I read DB’s medical blog, who is amazingly prolific and at times blogs about some aspect of quality. His blog entry with the title “quality measurement – a delusion” was alarming and I posted a comment about this blog entry. His next blog entry discussed (a portion of) my comment. Here is my analysis…
For any process, including medical processes, one can estimate an error rate. Some of the errors are preventable. This can be thought of as lack of quality, whereby quality is defined (ASQ) as “free of deficiencies”. There is nothing inherently wrong in calling an error rate a “performance measure”. Unfortunately, programs such as pay for performance (P4P) cloud the issue. P4P rewards and penalizes physicians for their performance on various measures. However, these measures go beyond the concept of reducing errors. For example lowering hemoglobin A1C to less than 7.0 in a diabetic patient, while desirable, is more of a policy than a means to reduce preventable errors.
One of the problems is that one must view the mitigation of an error as part of the overall picture. With an error such as wrong site surgery, the error can be considered as part of the surgery process and the solution to prevent this error is a modification of the surgery process.
In lowering A1C, many of the processes are outside of the control of the physician. An A1C value that has not been reduced to less than 7.0 cannot automatically be called a preventable medical error whose mitigation is the responsibility of the physician.
There are plenty of easy to see preventable medical errors such as wrong site surgery, giving the wrong amount of a drug, mixing up a laboratory specimen, and so on. Tools such as FMEA and FRACAS help to reduce errors. It would appear that some physicians, who are not familiar with quality tools but have been bombarded with P4P have overreacted, and when this has been pointed out, call on semantics.