Measuring performance is essential to patient-centred care

I enjoyed your editorial “Measuring Performance” in the 23 Feb. 2010 issue of C.M.A.J. I assume that you would appreciate some feedback.

I am a “senior” senior for I graduated (U. of Manitoba), in 1945. I retired from consultant practice (In Otolaryngology), in 2006. Although I am ageing, I am not old. I am fortunate in that I am able to think both objectively and subjectively. Further it has been stated that as we age, we “increase in wisdom”, or at least, sometimes!

I am, as of Sept. 2009, on the board of the Mel Lloyd Family Health Care Team in Shelburne, Ontario, a town of 5,000 with a catchment area of 29,000. One of our objectives is to develop what we consider to be the best health care system for the above mentioned population. In early February, I received a letter from President Anne Doig, that she called the `State of the Union address``. I assume that all Canadian physicians received her letter. In the 3rd paragraph, she stated, “one of the key projects of the working groups is the creation of a charter that spells out the rights and responsibilities of patients”. I sent her an email on Feb. 6th. To date, I have not received a reply.

Our health care system is controlled by the Ministry of Health and we, the physicians. We hold all the cards. Your editorial emphasises the importance of a third group and that is the patients. They are increasingly monitoring their medical care. A second opinion and even a third opinion is common. The noun `Google` is now a verb. And websites are being used more and more.

I am now a farmer in that I grow spruce trees for the landscape industry. Recently I purchased several new implements from the local John Deere dealer. It contained a `Dealer Experience` for my completion. Not too long I received a similar request from the Ford Motor Company. Performance is very important.

You mentioned several items: 1. Poorly coordinated visits for diagnostics tests and follow-ups.

2. Rates of surgical success and complications.

3. Accessibility, timeliness of care, courteousness and overall satisfaction.

The commonest complaints here in Duffer in County are wait times in doctors` waiting rooms and in Emergency Room. Our “fee for service” system rewards the physician but perhaps not always the outcome. So your statement “align funding with performance” cannot be dismissed. John F. Kennedy stated “we are going to the moon“. A very difficult feat but we did. We have made tremendous advances in medical care; transplants, bionic surgery to mention two. None of these advancements have been easy.

Yes, the measurement of performance will not be easy. But it is possible. Perhaps the sensors, computers, research labs, cameras, iPhones and the like will make it easier.

Our number one priority is to make the start. Perhaps we should consult with our engineers or “Mr Google” himself! Respectfully submitted

Wilfred S. Goodman, M.D.

Conflict of Interest:

None declared

As we strive to provide improved patient-centered care, I am confused by Dr. Hebert’s call for aggregating data of questionable value. Patient- centered care should revolve around individualized approaches to patients and their needs – not tailored to statistics that may only confound true patient preferences.

The lack of by-in from healthcare professionals and decision-makers represents healthy scepticism on the value of performance measures. Improvement requires both proper, reliable comments, and knowledge on how to translate this feedback into practical enhancement.

The approach to measuring performance should be the same as any clinical scientific endeavour; we should develop objectives and methods, establish their validity, and then determine their value in practice. Otherwise, we may end up with another Swan-Ganz catheter: unreliable, puzzling, and equivalent. Only in this case, the consequences may be detrimental to patients, physicians, and our healthcare system.

Conflict of Interest:

None declared

Andre Picard's Second Opinion commentary (Globe and Mail, February 26, 2010) on the most recent display of dyspeptic cognitive dissonance by one D. Williams, resonates with Paul Hebert's recent editorial (CMAJ 23 February 2010. This timely juxtaposition is a reminder that the ability to access information on the performance of Canada's health care system remains at best fragmented, and largely elusive.

Recommendations linking performance measurement and quality improvement in Canada's Health Care System in the interests of organizational accountability and public stewardship in a transparent fashion where the information to assist decision-making by patients, providers, organizations, and government is easily accessible are nothing new; such recommendations, including the way forward, are refreshing highlights of the 2002 Romanow report on the future of health care in Canada.

In the interests of his own redemption, the Premier of Newfoundland and Labrador, and the steward of his province's health care system, might take the lead among Canada's provincial and territorial jurisdictions to champion the solutions required to bring the Romanow recommendations to life. Instituting a co-creation model process to which I make reference in an earlier e-Letter (CMAJ, 9 February 2010)is perhaps a way forward worthy of consideration.

R.J.Riopelle, MD, FRCPC, FCAHS

Conflict of Interest:

None declared

To the editor: We agree completely with Dr Hebert’s position that performance measurement should be a major priority within the healthcare system(1). In his article, he poses the question “So why do measuring performance and health outcomes elude us?” We suggest an additional reason not mentioned by him – measuring quality of care is complex.

Measuring quality of care is complex because it is a vague concept that means different things to different people (2). As a result, different groups derive different indicators. Furthermore, a patient’s condition has a large influence on how one will measure and interpret quality data. A patient in a palliative care unit will experience care differently than one on an obstetrical unit – and therefore measures should vary. Because measuring performance is difficult, the system has gravitated towards pragmatic solutions, which are deemed inadequate by some(3).

Health systems need to be strategic in moving this agenda forward. We recommend four different but inter-related investments, which we predict will have a large and synergistic impact. One, there should be increased investment in information management technologies, such as data warehouses and business intelligence tools, which can support performance measurement. Two, there needs to be enhanced training of statisticians, epidemiologists, economists, clinicians and managers to use the clinical data within health information systems to support informed decision making. Three, there needs to be increased funding to support thoughtful evaluations of innovations designed to improve quality of care. Four, we need to support collaborations amongst health system institutions to allow them to improve the consistency of their approaches.

The healthcare system is a valued resource. Although the current economic climate will make it attractive to avoid the investments we propose, this may be a grave mistake. We suggest that better assessment of performance has the potential to increase quality and decrease cost. Even if we simply do the former, our patients and clinicians will be grateful.

Sincerely,

Alan J. Forster, MD FRCPC, MSc, Scientific Director, Clinical Quality and Performance Management, The Ottawa Hospital

Jack B. Kitts, MD FRCPC, President & CEO, The Ottawa Hospital

(1) Hebert, P.C.; Measuring performance is essential to patient- centred care; CMAJ 2010; 182(3):225. (2) Donabedian, A.; The quality of care. How can it be assessed?; JAMA 1988; 260 (12): 1743. (3) Park,R.E.; Brook,R.H.; Kosecoff,J., et al; Explaining variations in hospital death rates. Randomness, severity of illness, quality of care; JAMA 1990; 264(4):484

Conflict of Interest:

None declared

From my experience in Sudbury, I am not able to discuss with my patient for certain specialties (ortho is a big one) which doctor is likely better because the wait time for all of them is a year or more for non emergency referrals. I have to send people out of town.

In terms of hospital care, we only have one main one, but like most cities, I believe that patients would feel lucky to even be admitted to a hospital since the bed crisis is national.

For famillies with loved ones suffering from dementia and other debilationg illnesses at home, the wait for admission to a nursing home can be years, so any will do!

Also, for family doctors, having one is better than none.

I would put forth, that basic Accessibility in some cases and in some areas precedes the need for Standards of Performance.

Conflict of Interest:

None declared