CQI process and data are often misused by people who do not understand the necessary preconditions for success. A textbook example has been provided by recent reports from the VA Healthcare system. Some years ago, the VA was criticized because veterans often waited very long times for appointment to see physicians. Senior leadership decided to set a goal of getting patients an appointment to be seen within two weeks. The two week target was undoubtedly arbitrary, but as it happens, this is a widely used goal—we even used it once for planning in my medical group as we thought about manpower needs.
To show they were serious, senior leadership set up a series of bonuses and penalties for local hospital directors based upon this indicator. Does this sound familiar to you as a practicing physician? When the demands for access by the now gray Vietnam-era veterans and the needs for service from our veterans from the past 13 years of war in the Middle East began to impact the system, the indicator started showing slippage—performance in meeting the two week goal became progressively more difficult. (http://www.nytimes.com/2014/05/30/us/doctor-shortages-cited-in-va-hospital-waits.html?emc=edit_th_20140530&nl=todaysheadlines&nlid=58452873)
In an ideal world, this would have been brought to the attention of senior management, and one of two things would have happened. Either more resources would be brought to bear, or the performance expectations would have been adjusted, or both.
However, the VA is a very large bureaucracy, and a director is not going to enhance his chances for promotion by telling the Secretary he can’t get the job done. And the Secretary was not going to want to tell the President and the Director of OMB, much less the Congress, that he needed more resources to get the job done, since that would mean either raising taxes or taking the money from somewhere else. But the situation might still have been salvaged if the performance bonuses and penalties had been suspended. Since they weren’t, a significant number of medical center directors decided to game the system so the indicator reflected what they wanted it to reflect, not clinical realities.
Congress has expressed outrage, the incumbent Secretary Shinseki has resigned, and everyone is saying things must get better. But setting more goals won’t make things better if the culture remains the same. CQI is a powerful method for improving care, but it will not work if the proper cultural conditions are not in place. Foremost among these is a willingness on the part of everyone to take an honest look at how things really are now. For that to happen, the individuals expected to take that look have to be insulated from blame, particularly for things beyond their control.
Clearly, hospital directors are not to blame for the decision to go to war, even though they do have to accommodate the load. And even if there are no more resources to bring to bear, do they have the flexibility to make changes and experiment with others ways of providing care? It is fair to hold directors accountable for how they deploy their resources, but not if they are only allowed to make minor changes around the edges.
I think it is obvious that the problems in the VA are a microcosm of what the rest of us are going to be facing soon. A “root cause analysis” would suggest the drivers of the problem were an increase in demand and a shortage of providers. The Affordable Care Act promises to provide access to insurance coverage for those not currently covered, but it does not generate more primary care physicians. The linking of payment to performance measures in clinical practice using measures that are not under the control of physician creates pressure to game the system.
One difference, though, is the VA is a government agency, and as such represents the closest thing to immortality in this world. For the rest of us, though, the price of failure is going out of business. So what should we be doing? Maybe the most important thing is work to create a culture of honesty in our organizations and take blame out of our local systems. We may not be able to stop the lawyers, governmental or otherwise, but we don’t have to do it to ourselves. Think about your organization. Is it really committed to taking a hard look at itself? Is it open to real innovation and taking risks to improve quality of care, or is it more dedicated to looking good in the name of revenue enhancement? I don’t know about you, but I believe doing well is more important, even though it is harder, and may not be rewarded. At least you don’t have to fall on your sword to appease the public.
Update: Similar conclusions were published in the 24 July 2014 issue of The New England Journal of Medicine, and originally published online 4 June 2014 at nejm.org. Kizer KW and Jha AK. Restoring Trust in VA Health Care. NEJM 2014;371:295-297. Chokshi DA. Improving Health Care for Veterans--A Watershed Moment for the VA. NEJM 2014;371:297-299.
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