient-centeredness. He initially was drawn to a patient-centered surgeon but ultimately chose another surgeon for the latter’s perceived clinical skills. Academic health centers have the expertise in the humanities and decision sciences that can help us understand how to best help patients make difficult decisions about quality.
Finally, academic health centers must become the exemplars of high-quality medical care. We cannot expect our students and residents to learn about quality in an environment that does not provide high-quality care. Our hospitals and clinics are far more than locations for interesting patients and problems. Academic faculty have typically been fragmented between the missions of teaching, research, and clinical care and have not been recognized for involvement in improving clinical systems. We could recognize and value a scholarship of clinical quality and, in so doing, help to unify our missions around a quality of care that would be unsurpassed.
David P. Sklar, MD
1. Gladwell M. The Ketchup conundrum. New Yorker.. September 6, 2004:79 http://www.newyorker.com/archive/2004/09/06/040906fa_fact_gladwell?currentPage=2
. Accessed October 12, 2012
2. Sklar D, Liang PJ. Antacids: Cost, taste, buffering. N Engl J Med. 1997;276:1007
3. Institute of Medicine Committee on the Quality of Health Care in America.Crossing the Quality Chasm—A New Health System for the 21st Century. 2001 Washington, DC: National Academy Press
4. Centers for Medicare and Medicaid Services. . 2010 reporting experience including trends (2007–2011). http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html
. Accessed October 12, 2012
5. Boudreaux AM, Vetter TR. The creation and impact of a dedicated section on quality and patient safety in a clinical academic department. 2013;88 Acad Med.:173–178
6. Barach J. Big incision. Ann Intern Med. 2012;156:836–837