Is Anyone Listening to What Docs Say About Quality?

Elyas Bakhtiari, for HealthLeaders Media, February 12, 2009

Pay for performance? Doesn't work! Withholding reimbursement for never events? Ineffective! Improving transparency? Mediocre, at best!

That's the impression you get from this year's HealthLeaders Media survey of physician leaders. Physicians didn't exactly come out and say these quality improvement approaches are worthless, but when we asked them to rank the most effective strategies for improving quality of care, these supposedly cutting-edge programs fell far behind much simpler methods—spending more time with patients and improving communication between hospitals and physicians.

There are a couple of ways to interpret this. A cynic might note that physicians aren't too keen on quality improvement efforts that involve meddling with their paychecks. That's a fair criticism and probably true for many doctors. But keep in mind that we surveyed physician leaders, who have a much larger stake in their organizations and aren't very likely to let self interest cloud their judgment about large-scale quality improvement.

Perhaps a better explanation is that these physicians are on the front lines of healthcare and understand better than administrators and policy makers how difficult it is to measure and financially reward quality care.

As a writer, I have wondered how different my work would be if it were subjected to some of the same financial incentives and restrictions that physicians' routinely face. How do you quantify and reward quality writing?

I could lose compensation for "never events"—grammatical or factual errors in my work. That would no doubt make me more careful. A more complex pay-for-performance system could be created that sets process benchmarks (proofreading and sourcing) and desired outcomes (factual accuracy and reader interest). No matter how complicated the system becomes, however, it misses the real mark. The final product depends a lot on the time spent on research and writing, and there are limits to how much that process can be diced up and quantified.

Not that my work compares to the complexity and importance of physicians'—I'm not routinely saving people's lives and haven't gone through eight-plus years of training. But physicians seem to grapple with the same distrust of top-down, quantified approaches to quality improvement. Every well-reasoned incentive seems to create unintended consequences. The requirements are often hard to define. And no matter how well-intentioned, financial incentives don't work if doctors don't have enough time with patients or aren't getting feedback from hospitals.

The takeaway from these survey results is not that pay for performance and other big-picture, financially-driven attempts to improve quality are ineffective. They deliver measurable, though far from revolutionary, results. But we must be aware of their limits.

Policy makers and healthcare reformers spend much time, money, and energy engineering grand systems that will poke and prod doctors into delivering better care. How much attention is paid to some of the real drivers of quality—particularly doctor-patient interactions—at that macro-level?

Not enough, if you ask today's physician leaders.

Elyas Bakhtiari is a managing editor with HealthLeaders Media. He can be reached at
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