Friday, May 05, 2017


There is talk of quality in health care. There is talk of safety. Millions upon millions of dollars are spent on "quality and safety" in health care each year. After all, without "quality" and "safety," how can you have "value?"

Business people now call quality and safety "MIPS," "MOC," "MACRA," or "measures." To me, these are not quality, but rather very flawed attempts to define it. Acronyms and business strategies, no matter how well-meaning, can't define "quality" or "safety" or 'value" in health care. When it takes teams of consultants dispatched hospitals to explain how to make money with these new terms, that's called marketing, not "quality" or "safety."

The truth be known, "quality" is very difficult to define. That's because each of us brings a different perspective as to what defines health care "quality." A gruff neurosurgeon who is technically flawless in the operating room is likely perceived differently by the recipient of his services compared to his coworkers. Defining quality in medicine is like defining pornography - you just know it when you see it. The tricky thing about "quality," though, is that we often miss it when it lies right beneath our nose.

Last Friday I had the luxury of working with my favorite technician as we worked to install a pacemaker. For that short period of time, he was my wingman. I didn't really think about much. Neither did he. It was a quiet, pleasant moment as we complemented each others' skills: instruments assembled neatly on the table, soft music playing in the background, the ultrasound ready, a blade dispensed, a quiet whisper for another instrument that was already in his hand. A sheath, a suture, a steristrip, a gauze and Tegaderm - and a mutual respect that had quietly developed over our many years working together. A "quality" effort for sure.

Foolishly, I took it for granted.

I have been fortunate to work with great wingmen (and women, too) all my career. They know who they are. They never ask for accolades and are often embarrassed when they are passed along. They get up every day, report like clockwork to do their job, and do it really well. There is pride in their work because they know it matters. They treat others as they'd want to be treated themselves, and patients remember - maybe not their name - but their touch, their reassurance, their confidence, their kind words. I have learned you don't need an advanced degree to define "quality." Nor do you need a National Quality Forum or National Committee on Quality Assurance. It takes time and mutual respect to develop real quality, not checklists, metrics, or administrators.

So when the call came a few days ago that my wingman was sick - suddenly and unexpectedly - time stood still for all of us. This quiet, humble guy who knew the composer of every golden oldie that played in our lab. A guy who's stood at my side so many times, helped so many, now a patient himself. Why? Naively, I had convinced myself that things would always stay the same and only get better. Instead, life intervened and his vacation trip to California became a trip to the hospital - a scan - a serious cancer - and a life turned upside down in an instant.

Sometimes it takes tragedy to open our eyes and appreciate the small but important things we have. Sometimes it takes tragedy to help us acknowledge the real quality we have among our ranks. Quality metrics, by comparison, seem trite.

My wingman is back home now among family and friends. I went to check in on him and there he was smiling, with PICC line in place and chemo infusing. He spoke a bit and exchanged some pleasantries. As I turned to walk away, what did he say?

"Thank you, doc. It might be a while before I can come back."

Spoken like a typical wingman.

I thanked him back. "Take your time," I said. My response seemed so trivial compared to all he's done for me.

I returned to our lab and saw our closely-knit team working together on another difficult case - like flying in formation with one jet missing. The elephant in the room was standing there. We could feel it. No one said a word. They chose to focus instead.

Quality wingmen all.



Anonymous said...

I feel the same way about the staff at my hospital. They are some of the best anywhere.

I worry that the radiation exposure in the cath lab will soon cause more of us to be patients.

Anonymous said...

Oh - the reminders ( often slaps in the face ) ,, of what are life's important gifts .. Many --> we take for granted . Not deliberately ,, just need that reminder , that comment , that " event ". A Psyc Professor in school ( last century ) ,, took great pains to present Kindness ,,, as a foundation for Life -- given and accepted .
Well , my tragic event was 21 months ago --- a gloomy October day . The Call ! Cute , fun , smiley Baby Grandson has brain cancer -- in fact , two tumours . He's 3 months old . NO ! Been in healthcare - research , management , clinicals --- for a long time ! This was , indeed , different ! Discovery : the dedicated Angels who care for the Kids -- with cancer !! Nurses , docs , tech , rehab --> Who are these People ? And, the Team work -- > our local great Teams / Univerisity ,,, consulting with cross county Teams ! Whew !
100 Turesdays , in a row ,, of Chemo ! MRI ,,every 3 months ,,, adjust chemo ( did you know only 3 per cancer drugs in 30 years ) ... Can't do radiation -- too young ! Watch him --> what's the word ? = Trooper ! Innocent ! Smiles ! ( all life's trivia ceased to exist ). Jeez --- I'm a hugger , now !
Wingmen ( ? Wingpersons ),,,, those Angels ! Bless them ! Where do they come from ! Kindness !

Alan Kogan, MD said...

Wes, we have both been around long enough to know that "quality" in medicine is immeasurable in binary computer language and that any attempt at such is doomed to failure. Unfortunately, this failure will come at the cost of health care outcomes for individuals - you, me, our children and our children's children will pay for this folly. MIPS, MOC, MACRA be damned.

Anonymous said...

