Download Responsible for What? Improving the Quality of Health Care: Who Is

Improving the Quality of Health Care: Who Is
Responsible for What?
J. Frank Wharam; Daniel Sulmasy
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JAMA. 2009;301(2):215-217 (doi:10.1001/jama.2008.964)
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Resource Use, Patient Education, and Improving the Quality of Health Care
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J. Frank Wharam et al. JAMA. 2009;301(19):1990.
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COMMENTARY
Improving the Quality of Health Care
Who Is Responsible for What?
J. Frank Wharam, MB, BCh, BAO, MPH
Daniel Sulmasy, OFM, MD, PhD
S
UBOPTIMAL HEALTH CARE QUALITY IS AN URGENT NAtional concern.1 Recently, policy makers have sought
to improve quality by providing bonus dollars to physicians whose patients achieve certain health goals.2
The privatized US health care system has engendered decentralized quality improvement approaches3 and an unintended consequence has been ambiguity regarding who is
responsible for quality and the scope of stakeholders’ obligations. For example, some pay-for-performance arrangements effectively pay physicians less if their patients with
diabetes miss appointments and fail to take prescribed medications.4,5 Pay-for-performance also does not typically assess diagnostic skills or clinician empathy,3 traits that patients value highly.6 These measurement flaws have frustrated
physicians5,7 and a backlash could derail potentially valuable improvement efforts.
In this Commentary, the stakeholders responsible for improving health care quality are identified and their shared
and unique obligations are outlined. The resulting framework may help promote valid quality measurement, coordinated improvement efforts, and systems rewarding genuine quality rather than isolated “performance.”
Quality Health Care: What Is It
and Who Is Responsible?
One prominent definition of health care quality is “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and
are consistent with current professional knowledge.”8 Although broadly valuable, this and other frameworks fail to
identify the stakeholders responsible for improving quality
or their obligations. Furthermore, the definition leaves unclear whose “desired health outcomes” should be promoted.
Health outcomes desired by administrators, insurers, and payfor-performance architects may differ substantially from those
of patients.6,7 A definition of health care quality grounded in
the fundamental moral purpose of medicine could clarify these
shortcomings and help illuminate a framework of accountability for quality improvement.
Quality Health Care for Individual Patients. The central act of health care is a response to the needs of indi©2009 American Medical Association. All rights reserved.
vidual patients whose inherent human dignity engenders
an obligation to provide respectful, compassionate, and competent care.9 Fulfilling these essential patient-level obligations is the fundamental component of quality health care.
As Aristotle stated,
The doctor does not treat ‘man’ except accidentally; he treats Callius or Socrates or someone else described in this way, who is accidentally ‘man’. So, if someone has grasped the principles of the
subject without having any experience, and thus knows the universal without knowing the individuals contained in it, he will often fail in his treatment; for it is the individual who has to be
treated.10
Quality for individuals therefore equates with how well
the central act of health care is accomplished (ie, the degree to which appropriate health care obligations to the individual patient are fulfilled). As key advocates for patients, physicians have a central role and institutions
facilitating patients’ health goals such as physician groups,
hospitals, insurers, and political entities also have crucial
responsibilities.
Quality Health Care for Populations. Because health care
is fundamentally individualized, the essential indicator of
quality population care remains high-quality patient-level
care. Although seemingly obvious, this view contrasts sharply
with current approaches to population-level quality.
Resources for maximizing patient-level quality will be limited in the short term, introducing 3 key obligations engendered by the central act of medicine. First, health systems
ought to maximize efficiency before engaging in explicit rationing. Second, savings should be distributed broadly across
the population to facilitate the achievement of patient health
goals, perhaps reserving a portion as an incentive for those
individuals achieving these efficiencies and distributions.
Third, systems ought to promote equitable resource
allocation.
