Editorial

Our Role in the Quality of Healthcare

Niranjan Kissoon, M.D., Editor

A recent World Health Report of the World Health Organization stated that the United States spends more per person on healthcare than any other country, yet in overall quality it ranks 37^th in the world. This is indeed sobering information for those who believe that the United States has the best healthcare system in the world. I have long argued that we have the best technical expertise in the world and are very well equipped to provide care for the critically ill, technology dependent or those who suffer from complex or rare diseases. However, if we believe the American Medical Association definition of high quality care as care which "consistently contributes to the improvement and maintenance of quality of life" or that of Donabedian, who defined quality of care as "that kind of care which is expected to maximize an inclusive measure of patient welfare, after one has taken account of the balance of expected gains and losses that attend the process of care and all its parts" then we have fallen woefully short of quality. There is no doubt that on the macro level the United States has always ranked lower than many developed countries using different scoring systems and indicators of care. Access to care is a major contributor to our poor ratings and can only be rectified by major changes in health care policy. Obviously something is wrong when 9% of healthcare dollars are spent in rural America where 25% of its population lives. Instead of waiting for policymakers to take the first step we can all do our best to improve quality.

What can we do at the micro level to improve quality? Quality of care as it relates to individual practitioners has generated great interest in the past decade. Powerful informatic systems and accepted yardsticks to evaluate care processes and outcomes have led to physician and practice profiling. While this may imbue us with trepidation, many also recognize the objectivity and fairness of informatic systems in policing us as opposed to the vagaries of medical malpractice litigation and medical board disciplinary actions. Regardless of our opinion, reporting of quality measures is likely to prove an enduring feature of our new healthcare system since many influential groups, including public and private purchasers and managed care health plans are clamoring for data. In addition, consumers seem to support strongly the release of data on the performance of individual practitioners.

The rationale for these measurements and reporting of quality rests largely on the belief that the public release of data on performance will lead to behavior changes and improve quality. This approach of total quality management has a long history of improving quality in other industries, however, despite its successes in particular instances there is so far no convincing evidence that the application of these techniques have improved healthcare in institutions and among large number of physicians. However, changes are underway that should give us reason to be optimistic. Valid, reliable and useful techniques to measure and improve quality of care are being developed. In addition, total quality management builds on medicine's long successful tradition of improving its capabilities through the application of scientific methods to its daily work. At the end of the day however, we should base our quality management efforts on a careful assessment of our patients interest and circumstances as well as our own. We should seek ways to influence quality improvement endeavors rather than take an indiscriminate adversarial position, even in the face of fundamental, social and scientific upheaval. To do this we need to acquire new skills, attitudes and partners. According to David Blumenthal of the Massachusetts General Hospital, "the success of physicians in acquiring these resources, and avoiding entanglements that divide them from their patients, will powerfully affect the future of both the profession and of quality measurement and improvement in the U.S. healthcare system."

Our ability to reshape the landscape and to influence the next World Health Report should be a motivating factor for us all. Clearly, with our resources (financial and intellectual) we should be at the head of the class.