Writing in the Wall Street Journal (Why ‘Quality’ Care Is Dangerous) Jerome Groopman and Pamela Hartzband decry the overreaching quality metrics that force physicians into standardized practices that are not always in a patient’s interests. They say that government and private insurers have “overreached” and then go on to describe the emerging system as Orwellian and Kafkaesque.
They certainly have a point, and their example of a pediatrician caught in the Massahusetts Group Insurance Commission’s web will resonate with providers in this state, yet I think they are too dismissive of the forces behind this movement.
How did we get here? Initially, the quality improvement initiatives focused on patient safety and public-health measures. The hospital was seen as a large factory where systems needed to be standardized to prevent avoidable errors. A shocking degree of sloppiness existed with respect to hand washing, for example, and this largely has been remedied with implementation of standardized protocols. Similarly, the risk of infection when inserting an intravenous catheter has fallen sharply since doctors and nurses now abide by guidelines. Buoyed by these successes, governmental and private insurance regulators now have overreached. They’ve turned clinical guidelines for complex diseases into iron-clad rules, to deleterious effect.
I’m not sure why the authors think the sloppiness has been remedied. In the same Modern Healthcare news brief that mentioned the Groopman/Hartband article I read about how the famously transparent and excellent Beth Israel Deaconess Medical Center in Boston is being cited for serious deficiencies because of an outbreak of MRSA infections. BIDMC CEO Paul Levy acknowledged deficiencies in his blog yesterday, even as he cited great progress overall.
Informed patients (including physicians, nurses and hospital administrators) are justifiably frightened to go into even the best hospitals, so real is the threat of harmful or even deadly medical errors. (Read Levy’s recent Grand Rounds on When Things Go Awry for some examples.) Therefore it’s no wonder that there has been little resistance by the public to the “iron-clad” rules that Groopman and Hartband decry.
What we really need is personalized, evidence-based medicine practiced in a safe environment. If we can work cost effectiveness into the equation as well I’ll be really pleased.April 10, 2009