Importantly, resource limitations do not preclude a patientcentered understanding of population-level quality; they
merely imply that the extent to which care obligations can
be fulfilled must be adjusted in light of immediately availAuthor Affiliations: Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, Boston, Massachusetts (Dr Wharam);
and St Vincent’s Hospital, Manhattan and New York Medical College, New York
(Dr Sulmasy).
Corresponding Author: J. Frank Wharam, MB, BCh, BAO, MPH, Department of
Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim
Health Care, 133 Brookline Ave, Sixth Floor, Boston, MA 02215 (jwharam@partners
.org).
(Reprinted) JAMA, January 14, 2009—Vol 301, No. 2
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215
COMMENTARY
able resources. Population-level health care quality is thus
the degree to which care obligations to individual patients
are fulfilled while accounting for the degree to which they
are fulfilled efficiently and equitably across the population.
Processes that facilitate the just fulfillment of substantive
obligations to individual patients are therefore crucial.
Because disproportionate resource consumption by particular stakeholders reduces equity and efficiency, the activities of all parties using health care resources affect population-level quality. Physicians and health care institutions
have clear effects on utilization. Patients also affect resource use, and a seldom-discussed implication is that patients also have obligations to promote quality population
care. This is why, for example, patients are not ethically justified in demanding that health systems “do everything” to
facilitate their individual health care preferences.
Health Care Quality: Definition, Obligations,
and Implications
These insights lead to a patient-centered definition of
health care quality that also accounts for the needs of the
population—health care quality can be defined as “the
degree to which physicians and health care institutions fulfill their care obligations to individual patients, and the
degree to which patients, physicians, and health care insti-
tutions enable these obligations to be fulfilled justly across
the population.”11
Based on this definition, a framework can then be developed describing the quality-related obligations of patients,
physicians, and health care institutions (TABLE). This framework and its associated obligations have implications for both
pay-for-performance and the wider quality movement.
Pay for Performance as a Quality Improvement Approach. In contrast with the patient-centered definition, payfor-performance typically equates quality with achievement of several predetermined health targets by populations.
For example, some systems require that more than 65% of
patients with diabetes reach systolic blood pressure levels
of less than 140 mm Hg. Concerns have been raised that
this “one-size-fits-all” approach might be motivated by expediency or financial priorities.12 In addition, for performance targets to be truly “population” goals (rather than
those of a few experts), physicians and population members would have to collectively endorse them using fair processes.13,14 In reality, policy makers, health care executives,
disease advocates, and scientists with clinical or epidemiological expertise effectively choose population-level goals5
and thus impose obligations in a manner that might infringe on patient and physician autonomy. Without fair deliberation, such goals, however wise, cannot claim legitimacy.
Table. Examples of Quality-Related Health Care Obligations of Physicians, Health Care Institutions, and Patients
Health Care Institutions
and Political Leaders a
Physicians
Quality-Related Obligations With the Best
Reasonable Effort and Consistent With Current
Professional Knowledge
Be accessible for timely patient encounters or arrange
appropriate coverage
Accurately identify the patient’s goals within a trusting,
compassionate, and communicative clinical relationship
Guide or help shape the patient’s goals in a beneficent
manner that is respectful of patient autonomy
Determine how to achieve the patient’s goals in a manner
that maximizes benefit and minimizes risk
Initiate and skillfully carry through processes of care
that enable achievement of the patient’s goals
To the
Patient
X
To the
Population
To the
Patient
To the
Population
To the
Population
X
X
X
X
X
X
X
X
X
X
X
X
X
Measure effects of care processes to enable an iterative
reevaluation of the patient’s goals
X
Advocate for or provide fair resource levels to maximize
the patient’s access to existing services
Facilitate coordination and continuity of care for the patient
among appropriate health care facilities
X
X
X
X
Advocate for improving existing services or implementing
new ones to enable achievement of the patient’s goals
Facilitate or participate in ethical health care interventions
enabling equitable, efficient, or greater distribution
of health care resources
X
X
Facilitate or participate in fair deliberation processes
enabling equitable, efficient, or greater distribution
of health care resources
Facilitate or participate in monitoring physician
and health care institution quality
Patients
a Health care institutions include physician groups and practice associations, clinics, hospitals and hospital networks, private health insurers, and public payers such as Medicare
and Medicaid.
