Lisa Rosenbaum’s recent three-part series in the New England Journal of Medicine, “The Quality Movement,”is a detailed, nuanced and deeply reported analysis of efforts to use quantifiable measures to drive quality improvement. My over-simplified take on her bottom line is that the effort has largely failed. The component parts of high-quality care are hard to measure and forcing physicians to report data that are often disconnected from the actual needs of individual patients is dysfunctional and counterproductive.
I’ve been taking my time with the series, absorbing and appreciating how Dr. Rosenbaum builds a complex narrative brimming with history and information. Great stuff but not an easy read.
Her message suddenly snapped into focus for me while accompanying my dad to a follow-up appointment with the orthopedist. Prior to the doctor’s arrival, the nurse who was working up Dad’s info cut short what should have been a longer conversation by saying, “But I have to have a number.”
The nurse, pen in hand and hunched over a clipboard was asking Dad – who is 94 years old and has Alzheimer’s, an active sinus infection and a recently broken shoulder – to describe his pain on a 1-10 scale. He was stumped, and so was I. Sitting still in a wheelchair, with his arm immobilized in a very supportive sling, he’s pain free, as long as he’s had his Tylenol and ibuprofen. But we had just come from imaging where, despite everyone’s best efforts, Dad was in considerable pain as they tried to remove the sling, position x-ray cartridges, etc.
When I explained all that to the nurse, she impatiently repeated, “But I have to have a number.” We went through a similar drill with the doctor, who was less concerned about the clipboard and finally said, “OK; we’ll call it a five”
It’s easy to imagine that the pain score is required for billing and/or quality metrics and that the nurse was just doing her job. Unfortunately, it seemed clear her job was more about satisfying the needs of the form than the patient.
While I know there is no quick fix to this and other problems affecting the safety and quality of care delivery, it seems obvious that putting down the clipboards or turning away from computer screens and sincerely engaging with patients and their at-home caregivers would be more informative and satisfying for all. It’s hard to see how that wouldn’t improve quality.