The following letters were posted using the comment tool on the QP website. To share your thoughts, visit an article’s page and use the online tools on the right-hand side.

Where’s the care?

In his article ("Dare to Care," July 2009), Janusz Godyn makes a lot of good points. One of the things I have pushed, but with little success, is to measure quality of care by monitoring the actual outcomes as compared to the planned outcomes. Doing that would minimize one concern Godyn mentions:

"The results of the treatment would be compared to a benchmark to judge quality of care. The relative results of the treatment would form a quality score … However, quantitative measurement of medical outcomes is difficult. As a result, hospitals and overseeing institutions also tend to focus on compliance with processes that are believed to instead lead to higher quality of care … This model shares the first model’s weakness: The comparison of best evidence-based practices requires two medical cases to be extremely similar. Unfortunately, the multidimensionality of the problem confounds comparability."

I agree with his statements and offer the measure of what was planned for outcomes compared to what actually happened. This should account for the differences in patient demographics and the difficulties inherent in comparing to best-practice protocols and measuring the quality of care directly.

I would also suggest using a performance index of several measures. This index would be the result of examining a variety of areas and then weighting them to account for relative importance. These measures could be used mostly for quality of care but also for quality of service.

Marvin M. Christensen
Baton Rouge, LA

Culture change

Excellent point put forward by Peter Sherman and James Vono (" All Ears," July 2009), followed by a succinct management accounting refresher.

Unfortunately, in the world dominated by Jerry Maguire-style management, with a mantra of "Show me the money," the Joseph Jurans and W. Edwards Demings of the world go to Japan to use quality principles.

The sad part of today’s business culture is that quality is left to a few engineers and engineering managers in the lab or on the manufacturing line, where they are limited to creating reports or graphs that don’t spell out business issues and cost impacts.

My take is that the problem lies on both sides of the table (management and quality professionals). Everyone needs to see quality as an integral part of the business, with real costs associated with it—the lack of it—be it from inefficient processes, rework, poor customer satisfaction or market-share losses due to recalls or regulatory issues.

It’s high time to change the perception from "quality is engineering’s business" to "quality is everyone’s business."

Shree Balachandran
Melbourne, Australia

Many measures

Godyn makes a good point in his article in the July 2009 issue of QP. No one would argue that clinical outcome is the most important dimension of healthcare quality. However, Godyn takes the position that hospital quality is primarily measured in terms of patient satisfaction. In my experience, this is not true.

Patient satisfaction is one of many measures of quality. Godyn states that, "Even the MBNQA focuses on human perceptions of quality." It is true that customer focus is one of the seven elements in the performance excellence framework. However, the MBNQA Health Care Requirements for Performance Excellence says, "All actions point toward results—a composite of healthcare, patient and stakeholder, market and financial, and internal operational performance results, including workforce, leadership, governance and societal responsibility results." The first item addressed in the results section is healthcare results.

Godyn also criticizes quality-service questions as having "little to do with quality of care." However, the way in which medical professionals interact with patients has been shown to affect patient outcomes. A researcher at Duke University has found that the quality of hospital food affects patient outcomes. A physician who does not listen carefully to what a patient has to say may be missing an important symptom that could lead to a better medical outcome. These results indicate the service dimension interacts with the clinical outcome dimension.

The point is that all dimensions of healthcare quality are important and deserve attention. Service quality is one dimension. It should not, as the author states, be "the primary measure of quality in healthcare," but it should be one of the measures. While there may be instances of waste in spending to provide extraordinary service, overall national investments to improve service quality in healthcare are not wasted.

Superior medical outcomes do not arise exclusively from the most technologically advanced equipment and better-trained physicians. They are necessary, but they are not sufficient components of healthcare excellence. The entire system, including service quality, must be focused on results. That requires investing and measuring all dimensions of the system.

Victor E. Sower
Huntsville, TX

Personal experience

After reading Godyn’s article, I believe the quality of service I received following a January 2009 surgical procedure was excellent as subjectively evidenced by staff friendliness, my clean room, my comfortable bed and the tasty meals. But, as my standard three-day stay was extended to enable being fitted with an ankle-foot orthosis, it became apparent there was an adverse outcome, and quality of care was mysteriously nowhere to be found.

I’m fortunate to be a certified quality engineer who performs root cause analysis and frequent customer complaint investigations, because I have spent the last six months methodically investigating what exactly happened during my surgical procedure to cause the adverse outcome. I’m still astounded that my surgeon thought so little of me as a patient that he couldn’t take the responsibility to honestly disclose the cause.

I agree with Marvin Christensen’s comments regarding measuring the quality of care by comparing the actual outcome to the planned outcome.  For my situation, there was a tremendous gap.

Laurel Kirkwood
Grand Rapids, MI

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