216 JAMA, January 14, 2009—Vol 301, No. 2 (Reprinted)
©2009 American Medical Association. All rights reserved.
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COMMENTARY
This external and even “forced” population-level approach implies, at best, improved health and reduced costs
for patients whose goals match those of policy makers. At
worst, physicians could overlook urgent patient goals, provide inappropriate care, and increase costs via excess testing.5 Unmeasured domains of quality, such as communication, compassion, and trust could deteriorate as clinicians
divert attention to limited sets of performance targets.
Even if population goals were decided in a manner fair
to physicians, most current pay-for-performance systems
would still be flawed. Today’s arrangements primarily assign responsibility for quality improvement to individual physicians, physician groups, or hospitals.3 Truly valid measurement must include input from and evaluation of all
stakeholders responsible for ensuring quality.
In conclusion, current pay-for-performance arrangements
can be understood as holding a single class of stakeholders
(physicians) accountable for a small set of populationcentered goals chosen in a top-down manner. The continued
expansion of such a limited approach seems inadvisable. Given
the urgency to improve quality, however, a prudent shortterm strategy might be to increase emphasis on quality assessment from the patient’s perspective (eg, through surveys
such as the Consumer Assessment of Healthcare Providers15)
and institute safeguards to protect vulnerable patients. Ultimately, comprehensive and valid measures should replace these
temporary approaches. Fair processes, such as deliberative democracy14 (either to set population goals or allocate resources), would be essential to achieving population quality
under any ethically defensible understanding of the term.
Quality Improvement in General. The definition of quality and clarification of care obligations offered herein make
clear the extreme complexity of developing valid quality measurements. This results from the high degree of interdependence among stakeholders needed to achieve individualized health goals, the large number of obligations that must
be assessed, the necessity of using biased observers such as
physicians to assess key measures, and inherent difficulties
in measuring equity. Although this may portray quality improvement as impossible, this complexity is highlighted so
that, in the haste to measure, policy makers do not rashly
make mistakes through oversimplification.
Is truly valid quality measurement even asymptotically
approachable? Although the answer may remain unclear for
some time, focusing on this ideal goal will at least improve
measurement. Comprehensive assessment would account
for contributions from physicians, patients, and health care
institutions. It would require the refinement of techniques
such as in-depth interviews and standardized chart review.
New measures would assess patient goals, shared responsibility for care, humanistic physician values, available resource levels, and the inherent tension between patientlevel and population-level health care perspectives.
On a practical level of more immediate importance for
physicians, this framework demonstrates the difference be©2009 American Medical Association. All rights reserved.
tween quality physician care and quality health care in general, concepts that may mistakenly be conflated. To measure physician quality, only obligations within the physician’s
control should be measured. The disaggregated quality framework could at least facilitate isolated measurements of key
stakeholders and either exclude or adjust for domains beyond their control.
Additionally, by specifying general obligations for quality care, new avenues to explore in improvement efforts have
been suggested. Patient advocacy groups, health care institutions, and physician specialty groups could use this general framework to develop more specific lists of care obligations tailored to particular clinical settings or diseases.
Achieving valid measurement of quality does not settle
the question of whether financial incentives will improve
quality. The success of the health care system depends largely
on professional virtues, such as honesty, thoroughness, and
skilled communication, essential signs of quality that seem
difficult to improve with financial incentives. Balancing carefully designed incentives with systems that promote professionalism might ultimately lead to the highest quality
health care.
Financial Disclosures: None reported.
Additional Contributions: We acknowledge the helpful comments of Jim Sabin,
MD (Department of Ambulatory Care and Prevention, Harvard Medical School
and Harvard Pilgrim Health Care, Boston, Massachusetts). No form of compensation was provided in exchange for comments on versions of the manuscript.
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