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Monday, August 27, 2007

If we required evidence before initiating quality projects, there would be many fewer such projects

This thoughtful and -I think-spot-on commentary in the NEJM is worth reading.I always like to read things that make me say, "I wish I had said that", things that fit my current set of biases and beliefs.

The authors' main message is that in the rush to do the "right things" regarding improving medical quality and improving safety in health care, sometimes ( probably many times) the rules of evidence have been suspended. We are not demanding the same evidence we would to use adopt a new therapy. Quality measures are put into place without proof of efficacy and safety and often after they are in place no systematic evaluation of their value is done and to suggest that they should be is likely to evoke accusations of not being a team player or even worse being disruptive. It seems as if the skeptical analysis of the scientific approach has been pushed aside by blind belief in and allegiance to the paradigm of continuous improvement and other management buzz words of the month.

The authors list and refute a number of pseudo reasons used to justify programs that lack evidence of their effectiveness . Here are some of them.

Argument 1: We cannot wait.

Argument 2: Anything we do to improve something must be better than what we have now (my paraphrase)

Argument 3: Company X did it and it was great.

I can particularly relate to number 3. I had the occasion to do consultative work for 2 large corporations over the years and had the opportunity to be a bemused fly on the wall on some of the quality projects . Since it widely believed you have to quantify something to show how much you have improved, a early session with the highly paid outside consultant quality experts involved a mini course in how to draw a x-y graph. The pupils in the class I sat in on were from the company research center and were in fact senior scientists there most of whom had a PhD
in some hard science area. They were all made to do a "quality" project and then everyone had to agree how helpful it was. Later the company claimed how valuable their quality project was.

Some of the baseless medical quality efforts may not be as blatantly hypocritical as this one but the nurses and doctors who often get caught up in these programs feel the same type pressure to be a team player and not "disrupt" the effort with thoughtful criticism or healthy skepticism.

Twenty years ago when I began to do some consultative work with the corporate world,I felt rather smug that my field (medicine) was immune to the Dilbert like silliness that seemed to pervade the corporate culture. However,medicine has become more and more corporate and the business school belief that one does not need know a business to run it is increasingly applied to medical practice . The business-speak jargon now echoes through the hospitals and clinics and we talk about vision statements and leveraging this and that and the suits with MBAs are no longer minor distractions but are in control. What the Dilbert cartoons depict are as applicable to much of medicine as they are to the bureaucratic world of big business.


InformaticsMD said...

However,medicine has become more and more corporate and the business school belief that one does not need know a business to run it is increasingly applied to medical practice.

The same belief applies to those who create the computer tools (such as Electronic Medical Records) that supposedly help healthcare organizations capture data to compute "quality."

See this site.

postmeta said...

I think capturing data to calculate numbers of adverse events and first line treatment failures is certainly valid and useful information.

Imbuing hospitals with businessy BS is certainly not so great.

Computers can be great obfuscators or great knowledge tools, it's all up to us to differentiate real value from business fluff.

Speaking of med informatics, please check out this medical dictionary visualization tool we've developed. I hope if falls under the "useful" category, not "business fluff"... :)