I grew up not far from a kettle pond, oval-shaped and deep blue, stocked with perch, just small enough to swim end-to-end without parents’ blessings. Punched into the peninsula by receding glacial melt and ringed with bronze, grainy sand and towering conifers, it was the object of daydreams on early June afternoons between the interminable hours of noon and three p.m. (sometimes it still is), and the giver or withholder of summer’s great joy. Near the end of a school year, eager speculation would stir regarding the pond’s condition: the water, we might say, had risen all the way to the third rock at its edge – this summer would be the best yet.
Our world is full of oblique indicators not so different from this one. We choose qualities which are sometimes arbitrary to approximate the condition of things we consider intuitive and thus not in need of precise measurement or accounting. The trouble with measurement, with goal-setting and benchmarking and standards of quality assurance, is that once the measures are known, they stop meaning what they were meant to. As kids we never tried to force a great summer by moving the rocks that served as markers, or add more water to the pond, yet we sometimes employ reasoning in health care just as illogical as that would be.
The trouble with measurement is that once the measures are known, they stop meaning what they were meant to.
We aren’t alone. When school districts’ budgets are supplemented or penalized according to their scores on standardized tests, superintendents, perhaps naturally, pressure their teachers to emphasize those tests in their lessons. This has the deleterious result of “teaching to the test,” favoring memorization and recitation over critical thinking and reasoning. Are the administrators wrong? There’s an argument to be made that they’re doing precisely what they were hired to do, and that schools have little choice but to comply with these metrics in the face of thin operating margins. But at the same time, if administrators’ sincere commitment is to the students they serve, perhaps there is a path of genuine quality–of providing better education without teaching to the test but scoring better as a byproduct.
A similar pattern of “teaching to the test” can be observed in hospitals’ responses to quality metrics. Medicare mails a survey to patients after hospital discharge to gather feedback about domains like staff communication, hospital cleanliness and whether a patient would recommend a hospital (the survey is known as HCAHPS). When hospitals focus on these scores as target metrics, it detracts energy and focus from genuine problem-solving. Their nearsightedness inhibits the creation of an overall culture of quality.
When hospitals focus on patient satisfaction scores as target metrics, it detracts energy and focus from genuine problem-solving.
If we need better quality (we do), then we’ll need to exercise some creativity in how we look at the work we’re doing. I’ve seen a hospital system where pay was lower than what was available nearby, where days were longer and busier, where patients were more complex and challenging to manage, and where the clinical people who lasted there were, with certainty, extremely fulfilled in their work. I’ve seen a hospital system where cases were less complex, where no work was expected outside of clocked-in hours, where compensation was better than average, and where trained and educated employees teetered between dissatisfaction and burnout. The first had good HCAHPS survey scores because it provided good care. The second had good survey scores because it worked feverishly to improve them, with different projects focusing on those items as outcomes.
A hospital’s culture is its engine. The way it functions can be measured and maintained and recalibrated, but first it must be engineered. A ‘soft’ quality away from which the organizational improvement pendulum has presently swung, culture is much more difficult to measure and report than it is to see and understand. But the focus will change; the current trajectory of American health care is misguided at the most fundamental level, and only organizations which have invested the resources and energy into building engines of quality, who have placed development of their people above development of new revenue streams, will be able to continue as they are. Bright and dedicated people who are both capable of and committed to doing excellent work for patients will tend towards institutions that are likewise committed to quality and continuous improvement. Conversely, organizations which fail to reciprocate the commitment of their best clinical people will be unable to retain those eager to make a difference, and over time workforces will bloat with those driven by paychecks and lifestyles rather than quality.
That worker satisfaction is much lower in health care than in other industries is a good sign – it means we are responding appropriately to a dysfunctional and profit-driven system.
This imbalance, I believe, is a more valuable and important signal of how well a hospital is doing than any other. No set of process or outcome measures will quite capture it, yet every employee can see and feel it. Satisfaction and fulfillment are not the result of generous compensation or uncomplicated work or pleasant environments; they arise from challenges well-met, and from transparency, from peers who do their best, and administrative empowerment and support. This is not an original idea. Volumes have been written; experiments already carried out. Most clinicians learn this basic psychology on their way to practice, and still we fail so thoroughly in health care to harness the power of these ideas.
Satisfaction is much more than the absence of burnout, in the same way that health means many things beyond absence of disease. That worker satisfaction is much lower in health care than in other industries is not a bad sign, it is a good one – it means we are responding appropriately to a dysfunctional and profit-driven system. The present factory contrived around provision of services and maximizing volume and RVUs and squeezing out face-time with patients and whittling down a complex person with unique challenges and needs into a diagnostic code, which prefers costly and invasive treatments over equally-good cheap and conservative ones, which turns away chances for real impact in favor of opportunities for better reimbursement, is not a structure in which capable and dedicated people should feel fulfilled, but one against which we should rebel.
This raises the question of whether satisfaction can be seen as good or bad: people functioning within teams sharing commitment to doing good work regardless of difficulty should feel fulfilled, and people committed to doing good work for patients within a system as dysfunctional as this iteration of American health care should feel frustrated. It’s possible to be both, and I posit that very many clinical people would report both of these feelings. Recognizing these pressures is the spark which will start the virtuous cycle of long-lasting improvement, and success on ancillary measures will be an incidental result.