Cast & Curious

Tag: measures of quality

  • Personalising Quality of Care in Healthcare Professional’s Practice

    “What doesn’t get measured doesn’t get done.”-William Thomson

    John is a 55 year old software engineer at a large firm in Manila. For four consecutive days now, he had episodes of vague “chest heaviness” coupled with some difficulty breathing. Privately insured, he asked for a day off to seek their company physician’s consult. He drove an hour to the clinic, waited for another two hours in the waiting room before being seen by the company physician lasting for 15 minutes. He was given a list of diagnostics and was referred to a cardiologist. The process of seeing a cardiologist is almost the same, only this time, much longer.

    “Travel time was two hours because of traffic, waiting time doubled to four hours, diagnostics to 2 days yet being seen by a doctor lasted only for 8 minutes” said John.  “I’m nervous. I’m not sure if its about my chest tightness or the whole rigodon of trying to determine what cause it. All I’m told it was a Non Specific T wave changes. I don’t even know what that means but it took me two weeks to finish the whole check up thing!”

    Manang Tina is a 35 year old vegetable vendor. She temporarily stopped selling vegetables because her 7 year old daughter had a throat pain, difficultly eating food and fever for 3 days already. She asked her daughter’s teacher if she can be excused for a day. “I had to bring my daughter to the rural health unit” she said. At the RHU they had to wait for almost 4 hours before being seen by the doctor. Her daughter was seen and examined for 10 minutes. “She needs a CBC, a chest x-ray and urinalysis Manang Tina” said the doctor. “Have this done and come back here once the results are out. In the meantime, your daughter may take paracetamol and gargle with this liquid 3x a day” followed the doctor. The diagnostics took a week to finish, the fever and pain now gone and my daughter able to eat painlessly now. In fact she is already back in school. What shall I do with this lab results?” ask Manang Tina.

    In this digital age, did Mr. John or Manang Tina’s daughter, received quality health care?

    Quality of health care, defined
    Agency for Healthcare Research and Quality of the US Health and Human Resources Department cite The Institute of Medicine’s definition of health care quality as “the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” I has six domains- effectiveness, efficiency, equity, patient centeredness, safety and timelines but has concomittant consumer perspectives of staying healthy, getting better, living with illness, and coping with end of life.

    Complex, Divisive Issue
    Quality of care is a complex, multi dimensional topic that most healthcare professionals avoid discussing. True enough, learning quality health systems and models could take some 4 or  5 years of formal study and a lifetime of iteration and improvements. Simplifying quality of care seems to be an impossible task for every health stakeholder. Everyone have the answer to quality issues yet our health system is going everywhere but forward.

    “I leave that to experts” said Dr. D a busy private heart specialist. Dr. D is referring to quality assurance professionals, compliance personnel and regulatory agencies “to do their thing while we, healthcare professionals do what we’re good at- taking care of our patients.” We’re too busy to debate on such topic.” Dr. D explained.

    But if a healthcare professional, a primary mover and health stakeholder doesn’t have a good grasp of what quality care is, how does one know he’s providing one?

    “Look, I have a full, standing only waiting room at my clinic. If that’s not a measure of how patients see the quality of my care, I don’t know what is.” Said Dr. S a family physician.

    Making quality care, personal
    But how do we know we are giving the best of care to our patients? If you are a patient, how do you know you’re receiving quality medical care? What are our personal “yardstick” for “quality of care”? In the digital age where technological innovation has disrupted some areas of medicine- form intuition to precision diagnostics, did quality of care improved? How does this affect the present “business model” of physician’s practice? Of nursing care practice?

    These are just some of the questions a healthcare professional, student or even patients must confront head on to improve health care. While healthcare professionals need help from external personnel for regulatory compliance and quality assurance, quality of care should be “personal” to every health stakeholder. In this technological age where innovations have the potential to improve some aspects of our health system, every health stakeholder has the responsibility of knowing what quality of health care is.

    This is the topic of our #HealthXPh chat this Saturday 9PM Manila time. I’m inviting every health stakeholder out there- patients, healthcare students, healthcare professionals etc, join in your personal views on quality care in this interesting chat. In your personal practice ( if an MD, Nurse, allied professional), plan (if you are a student), experience (if you are a patient),

    • T1. What is your personal idea of quality health care and how do you measure it?
      T2. Name one innovative step you implemented to improve quality of care in your practice.
      T3. Name one technological innovation that should improve quality of healthcare in 3-5 years. Explain

    References:

    William Thomson (June 26, 1824–December 17, 1907), 1st Baron Kelvin, often referred to simply as Lord Kelvin, was an Irish mathematical physicist. https://en.wikiquote.org/wiki/William_Thomson

    Understanding Quality Measurement. Content last reviewed July 2018. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/chtoolbx/understand/index.html

    Christensen, Clayton M., Jerome H. Grossman M.D., and Jason Hwang M.D. The Innovator’s Prescription: A Disruptive Solution for Health Care. McGraw-Hill, 2009.