Don't worry, Anonymous. The cath lab radiation only causes early cataracts. My dad got cataracts and was able to drive just fine as long as he turned his head to the side to see what was in front of him. hen we were able to talk him into cataract surgery and it was no big deal. He never went near a cath lab. Who knows how he got that, maybe some Army thing.

Mel said...

All docs need to unite to fight mandatory MOC at the state and federal levels. Why is this so critical? Physicians and patients are under assault from all directions and on so many levels that the higher standards of care everyone has worked so hard to achieve are being sacrificed to fatten the corporate bottom line; the heart of medicine is being cut out by the big insurance companies and mega corporations to increase their flow of revenues.

MOC is a rallying point; the fight is partly the battle against corporate medicine controlling physicians just to increase corporate profits for the elites, and growing revenues for the one-percent club at the expense of the patient.

With every prior-authorization a physician and patient stares at and discusses together the first, second and third times; with every denial of a standard medication in the shifting sands of acceptable prescription lists; every denied test or procedure that were all once covered by insurers on a physician's order are now suspect or forbidden fruit. And this keeps getting worse with added useless meaningless clicking to support the quality cartels.

Physician authority no longer means anything to the insurance companies or their corporate partners. Patients are now encouraged by corporate surrogates to blame their providers for the payers larceny - insurers who now deny almost everything as a general principle.

NSA's "Stolen" Hospital Malware said...

If @NSAGov had privately disclosed the flaw used to attack hospitals when they *found* it, not when they lost it, this may not have happened

AfterMidnight CIA Spying Tools said...

Is Wikileaks really working for bad state actors? Or exposing some of the most egregious ones?

NQF/CMS Quality Measures and NSA/CIA Contractor Booz Allen Hamilton said...

The Making of a Surveillance State (ABIM's Christine Cassel (PCAST, NQF), Richard Baron (CMS), Bob Wachter (AHRQ, NHS) and company)

Do physicians and patients know that the NQF/CMS hired the same CIA/NSA contractor which NSA/CIA contractor/employee Edward Snowden worked for? Why? What for?

BAH - Booz Allen Hamilton is the company Edward Snowden last worked for before he disclosed what Snowden, journalists and annalists believed to be "company" wrongdoing. Violations to US citizens' eroding constitutional guarantees. All should be informed by now about ABIM/ABMS' goon squad/surveillance state they created under Cassel, Baron and Wachter.

But what was/is the role of the NQF/CMS. Anyone so inclined to read NQF's IRS filings can see that Booz Allen Hamilton was hired as their top contractor at the beginning of the era of "meaninful use" and "click surveillance". It does not take a top political analyst or civil rights lawyer to figure out why.

What did the NQF/CMS hire BAH for? "Meaninful Use" and "Quality Measures" other physcian/patient surveillance of course. And creating a deeper means of keeping track of physicians along with the ABIM/ABMS.

"They" needed to keep track of who was "keeping-up" with all those wonderful quality measures that were written by NQF's most esteemed and powerful "stakeholders". Does any physician or patient ask the fundamental questions relating to "for what purposes"?

- ABIM pop quiz question: Prior to Christine Cassel joining the "firm" at NQF/CMS Chris sent her ABIM policy adviser over to be spokesperson/media liason/troubleshooter in advance of Cassel's appointment to the NQF. Can anyone name that ABIM policy advisor?

Anonymous said...

So who is in charge of the NQF?
CMS? United Health Group? Kaiser Foundation Health Plans?

A Texas Internist said...

Wanted everyone to know about happenings here in the Lone Star State -

As many of you may have heard - the Texas Legislature - particularly the House - has descended into a Tea Party fiasco - and hundreds of bills have been basically shelved out of spite.

"you didn't scratch my back - I won't scratch yours now." has become the order of the day - and literally hundreds of important bills important to the people have been killed.

Also - the Texas legislature convenes only every other year - so whatever does not get down now before the Memorial Day adjournment will get held until 2019.

When I heard this news yesterday, I just knew that the MOC bill - SB 1148 - was likely dead this time.

HOWEVER - hundreds if not thousands of physicians all over Texas have flooded the legislator's offices with calls, emails and letters - and this just in from the Texas Medical Association -

Maintenance of Certification Measure Moves: This morning, the House Public Health Committee approved a bill that would prohibit hospitals and health insurance companies from discriminating against physicians based on their maintenance of certification (MOC) status. Senate Bill 1148 by Sen. Dawn Buckingham, MD (R-Lakeway), is a TMA priority. It also would prohibit the Texas Medical Board from requiring MOC for physicians to obtain or renew a medical license. Houston neurologist Kim Monday, MD, testified for TMA in support of the bill in two committees this session. “We are asking that you give physicians a choice in whether they continue to participate in this expensive and somewhat monopolistic endeavor,” she said.
The bill now moves to the House Calendars Committee to be scheduled for floor debate. Thank you to the hundreds of TMA members who have called and written their state legislators to keep this bill moving.

The MOC bill in Texas - is most definitely alive - and appears to be stronger than ever - and in a better chance to get passed. It was NOT in the group of bills killed earlier - so there is still more than a fighting chance that this is going to happen.

Texas has 1 out of every 14 physicians in America - I wonder what this could do the budget of the ABIM and all the other Boards.

Again - Wes - Thank you so much for everything you have done -