Quality: It's All About the Bike

Morley Robbins, for HealthLeaders Media, November 20, 2008

I do some of my best thinking while pedaling my bike through the streets of Chicago or the countryside of North Carolina (I confess I'm a Lance Armstrong-wannabe). I was riding along the shore of Lake Michigan recently, pondering the state of healthcare in our nation, when I had an epiphany regarding the concept of "quality" in healthcare.

I believe we've got it all wrong as to what constitutes "healthcare quality." Our mistake is in thinking that quality is a unicycle—a singularly focused discipline that measures and seeks to improve the caliber of our clinical and technical processes, thus assuring superior patient outcomes. And while these clinically oriented processes and investments are centrally important to improved patient care delivery, this singular focus compromises the real depth of what determines "quality"—particularly as it relates to patients, their families, and caregivers.

The "ah-hah!" during my ride is that quality is, in fact, a bicycle. It has two wheels, both of which are essential to a successful ride—or more appropriately, a successful patient experience. One wheel is devoted to clinical excellence, while the other is devoted to service excellence. To focus solely on clinical excellence at the expense of service excellence robs the patient and the healthcare enterprise of its soul, and to engage in service excellence at the expense of clinical excellence robs the healthcare enterprise of its purpose and the patient of their improved health.

Relevance to my hospital

OK, the point's been made. Just how does this concept apply to my hospital?

Here are some very real and tangible examples from a recent client engagement. I was retained by a four-hospital regional health system in the Midwest to conduct what I call a "customer commitment audit" designed to measure the organization's ability and resolve to deliver a compelling patient experience—particularly from a service excellence standpoint. The capstone diagnostic of this audit is to routinely assess a hospital's emergency room—in my experience, it's the most efficient and powerful way to "stress test" what any given healthcare organization stands for, both in the clinical and service dimensions of quality.

Across these four hospitals, my average wait time from portal to portal was just under three hours. However, my total elapsed time spent with the ED physician on average—just over two minutes. Following these assessments, I met with the president of the ED Group servicing these hospitals and shared the headlines of my encounters with "his?" emergency departments (set off in quotes because the physicians claimed they merely worked there—a noteworthy subject for a future article). When he heard about the extended length of the wait juxtaposed to the brevity of the professional encounter, he immediately responded with the immortal call of the healthcare wild: "But the physicians provided you with good quality care, didn't they?"

And that's the point—and the problem! As a professional field, we continue to hide behind the unicycle of clinical excellence and somehow justify the deplorable service provided to patients because we provided excellence along the clinical domain. The end somehow justifies the means.

My response to this ED physician leader: "Truth be known, it was excellent clinical care, but quite frankly, doctor, it wasn't worth the wait!" Once he got over his shock at my candor, he demonstrated tremendous leadership and asked to hear more about my experiences, some of which are highlighted below:

  • Having a registration clerk stare at me and do nothing because I wouldn't ring the "red bell" designed to announce my arrival.
  • Having another triage nurse ignore me upon arrival for several minutes (while legitimately being distracted by a much sicker patient) and then suddenly look my way and extort: "Well, find a seat; it's going to be a couple of hours!"
  • Being admitted to a storage closet with a gurney—in a brand new hospital.
  • Interacting with countless staff members who never introduced themselves, nor have their names badges flipped so I could see who they were.
  • Being provided with four pages of "discharge instructions" in eight-point font, but not having anyone explain how to leave the ED so I wouldn't get lost.

And I could go on and on and on. But anyone who's worked in a hospital is acutely aware of similar types of experiences. And each of you reading this list could quickly add five more vignettes equally as graphic from your own institution. And we in healthcare justify this deplorable level of service because, "Well, we provided good quality care, didn't we?"

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