  • Are patient “proxy measures” helpful in assessing the quality of care rendered by a healthcare professional?

    A patient consulted me years ago for a draining sinus in his right leg. He previously underwent several surgeries in the leg for multiple open fractures in the lower extremities sustained from a motorcycle crash. The fractures got infected despite repeated surgeries. After almost 6 months of treatment, clinical and laboratory findings suggest the infection is “controlled’ and the draining sinus is healing. The surgeon applied a closed circular leg cast on his right lower extremity.

    “I asked the doctor if he can place a cast window over the wound” said the patient. The doctor replied “there’s no need for that”. “Your wounds are healed and I’m placing cast so your leg bones will unite”.

    Two weeks after, the cast emitted a foul smelling odor. His right leg is still on circular’ long leg cast when he came to our clinic. The foot part of that cast is nowhere to be found and the patient is “walking” with crutches on his affected leg.  After opening the cast, a draining sinus is again right where the wound is supposed to be “healed”.  The worst part of this experience according to the patient is not that he had another draining sinus heralding an infection,  but this.

    “We asked the surgeon to place a cast window over the wound, but he didn’t listen. The odor is unbearable, I couldn’t clean it. Everybody avoided me because I smell very bad.

    The phrase “he didn’t listen” stuck even now that I am in my private orthopedic practice. It served as a constant reminder for me of how I will ultimately  gauge the quality of care I deliver as a physician. This may arguably be, a very controversial mantra of service for a healthcare professional. Personally though,  I’m reminding myself why I am in the business of medicine and who I’m supposed to be “servicing” first . Patients. They are exactly why I wanted to be a doctor in the first place.

    A very interesting offshoot of this patient encounter was the fact that he wasn’t really concerned of another infection. It is the fact that the doctor “didn’t listen to him”.

    Scientific evidence and Peer reviews

    Quality of care for physicians is measured by how well we render service using available scientific evidence and peer reviews by colleagues.  No matter how we try to convey these scientific evidence into understandable bits of information, patients seem to have a “different” criteria of measuring the quality of care we render to them.

    In the example I mentioned above, the patient measured the “quality” of care rendered not by how “scientific” his chronic leg infection was managed, but by how the doctor “listened” to his suggestion.

    No matter how physicians strive to be objective, patients will always take their “health experience” as personal. The context of this health experience is a manifestation of their personality, values and expectations. Thus patient measures health care effectiveness by making comparisons of what physicians do against what they understand, of what they “experience”. In short, patients uses proxy measures- a reasonable default because often, the complexity of medical science baffles even the best of its practitioners.

    What is a Proxy Measure? A proxy is an indirect measure of the desired outcome which is itself strongly correlated to that outcome. It is commonly used when direct measures of the outcome are unobservable and/or unavailable. An organization should use a proxy measure when there is little or no data available about the program being implemented, but the outcome the program is designed to influence has an existing and commonly accepted proxy.

    A lady patient once whispered to me asking my team to leave the room for a moment and come back after 5 minutes. “I just had my bedside bath and I’m still in my underwear when your service entered my hospital room”. She said he would appreciate it next time if the station nurses warned us before going inside the room.  Respect for the patient’s privacy as an individual or a person rather than just as a disease or medical condition is another proxy measure most patients used to gauge us physicians.

    A third proxy measure that is of interest to me too is how well coordinated is my whole medical service team. A patient once asked a nurse who was dressing her wounds why she and not the surgeon is cleaning her wound bedside, the nurse replied “I’m did because I was ordered to”. When patients sees the healthcare team in disarray or is uninformed about his or her treatment plan, it reflects bad on the whole healthcare team.

    These are just some of the proxy measures that patients use that I personally had experience.  Some physicians would argue for or against the validity of these proxy measures. Personally though, many patients do not really care what “99.99% of patients with this medical condition get well” meant for their own illnesses. Their health experience matters most. If this is true and valid, why are proxy measures not included in the physicians criteria for assessing the quality of care we deliver?

    Join us this Saturday, August 13, 2016 9PM Manila time as we discuss the importance patient proxy measures in assessing the delivery of care by health professionals

    • T1. Are patient “proxy measures” valid measures for quality of health care? Why or why not?
    • T2. What are your top three patient proxy measures of care and how do you validate (investigate) these measures as a physician?
    • T3. Is it helpful if we incorporate “patient proxy measures” into our system of assessing  quality of service? Why or Why not?

    Again, see you this Saturday 9PM for another lively, interesting tweet chat by using the #healthxph.

