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Let’s Learn From No Child Left Behind: Measuring Quality In Healthcare

Thu, 01/23/2014 - 11:01am
Luis Collar, M.D.

As we address the issue of quality in healthcare, there is much to be learned from other industries. I believe our current approach, though, is a dangerous one, one that won’t yield the desired results. Thus far, we’ve approached quality assurance as if healing were an industrial process, a process similar to those that yield cars, air conditioners, or even cheeseburgers.

But in an age where science, technology, and health policy are all changing at an unprecedented pace, we must ask a simple question: How should we assess quality in our industry?

The word “quality” elicits confidence, a sense we are discussing something of great value, something highly desirable and useful. Corporate quality strategies such as Six Sigma, however, can only reassure us that products have been through a predictably similar process, that they contain no deviations from their intended design. And in manufacturing, because they limit unwanted variance, these programs make sense, despite telling us nothing about a product’s intrinsic value or effectiveness, about its suitability for our particular needs, tastes, or budgets.

In healthcare, though, it is often the very variances identified as “defects” by these programs that can improve a patient’s health. Good physicians are not assembly line workers executing repetitive tasks. Patients are not cars, comparatively simple, inanimate machines lacking free will. And identifying “defects,” in the industrial sense, is challenging given our incomplete understanding of human beings’ “intended design.” So directly applying industrial quality principles to medical care is an ill-conceived, albeit well-intentioned, goal.

Healthcare quality programs must limit unwanted variance (e.g. wrong therapy, unnecessary test), while retaining desired variance (e.g. patient preference, physician judgment) and accounting for inherent variance (e.g. genetic or socioeconomic determinants of health). Failing to recognize the need for this new paradigm will lead to problems, big problems, particularly as financial and therapeutic decisions are increasingly tied to quality. In fact, we’ve already witnessed this in other industries under similar pressure to measure and improve.

In education, No Child Left Behind sought to bring qualityaccountabilityscientifically based research, and standardization to our classrooms. It also fueled discussions about tying teacher compensation to student outcomes. (Sound familiar?) But the legislation has been deemed a failure by many educators. Why? It failed to recognize that every child is unique, that even perfectly healthy, well-adjusted children learn in different ways, that teaching is more than a series of easily reproducible tasks, that standardized test scores do not accurately measure learning.

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