• Mitch Keamy Photo Mitch Keamy is an anesthesiologist in Las Vegas Nevada Andy Kofke Photo Andy Kofke is a Professor of Neuro-anesthesiology and Critical Care at the University of Pennslvania Mike O'Connor Mike O'Connor is Professor of Anesthesiology and Critical Care at the University of Chicago Rob Dean Photo Rob Dean is a cardiac anesthesiologist in Grand Rapids Michigan, with extensive experience in O.R. administration.

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James Goldberg



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I don't believe extortion is a JCAHO motive; but I do believe that their 40 year monopoly on "deeming authority" has resulted in a certain complacency. My understanding of the change you describe comes from this blog;

and suggests that regular, recurring accountability will now be a feature of their relationship to Congress. Is this good or bad? Well, since the status quo is not particularly inspiring, change ought to be good, right? On the other hand, this will bind JCAHO more tightly to the whims of political power, further decreasing what little autonomy they possess, and the move opens the field to new players willing to do the political bidding of whoever is in charge of meting out contracts; we have seen how such ideological patronage contracting has served the country in the last years...

Scott Hodson

Many American health systems are significantly underinvested in quality management Infrastructure, Process, and Organization. To achieve breakthrough improvements in quality, patient safety, and resource utilization hospitals and health systems must develop a "world class" quality management foundation that includes:

Strategy: including a clear linkage of quality and patient safety to the organizational strategy and a Board-driven imperative to achieve quality goals.

Infrastructure: incorporating effective quality management technology, EMR and physician order entry, evidence based care development tools and methodologies, and quality performance metrics and monitoring technology that enables "real time" information.

Process: including concurrent intervention, the ability to identify key quality performance "gaps," and performance improvement tools and methodologies to effectively eliminate quality issues.

Organization: providing sufficient number and quality of human resources to deliver quality planning and management leadership, adequate informatics management, effective evidence based care and physician order set development, performance improvement activity, and accredition planning to stay "survey ready every day."

Culture: where a passion for quality and patient safety is embedded throughout the delivery system and leaders are incented to achieve aggressive quality improvement goals.

My firm has assisted a number of progressive health systems to achieve such a foundation, and to develop truly World Class Quality.


Your argument that the Deming model is not particularly applicable to medical care makes sense - but he and his disciples do make some important points to learn from. And one of them is defining quality.

Every discussion like this invariably brings up the definition of "quality". Then invariably we meander off into how hard it is to define (you guys did it in this otherwise sharp discussion) .

Deming and Frederick Taylor before him defined "quality" in a uniform and useful way - and one perfectly applicable to our discussion.
Quality is essentially conformance to standards. Makes sense. In this respect the JCAH is right- that's what they look for, conformance to standards.

The problems with the JCAH you identify, and problems they are -the Potemkin Village reference is perfect - is not their demand for conformance to standards but the standards they set up have very little to do with clinical care.

This is the problem we face - not defining quality but identifying the standards we desire. One of the reasons you anesthesiologists have been more successful than other specialties is your ability to identify standards for certain important clinical events- e.g. misplaced intubations. But again there is more of a uniformity in certain OR regimens than in other clinical areas (not to diminsh your efforts). So it is easier to define the numbers you have, and the ones you want to reach for events that are actually important.

It's not always easy in clinical care to identify standards -it is doable and should be done but unfortunately hospitals and clinicians don't keep internal statistics about clinical events very well. (Example - ask anyone in the hospital what the overall mortality rate in their hospital is within a half a percent. Of course by itself it doesn't convey much information but it's a basic statistic of what we do - I'm willing to bet no one you ask, clinician or administrator will know. NOT ONE PERSON will know the overall mortality rate in their hospital. Seems unbelievable but in my years I never met one person who knew, unless they were guessing. Ask them how they know if they give you a figure).

You might say that's not important. I would disagree based on my experience but regardless, that's just an example to show how primitive our knowledge is. Without simple internal statistics, how can anyone identify standards they should conform to? Case-mix and practice variability make it hard to identify standards for clinical care but we will not get very far with any nonuniform procedure without much better statistical reporting from every hospital about what they do.

In essence it's not defining quality that's the problem - it's identifying the standards that go into actually attaining quality. At that point the model you describe will actually work in getting us where we should be.

Mitch Keamy

Cory and Scott; each of you, in your admirable idealism, misses the gist of the argument. Cory, the reason we didn't discuss the nitty-gritty of what constitutes quality is because the argument is about the need to address techniques of quality improvement. I have no doubt that a list of standards could (and should) be established (no wrong sided surgery is just such a standard), but as the saying goes, "if wishes were horses, beggars would ride." But imagining that articulating that list would eventuate in improvement is optimistic; progress towards this goal will require the acquisition of basic understanding in healthcare quality improvement that is much more advanced in air transport, and which requires a tremendous intellectual commitment; not just the application of administrative tools and imperatives. Or, put another way, knowing where we want to go is not the same as being there. We just don't have the ruby slippers. Existing TQM-like technique may tell us how we are progressing, but they won't tell us how to get there; it's like a swim parent shouting "swim faster, swim faster" to their kid, wwithout any idea how he/she might accomplish that goal.

And Scott, while your finely crafted words reveal an obvious commitment to the goal of accomplishing higher quality, I just don't believe that the technology exists at this time in healthcare quality management to realize that lofty (and profitable) ambition. Understand that by technology, I don't mean computers and software; I mean procedural and behavioral approaches based upon a deep understanding of the process factors that lead to errors and suboptimal quality in healthcare. Just compare NTSB work product with healthcare system quality interventions. The difference is striking. They have it right. We don't. That's why commercial air travel is so darn safe, and healthcare is not. Yet.

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