Confronting the Quality Paradox - Part 1
Biomed Central published a collection entitled The Many Meanings of “Quality” in Healthcare 19 June 2015. This collection was cross disciplinary and addressed three broad themes: the practices of quality assurance, giving space to “the story,” and addressing moral complexity in the clinic. This is the first of a series of articles dealing with individual papers that resonate with the practice of medicine today.
In their paper, Caring for Quality of Care Emmerich and associates lay out a perspective that is philosophical and sociological. They start by noting:
There is a practical and moral obligation on health care organizations to manage the delivery of “care” or, perhaps more importantly, to ensure services are provided with care…It is in the manner of their delivery and the particularities of their provision that the essence of care is to be found…Care is not merely an attribute of a particular service, but the way it is provided or delivered. Care involves an emotional stance and relational quality that can, but may not, accompany the activities constitutive of health care provision.
This speaks to a concern many physicians and nurses have about quality assurance activities—it does not capture this fundamental aspect of the process. I think this is an elegant way of phrasing the ideas I have reviewed under the term clinical microsystems. Since care is fundamentally a group activity, the organization and training of the small group needs to take place in such a way that those things which should be standardized are, and those things which should not aren’t. The authors address this problem, too, focusing on the problem of scale. They point out they are specifically NOT addressing the micro level of practice, or
…the interaction between professional and patient, (where care is actually experienced in all its intersubjective nuance,) but the meso and macro level of social structure—the social organization of care and its institutional control…We suggest contemporary approaches to the care and the management of care reiterate the tendency to eliminate the messy business of “care itself” from the public sphere. The inherently (inter)subjective experiences of care and caring, the “life world” of individuals and small groups of individual participating in the actual provision of care are relegated to the private realm whilst only objectified measures of its “quality” are afforded “public”—managerial or political—significance.
They do note that caring, as opposed to quality of care, is an emotional action that can cause distress for the caregivers, and quote a paper from the 1960’s that observed “a task-based, rather than a patient-centered division of labor provide for a degree of organizational defense or structured distance.” Task orientation, seeking refuge in the tasks rather than focusing on the patient, is common in physicians, too. If we conceive of care as a clinical microsystem, or team activity, team members can often support each other during difficult times.
Physicians and nurses have always been concerned about maintaining standards of practice, but current efforts are different.
Concern for standard(s) of practice has been translated into concern for not just the assessment, audit and evaluation of those standards, but a particular form or approach to “quality assurance.” In practice any attempt to conduct “quality assurance” assessments will be embedded in specific managerial and bureaucratic processes…what is important enough to be measured and promoted within particular contexts is politically determined: it is a function of power.
In the U. S. context, most health care organizations understand that what is driving a lot of the quality assurance efforts of the Federal Government reflect the sense that we cannot afford to spend more than we currently are. On more than one occasion, when meeting with organizations struggling to meet a Federal mandate, I like to point out my two rules in dealing with the government. First, no matter the stated agenda, the real issue is money. Second, the government assumes we are out to “steal” as much money as possible. The authors address this issue thusly.
Whilst the social organization of social organization of health care can, and sometime does, militate against the caring dispositions of professionals, it would be facile to suggest that any and all bureaucratic procedures or managerial processes should be abandoned because of this; a lack of proper managerial oversight will also lead to failures in care…What is required is a more sophisticated understanding of the relationship between the front line practices of care and the way(s) in which they are managed…From an “audit culture” perspective, the collection of data about a particular practice has tangible and immediate effects; it is fallacious and potentially harmful to dichotomize frontline practice and the managerial structures that command, control, and facilitate it.
The authors stress that the “law of unintended consequences,” which in this part of the country we call the Kudzu principle, is alive and well, and so they discuss in depth the unintended consequences of the bureaucratic approach to quality assurance.
The supposed objectivity of administrative and bureaucratic records, the instruments of governance, has brough about the dissolution of perspective and allowed an increase in “data” to be mistaken for an increase in insight and understanding.
They point out that there are two problematic assumptions imbedded in this approach, which are often not recognized. The first assumption is that information increases the transparency with which we can understand a subject. Second, that this information can be used to control or (re)engineer the project. But the logic of governance dictates “that which is measurable, standardizable, and auditable is measured and comes to represent the reality of interest. The corollary is that which is not measurable is not real
I have addressed the question of big data and its potential uses and limitations elsewhere, but the key point here is the notion that only what is measurable and subject to standardization is important. Now I don’t want to minimize the value of standardization. In the context of dialysis units, my conception of the goal is to deliver dialysis in a standard fashion, since the goal for each individual patient in terms of the procedure is the same. However, this does not mean the goals of care for every individual are the same, which is the thrust of current government-mandated inspections and audit procedures. The blunt instrument of government mandates is actually hurting the care of some, but not all, individual patients. The authors address this rather bluntly.
