Joanne Lynn and colleagues have just come out with a great new book, The Common Sense Guide to Improving Palliative Care. (OxfordUniversity Press, 2007). Like their prior work in this area (Improving Care for the End of Life, now in a revised version, 2007), this pocket-sized book discusses quality improvement strategies. Using explicit examples from teams working in various venues in which palliative care is practiced (palliative care consult teams, ICU, nursing homes, hospices, etc.) the authors demonstrate how measurable improvement can be accomplished by following some straightforward quality improvement steps.
In reading the book one is struck over and over by the thought, “Yup, that really is common sense. The rationale for the described projects (improving pain management, transitions in care, advance directives etc.) and the steps taken seem clear. ‘We could do that where I work!’ And yet, I suspect in many if not most places we work, this is not what happens. Why? Here, I will consider three possibilities: 1) Quality as someone else’s job syndrome 2) Lil’ ole me syndrome and 3) the Saints and Angels Syndrome.
Quality as someone else’s job
All organizations struggle with variants of “it’s not my job syndrome.” However, in recent years a relatively new problem has arisen – especially in large healthcare organizations. A whole industry has arisen dedicated to improving quality. The ease of collecting and organizing data in healthcare has made it possible to track, trend, and compare much of what we do. Often, this is a very good thing. Large data-base driven quality improvement can result in tangible good by mandating, for example, flu vaccines for the vulnerable and then measuring the percentage that get vaccines. However, there is a down side. Too often there is a wild proliferation of “quality measures.” Huge teams of “quality managers” must be hired just to keep track of it all. The clinician, if he or she is paying any attention, must spend a lot of time “coming into compliance” with somebody else’s idea of what is important. And that’s the problem. “Quality” can become a dirty word – something to be avoided and a threat to the individual and the organization. I fear clinicians are becoming adverse to the concept of quality improvement as an intrinsic aspect of their job. Lynn and colleagues make a compelling case that we must not let this happen. Some problems cannot be improved by fiat from managers on high. Some problems are best identified and solved by people living with those problems.
Lil’ ole me syndrome
Look around. It’s so clear that we have some huge problems in healthcare that will require large-scale, national fixes. When we get busy and overwhelmed, it is so tempting to say, “Well, who am I? I’m just one person. What is really needed is…” That may be true, but it is easy for this to become an excuse for not tidying up our own backyard. The “Starfish Story,” so popular in the hospice and palliative care world addresses this problem. You probably know it, but for those who don’t: After a bad storm (like Katrina) thousands of starfish are washed up on a beach. A boy walks along throwing back one starfish after another. A man comes by and says, “Look at all those starfish! You’ll never make a difference doing that.” Flopping another starfish back into the surf the boy replies, “Made a difference to that starfish.” Good point!
Now if you think about it, the man also had a point. While tossing individual starfish back did help those individuals, perhaps it would have been more effective for the boy to rally his friends, or his school to help out. So, we may be more effective in what we do if we work in teams, as admirably described in Lynn’s book.
The Saints and Angels Syndrome
There is no need for quality improvement in heaven. Hospice and palliative care rightly pride themselves on the wonderful people who work in the field. While we sometimes draw scorn from people who, I think, misunderstand us, more often we bask in the praise of patients and families who receive our care. There really are some saints and angels in our field. But that too becomes a problem IF we come to believe that things are so wonderful, so close to heaven that there is really nothing to improve upon. So here’s a dirty little secret. Too many in our field are allergic to the types of quality improvement efforts described by Lynn and colleagues in their book – where data (numerators and denominators) must be tracked. I’m not exactly sure why this is so. Perhaps it is because some think that numbers dehumanize what we do. Hospice as a movement arose in part in reaction to an overemphasis on scans, numbers, and data to the neglect of the human heart.
I think we need to take a cold, hard look at the problem. While too much of an emphasis on data and numbers really is a risk, if we are really going to be of help to the patients and families we serve, we must be willing to use all tools available. And sometimes that means numbers. Lynn’s book suggests a happy medium for this conundrum. While encouraging systematic planning and data collection, the authors never loose sight of the ultimate goal – to improve quality of life.
The book is highly recommended.
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