    Resources:

    1. Gitbooks  https://centerforgov.gitbooks.io/benchmarking/content/Proxy.html
    2. Patient Safety Quality Improvement, Department of Family and Community Medicine, Duke University School of Medicine http://patientsafetyed.duhs.duke.edu/module_a/measurement/proxy_measures.html

  • Social media feedback to improve healthcare quality of care

    Having been on social media for some time, I had my share of feedback for the quality of medical care I render. Yes, despite boundaries we define to keep our social media profiles “professional”, there are those who went beyond norms to convey a “feedback”.  Social media has made that easier for patients. In my case,   direct message is the most common method of feedback, followed by comments or likes of my social media postings. Comments, no matter how unrelated to my social media post, have undeniably inspired me to do even better in my clinical practice.

    Imagine though if the message goes like this: ” Why do you have a long clinic waiting time?” or “I can’t afford your professional service. It is expensive”.

    I can understand your reaction.  “What the ???”

    As a healthcare professional whose mantra is “to improve the quality of care”, a “negative” feedback like this hurts the most.  It’s never easy dealing such feedback, but when you do,  it’s also one of the most eye opening.

    The authenticity and transparency of social media placed a balance to the equation of care by providing a platform for the patient’s voice. The quality of care mirror, isn’t limited to our peers or experts anymore. It went past beyond the structured patient personal satisfaction survey to the social media platforms- healthcare’s social mirror.

    In this increasingly interconnected, social and consumer driven world, healthcare has no escape from this social mirror.  Social media is a microscope where patients examine their healthcare providers and ostentatiously give their feedback not only to the healthcare community, but to the public as well.

    In 2002, the ABIM Foundation, American College of Physicians Foundation and the European Federation of Internal Medicine jointly authored Medical Professionalism in the New Millennium: A Physician Charter.

    Published simultaneously in Annals of Internal Medicine, The Lancet and theEuropean Journal of Internal Medicine, Harold C. Sox, MD, then editor of Annals of Internal Medicine, wrote, “I hope that we will look back upon its (the Charter’s) publication as a watershed event in medicine.”

    The charter was created in response to the challenges of the new millennium that will impact medical professionalism- the internet and ten years later, social media. Included in this physician charter is a preamble and a set of responsibilities termed “commitments” to healthcare, our patients and humanity in general. One of these  is the “commitment to improve quality of care“. Years after this charter’s  creation, social media emerged as both an opportunity and challenge to medical professionalism.

    This is the anchor to our topic on this Saturday’s tweet chat.

    How patient’s social media feedback could improve healthcare professionals’ quality of care?

    In the Spark Report, 60% of the physicians included in the study believe “social media improves the quality of care delivered to patients”. How they were able to measure this isn’t available publicly, but 60% is a huge majority.

    Spark Report infographic showing 60% of doctors believe social media is improving quality of care
    Spark Report infographic showing 60% of doctors believe social media is improving quality of care

    Another study by Timian et al measured hospital’s quality of care via facebook likes.

    The results showed that Facebook “Likes” have a strong negative association with 30-day mortality rates and are positively associated with patient recommendation. These exploratory findings suggest that the number of Facebook “Likes” for a hospital may serve as an indicator of hospital quality and patient satisfaction.

    Greaves’ study used social media to detect poor quality of care by harnessing the cloud of patient experience. Cloud of experience meant “unstructured descriptions of patient experience on the internet”. The limitation of this study was that measures wasn’t measurable as of that time. It showed though some variable association between patient experience and quality of care.

    Could social media  really improve a healthcare professional’s quality of care? That we will try to answer in this Saturday’s chat.

    Join us this Saturday 9Pm Manila time as we discuss how patient’s social media feedback could improve an individual healthcare professional’s quality of care.

    • T1: Will patient social media feedback improve healthcare professionals quality of care?Why or why not?
      T2: What aspect of care would patient’s social media feedback impact the most? The least? Positively? Negatively?
      T3: What social media feedback method would most likely improve quality of care by HCPs? Comments, tweets?Private?/Public?

    Closing thoughts: Your take home message about how could patient’s social media feedback could improve on the quality of care by healthcare professionals.

    Resources:

    Medical Professionalism in the New Millennium: A Physician Charter. Ann Intern Med. 2002;136(3):243-246
    http://annals.org/article.aspx?articleid=474090

    Spark Report by Demi & Cooper Advertising and DC Interactive Group
    http://thesparkreport.com/infographic-social-mobile-healthcare/

    Timian A, Rupcic S, Kachnowski S, Luisi P.Do patients “like” good care? measuring hospital quality via Facebook; Am J Med Qual. 2013 Sep-Oct;28(5):374-82
    http://www.ncbi.nlm.nih.gov/pubmed/23378059

    Greaves F1, Ramirez-Cano D, Millett C, Darzi A, Donaldson; Harnessing the cloud of patient experience: using social media to detect poor quality healthcare. BMJ Qual Saf. 2013 Mar;22(3):251-5. http://www.ncbi.nlm.nih.gov/pubmed/23349387