What does quality mean in healthcare and how do you find it?

During my preventive medicine residency at Hopkins I worked in Dr. Peter Provonost’s Institute for Patient Safety and Quality. In addition to leading all safety and quality issues at Hopkins, he’s also credited with creating the concept of the surgical checklist, a tool that’s proven to save a significant number of lives and best described in Atul Gawande’s book, The Checklist Manifesto. Peter taught me that everything is a process, and if you don’t design the process with intention and outcome in mind, the process evolves into the easiest, rather than the safest. That being said, in healthcare, I deify process mostly because the data on individual physicians isn’t plentiful enough to be statistically significant (by the way, the photo above is a shot of Sherpaa’s process maps, the first thing you see as you walk in the office). For example, a surgeon who does 32 tonsillectomies a year isn’t enough data to be scientific. It’s meaningful because it’s common sense that you almost always want to go to the surgeon/facility who does the most of the exact thing you need. But, you need much, much more volume than that for the outcomes to be scientifically statistically significant.

Physicians are also always taught that the practice of medicine changes every 5 years. New evidence comes out and gold standards change. This also throws a wrench in the concept of studying doctor quality. If the gold standard is a moving target, there’s again not enough time to generate sufficient data/volume. It’s also relatively common knowledge that the older the physician, the further they are from state of the art training. As humans, we all get set in our ways. Older physicians, unless they take it upon themselves to learn new procedures through curiosity and continuing medical education, will likely be doing an exceptional job with out of date procedures. Younger physicians will be doing state of the art procedures with less experience.

All of this takes us back to the concept of process. What is a surgeon’s process and what is the hospital’s process for following best practices? Without standardized processes, things quickly get ugly.

Without super reliable data, people are left to compile a list of soft data points and hope for the best. I’m not a huge fan of patient reviews mostly because the volume and quality of those reviews are quite low. Amazon has stated that about 1% of purchasers actually review their items and that’s with a very clear and promoted single source to easily and quickly leave a review. 1% of a doctor’s patient panel is way too low to be hard data. Of course, you can often still get a decent feel for the doctor’s personality. In order of priority, I’d say this is how you make the decision:

• Rule out the terrible doctors with malpractice reports. 6% of doctors are responsible for 60% of malpractice cases. Don’t go to that 6%. That’s mostly incompetence mixed with being an asshole.
• Once you’ve ruled out the incompetents, research to find out who does the most cases of the very procedure you need
• Schedule a meeting with this surgeon to understand the priority they place on process before, during, and after the procedure. Healthcare is simply problem solving powered by communication. So clearly understand the surgeon and their team’s process for communication post-discharge. I’d also ask if this was his/her kid, who would they take their kid to for this procedure?
• In addition to other physician recommendations, nurse recommendations are way more valuable. Nurses seriously know everything. They keep the healthcare train running and they know who’s a good doctor and what their patients are saying about the doctor. They also know who to stay away from.
• Time since completing their residency. I’d say the ideal time is more than 5 years and less than 15. If it’s more than 15, ask the name of the procedure they plan to use to see if it’s up to date.
• Where were they trained? Medical school is relatively meaningless. It’s essentially studying books and shadowing residents and just getting exposed. American medical schools are superior because best practices/doctor culture vary wildly in different countries. What really matters is where they did their residency/fellowships. Was it a well regarded academic medical center here in America or a community hospital?
• Surgical facility. And what is the hospital/facility’s statement on process/patient safety?
• Admitting privileges to what hospitals? High quality doctors tend know each other and cluster together.
• Academic appointments/publishing. I think this correlates to how passionate and interested you are in the field and is a soft metric that you’re doing everything you can to be relevant and push boundaries. It’s a far stronger metric than board certification.
• Yelp/Healthgrades/ZocDoc/etc. There’s no clear winner here so you’ve got to combine them all. We’ve found that for most specialties, Yelp is most valuable. ZocDoc is good for specialties that depend on churn like dermatology and dentists. Those specialists are all competing for patients. If you’re an in-demand physician, you don’t need ZocDoc.
• Personal website. I actually think this is meaningful. If it’s well designed and articulate, it’s a soft data point that the doctor emphasizes the patient experience and good communication.
• Board certifications. Honestly, these things are not difficult to pass. The vast majority of doctors are good standardized test takers, so when I see board certification, it’s pretty meaningless to me. These are mostly just revenue for the speciality associations.
• Cost. There’s no correlation to quality. And most doctors aren’t even the ones determining their actual costs. It’s mostly in the facility’s billing department.

Unfortunately, this isn’t an easy process that can be automated.