Audits are contemporary technologies of evaluation and should be considered part and parcel of the fields they render accountable. This is precisely because as forms of bureaucracy, as organizational devices, institutionalized audits act in such a way as to engender “audit-ability.”…This creates the potential for bureaucracies to not only “slip from the model of reality to the reality of model,” but for structurally embedded procedural imperatives to become privileged over the ends of practice”…The actual practice(s) of health care have become subordinated to “Quality of Care” and, rather than being responsive to patients, professionals are increasingly required to respond to the imperatives of the evaluative bureaucracy invested with the symbolic power to pass judgment.
This last point is one that is a common theme in conversations I have with thoughtful veteran practitioners. No matter how hard we try to keep our eye focused on the patient, we are constantly pulled toward meeting audit goals such as filling in blanks in the EMR, ordering laboratory tests, or giving medications of problematic utility, or otherwise putting the need to “look good” on the audit ahead of the primary needs of the patient to balance cost, side-effects, and effectiveness for his/her particular set of circumstances.
So what are we to do—we certainly aren’t going to make bureaucracy or audits go away. In fact leaders of medicine are fully involved in the “accountability” motif as outlined in this paper. The authors have a number of specific suggestions which I find important from the practitioner perspective, so I will close by quoting from them at length.
The practicalities of bureaucracy, audit, evaluation and “quality assurance” methodology mean that whilst we can construct symbolic representations of the Quality of Care predicated on the practical delivery of health care, care itself remains a frontline task that can only be guaranteed by those who actually deliver it, their ethics and professionalism. The Quality of Care discourse finds its main usefulness in the management and organization of health and social care. As such it can contribute towards the provision of care, but cannot guarantee care as a moral phenomenon. Furthermore, the law of unintended consequences means that institutionalized auditing processes of such bureaucracies may actively militate against care as a moral practice…
If we regard care as involving emotional investment…then it is not something that can be subject to a comprehensive audit. It cannot be considered fully accountable to any organizational device or bureaucracy, and any attempt to render it fully accountable will founder…
Rather than adapting practice to bureaucratic structures…we should become attuned to the limitations of procedurally generated data and attend to the way in which this data is used. In this way the assurance of care quality becomes a form of ongoing experimentation and, ideally, one that encompasses the ability to reflexively respond to changes in practice, some of which will be produced through Quality of Care activities themselves.
Perhaps we would have more success if there was more focus on local institutions doing quality improvement activities for their own patient needs rather than to meet government targets. We certainly need more realistic attention to clinical performance measurements, as the present regulatory environment often translates ideal performance on a measure with expected performance. Ultimately, though, the challenge for us as physicians and nurses maintain our commitment to care for our patients “carefully” with the best data and tools available, and to constantly innovate with ways to make it better. Quality improvement is a worthwhile activity for clinicians, but not a good way to prove quality of care.
27 June 2015
 Swinglehurst D, Emmerich N, Maybin J, Park S, Quilligan S. Confronting the Quality Paradox: Towards New Characterizations of “Quality” in Contemporary Healthcare. BMC Health Services Research 2015;15:240. doi: 10.1186/s12913-015-0851y. Accessed at http://www.biomedcentral.com/1472-6963/15/240, 21 June 2015.
 Emmerich N, Swinglehurst D, Maybin J, Park S, Quilligan S. Caring for Quality of Care: Symbolic Violence and the Bureaucracies of Audit. BMC Medical Ethics 2015;16:23. doi. 10.1186/s12910-1015-0006-z. Accessed at http://www.biomedcentral.com/1472-6939/16/23, 25 June 2015.
 Lyth IM. Social systems as a defense against anxiety. An empirical study of the nursing service of a general hospital. Hum Relat 1960;13:95-121.
 On several occasions, my dialysis team has experienced a particularly traumatic death—sometimes in the unit itself, but sometimes elsewhere. We have found it helpful to bring in an outside facilitator and have the group meet to discuss the events and process their feelings. We do pay them for their time and attendance, but the physicians and the administrator stay away, so they feel free to say what they need to say. This has been a very useful exercise, although we have resorted to it sparingly. More commonly we will do a “de-briefing” informally amongst ourselves, to acknowledge the losses and the feelings of guilt and failure that accompany some of them.
Confronting The Quality Paradox - Part 2
Accounting is not simply a matter of recording reality objectively, it makes things up and changes the definition of what really matters.
Confronting The Quality Paradox - Part 3
Confronting The Quality Paradox - Part 4
There will never be authentic quality within healthcare unless the word explicitly accommodates the truth that a human being is simultaneously both a subject and an object.
Confronting The Quality Paradox - Part 5
The Center Effect
Some dialysis units have consistently better performance than others, even after adjusting for individual patient variables, which is termed the center effect. This has important implications for hospitals and health care organizations as they respond to public reporting of data.