Michael K. Keng, MD
Quality improvement is a method for ensuring that all the activities necessary to design, develop, and implement a product or service are effective and efficient with respect to the system and its performance.
That basic definition was developed decades ago by W. Edwards Deming, the father of quality improvement. Deming is best known for his work in Japan after World War II, particularly his efforts to help the leaders of the Japanese automotive industry.
He discovered deficiencies in the process of car manufacturing and improved the efficiency and quality of the vehicles that we now know as the brand Toyota. Many in Japan credit Deming as the inspiration for how Japan rose from the ashes of war to become one of the largest economies in the world.
Yet Deming’s principles were not unique to the auto industry, and many professions have adopted his ideas to improve their disciplines. The field of medicine, where human lives are at stake, is even more in need of measures that can eliminate deficiencies and fine-tune efficiencies.
As physicians, we have not only a responsibility to care for our patients, but also a duty to improve patient care. Quality improvement is often known as a mechanism to reduce cost, but it is much more than that. It is an opportunity to improve the full patient experience. And, whether we want to admit it or not, quality control is becoming a significant part of our oncology world. Our licensing boards, governing bodies, and insurance companies are basing our competency and reimbursements on our ability to standardize care.
Programs such as the American Board of Internal Medicine’s Maintenance of Certification, the Centers for Medicare & Medicaid Services’ programs (Hospital Value-Based Purchasing, the Physician Quality Reporting System, and the Merit-Based Incentive Payment System), and the ASCO Quality Oncology Practice Initiative are changing the ways we practice. Although measures of quality have not invaded all cancer subspecialities, it is only a matter of time until we will all have to prove that we are delivering quality.
Better Training Needed
Most of our colleagues would agree on the importance of focusing on quality improvement. But they may be quick to give the responsibility to the administration or the nursing staff because, when it boils down to the process of assessing quality as a whole, we are not adequately trained.
When do we ever receive education on how to measure the quality of our patient care? Our medical students, residents, and fellows are focused on learning standard-of-care and clinical guidelines. Aside from receiving subjective evaluations about attending to patients, they do not learn how to assess the care they give patients as individuals and as part of the team. Evaluations provide feedback on individual performance but do not address the system and context in which the trainee is working.
Thus, learning how to evaluate and change the medium in which patient care is delivered is not a standard part of the medical training curriculum. But if we were to train our students on the basic principles of quality improvement as delineated by Deming—identifying a problem, planning a solution, executing the solution, and evaluating its progress—indeed, we would be training our students for the real world.
The real world cares greatly about quality because poor care leads to medical errors. We tend to learn about system errors only after they occur, instead of being proactive about finding ways to improve deficiencies. But if we taught our trainees how to approach these deficiencies before errors occur, they would be much more prepared for the less glamorous aspects of medicine.
Recognizing Value of Quality Care
Despite having practical applications on the macroscopic level, the field of quality improvement is not seen as a hard science. Involvement in quality improvement is not as sexy on the curriculum vitae as multiple research projects and published articles.
The hardest challenge to overcome is helping everyone understand the value of this kind of training. We say we understand the importance of quality care, but we do not think it is worth our time to obtain formal training in a “softer” side of oncology to find out how to deliver this care.
I only started to appreciate the value of quality improvement several years ago during a fellowship at the Cleveland Clinic, when I participated in a project and realized that my previous training did not provide me with the skills to tackle the problem at hand: timely antibiotic administration for patients with febrile neutropenia.
Through my mentor and coaches, I learned how to deliver a better system that not only met national guidelines but also decreased length of stay for patients with febrile neutropenia and improved their outcomes. We implemented a system that allowed patients to receive the correct antibiotics promptly and consistently.