Here's Lookin' at You
As a consultant, I spend a lot of time in the friendly skies. On a recent flight, while once again waiting on the tarmac for air traffic control to decide my destiny, I peered into the cockpit. As expected, the pilot and first officer were busy going through their pre-flight routine, but they were not alone. Squeezed ever so uncomfortably into the “jump seat” was a gentleman in civilian clothes, clipboard in hand, perched directly over the shoulders of both of the men who were in charge of getting me from point A to point B safely and without incident that morning. The captain and his co-pilot went about their normal duties, not acting as if the in-flight evaluator were a distraction, but even chatting with him and treating him as a welcome addition to their day.
As I watched this real time assessment of quality unfold, I had a great deal of comfort knowing that the people in charge of my life for the next few hours were happy and willing to be graded and assessed on their performance.
As physicians, our performance assessment is far from this model. At best we assess ourselves indirectly, infrequently, and retrospectively. We are in constant debate about the quality data that is available not really representing “true” quality of our care. I began to think what a real time assessment model might look like if we applied it to what we as physicians do daily. Could it actually work? What if rather than an annual “Maintenance of Certification” for our license, we all participated in a real time assessment by a peer through our individual specialty boards each year? What if we all agreed that this real time assessment was a much better indicator of clinical quality than a look through the medical record long after care actually occurred? What if the results of this data were reported publicly?
With any new model, of course, the devil is in the details. The issues of patient privacy, cost of assessment and training, and a myriad of others will be brought up as reasons that something like this simply won’t work. I am not here to say moving to this model would be easy and it certainly would not be popular among some. It would, however, move us away from debating about whether the data currently reported represents clinical quality and directs our energy on creating a renewed focus on getting our patients safely from point A to point B on their healthcare journey.
Mark, I'm intrigued, as I often am, by your ideas. Face to face evaluation and direct observation, in many ways, offer a better assessment of workflow and structure. But I'm not sure in a healthcare setting it would provide the answer of outcomes. It seems like outcomes like improved biometrics, reduced healthcare costs, reduced errors would still require some level of data collection and analysis.
If you took the same quality analyst out of the cockpit and asked him to follow the flight attendant to assess her/his quality of work, it would be cumbersome, awkward and expensive.
Another example, how would it make you or your clients feel if you were holding consultations and had a quality analyst there looking over your shoulder? It would change the dynamics in such a way that the desired outcome may be altered.
I'm a big advocate of CQI in healthcare. And I think you're on to a key feature of CQI, observing current state. The devil is in the details though.
Wayne, I agree that this may be a cumbersome method, but could we accomplish direct observation in a less intrusive way? Bidirectional cameras on tablets used for EMR? One way mirrors in select rooms (with patient permission of course)? Thanks for helping me think this through and being part of the quality conversation.
-Mark
Mark - great post and good thinking.
When we look at the current structure of healthcare, being volume driven as it is, we continue to value all the wrong things. Volume and RVUs are seen as important outcomes often justifying a provider's existence. Time and efficiency are given top priority in our continuous quality improvement activities.
So while I LOVE your idea, I think we still have some work to do on the system to allow for providers to deliver better patient-centered care where the person standing over our shoulder with a clipboard is not only looking at our clinical outcomes, but our level of patient engagement.
We also need those people with the clipboards (our peers in some cases) to be able to help mentor, model and move us to a better place as providers. And yet, the system has to accommodate this move and incent/reward us for this new style of care delivery.
One final thought - in our assessment, I think it will be important to track our individual costs we as healthcare providers accrue. This is something that providers are often blissfully unaware of, and something that we will all need to become accountable to if we are to start decreasing the out of control spending in healthcare. Maybe this could be a box on the checklist too.
Thanks for getting us thinking.
Ben, I couldn't agree more. Not only do we need to raise the bar on our clinical metrics, but blending them with cost and satisfaction measures is critical. I am awaiting (and crafting in my head) the creation and test drive of a true hybrid metric linking the three with a defined outcome. Always great to "group think" quality with you, Ben.
Great idea Mark!
I would like to see this put into practice in provider settings that have reached a high level of MU. This will be accomplished via intense data analysis of HCPs actions & decisions as they interact with people & systems. This 'industrialization' of Medicine will no doubt improve quality, effectiveness & efficiency. It is also likely that the current generation of providers will not appreciate this level of scrutiny. After all they have been granted an incredible degree of autonomy in the pre-digital era. So the transition from conductor to orchestra member will not be easy...