The Ethics of Quality and the Quality of Ethics

My academic division and clinical practice group at the major medical center where I work has been intensely focused on the issue of quality, as are most of our colleagues around the country. My institution formally became an Accountable Care Organization (ACO) in 2012, and one of the tenets of ACOs is their focus on quality measures and issues surrounding so-called "pay for performance" and "value-based purchasing", which are code terms for reimbursement based on reportable measures of quality.

Paul R. Helft, MD

It is a common-sense notion, borne out by years of research in the education, healthcare, and business sectors, that a disproportionate share of an institution’s resources and energy will be devoted to improving objective measures when they are reportable and, more important, when those measures have a direct economic impact on the institution. For example, several decades of research has demonstrated that the number of lymph nodes recovered and examined from a surgical colon cancer resection has a measurable impact on patients' survival. But it wasn't until this measure came under scrutiny and became a marker of quality highlighted by multiple organizations with oversight in the field and linked directly to reimbursement rates that hospitals and healthcare organizations devoted the necessary resources to the issue to improve the situation across the country. Currently, the majority of hospitals performing surgery for colon cancer meet these minimum quality standards for lymph node recovery and examination. One has to ask why the mere knowledge that such lymph node recovery and evaluation affected outcomes was not sufficient to alter widespread practices in the same way.

This kind of "teaching to the test" gives me great pause. It is not that I don't believe that we should be working hard to improve quality in cancer care, or that the measures coming into widespread use are unconnected or unrelated to real quality. I believe the quality industry's argument that quality measures-which by definition must be limited in number or it would be impossible to collect data about them-are important surrogate markers of real, overall quality. In other words, if your recovery of lymph nodes in colon cancer surgery has improved, there are likely to be other processes that are improved on the coattails of that effort.

Two things really bother me about these massive and expensive efforts, however. The first is that we will inevitably spend a lot of person-hours, effort, and resources improving the measures that are reportable and that therefore affect reimbursements. Other important aspects of quality cancer care will be neglected, and we will rely on the kinds of coattail effects hypothesized by those in the quality-healthcare complex. The second, more important issue for me is that many of the most important aspects of truly high-quality cancer care are likely to fall lower on organizations' priority lists because they are not important to quality metrics and in many ways difficult to measure. An example of this would be communication in cancer care.

I will grant that we already measure the quality of communication by assessing patients' satisfaction with various aspects of communication. And perhaps, in the end, all that really matters is that patients and families feel satisfied with the level of communication. But I know from experience that patients sometimes report high quality communication when the actual quality of that communication is low. This most central and integral aspect of cancer care (the central aspect, I would argue) deserves much more energy and devoted effort. But it is likely not to receive that attention by organizations, except as it relates to improving satisfaction scores.

My suggestion, as unrealistic as it is, would be to encourage the creation and maintenance of parallel groups of quality measures: one set to satisfy the reportable measures of quality that affect reimbursements and pay for performance, and a second set that would be developed by and adapted to each institution to measure and drive improvements in those things we felt were true measures of high quality care. We all know clinicians, for example, whose ability to engage, communicate, and develop relationships with patients is so exemplary that we recognize without question the quality of the care they provide. But can we reduce what those clinicians do to a measureable quality indicator? Probably not. Could we use what they do to drive improvements in how others practice? Almost certainly. In the end, my ethical concern is that the medical quality-industrial complex that we have created will cause us to neglect many important aspects of patient care because they are too hard to measure or simply don't lend themselves to straightforward means of quantitative assessment. There is only so much time in the day.